///2010 Abstract Details
2010 Abstract Details2018-05-01T17:52:49+00:00

EPIDURAL ANESTHESIA FOR CESAREAN DELIVERY IN A PATIENT WITH SEVERE PULMONARY ARTERY HYPERTENSION AND A RIGHT TO LEFT SHUNT

Abstract Number: 217
Abstract Type: Case Report/Case Series

Elizabeth I Krenz MD1 ; Stuart R Hart MD2

INTRODUCTION: Idiopathic pulmonary artery hypertension (IPAH) and Eisenmenger syndrome (ES) are both progressive diseases associated with a high maternal mortality. In ES, a left to right shunt through a congenital heart defect causes pulmonary hypertension with eventual reversal of shunt flow. A right to left shunt may also develop in IPAH if increased right heart pressures open a patent foramen ovale (PFO). We report the use of epidural anesthesia for cesarean delivery in a parturient presenting with severe pulmonary hypertension and hypoxia due to a right to left shunt, in whom the etiology was not established until after delivery.

CASE: A 38 year-old female, at 32 weeks gestational age, presented with shortness of breath and was diagnosed with severe pulmonary artery hypertension with a right to left atrial shunt by transthoracic echocardiogram (TTE). Due to the poor quality of the TTE images, we were unable to determine whether the shunt was through a congenital heart defect or the result of a newly opened PFO. The risk of anesthesia for transesophageal echocardiogram (TEE) was deemed prohibitive, preventing a pre-delivery determination of the etiology. Epidural anesthesia was administered for cesarean delivery, at 34 weeks gestational age, as we believed this technique would cause the least cardiopulmonary compromise. As a T-4 level of anesthesia was achieved, using titrated doses of 2% lidocaine with epinephrine, the patient began to develop systemic hypotension. Maintenance of systemic blood pressure, a prime concern in this patient, was accomplished using phenylephrine prior to delivery. After delivery, vasopressin, a nonadrendergic systemic vasoconstrictor with possible pulmonary vasodilating properties, was used to maintain systemic blood pressure. The patients oxygen saturations were maintained without increasing her FiO2. After transfer to the intensive care unit, the vasopressin was weaned and a transverse abdominal plane (TAP) block was performed for postoperative analgesia. TAP blocks have been shown to reduce narcotic requirements after cesarean delivery, which may have been beneficial in this patient. Prior to discharge, TEE revealed a right to left shunt through a PFO, indicating a diagnosis of IPAH.

DISCUSSION: Epidural anesthesia can be used successfully for cesarean delivery in patients with severe pulmonary artery hypertension and a right to left shunt. Vasopressin may have advantages over other vasopressors after delivery in patients with pulmonary artery hypertension, as it may have differential effects on the pulmonary and systemic circulations. The differentiation between ES and IPAH may be important for determining prognosis, but may not be important for determining antepartum or intraoperative management of these patients. Performing a TEE may be delayed until after delivery.

SOAP 2010