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

Management of a Parturient with Interstitial Lung Disease and Pulmonary Hypertension

Abstract Number: 235
Abstract Type: Case Report/Case Series

Jessica Rock MD1 ; Christopher Plambeck MD2; Elizabeth Ellinas MD3

Introduction

Pulmonary artery hypertension (PAH) in pregnancy has largely been studied in the context of series of case reports. There is controversy about the optimal management and mode of delivery,1 but authors agree that early diagnosis and intensive management increase the chance of good maternal outcome.1-3 We present a case of a 41 year-old parturient with PAH secondary to interstitial lung disease (ILD).

Case Report

A 41 year-old G1P0 was referred for anesthesia consultation prior to delivery. The patient was diagnosed with ILD in 2007 and required supplemental O2 with exertion prior to and during early pregnancy. PFTs showed FVC and FEV1 40% of predicted and diffusion capacity 16% of predicted. Echocardiogram revealed a normal LV EF, a borderline normal RV EF, moderate tricuspid regurgitation, and estimated systolic PA pressures in the mid-50s. As her pregnancy progressed, she began to wear nasal cannula O2 at 3LPM continuously to maintain sats above 90%. While the etiology of the patients lung disease was not clear, SLE or sarcoid were suggested. Other medical history included Raynauds disease.

Because of IUGR, the decision was made to deliver at 37 weeks. The obstetrical team planned a cesarean section, due to concerns about the patients tolerance of labor and likelihood of success for an induction, with arterial and CVP monitoring to guide treatment of any hypotension and a slowly dosed epidural in order to avoid sudden changes in preload. Two providers were unable to place an arterial line, presumably due to the Raynauds disease. However, central venous and epidural catheters were placed without incident and the epidural was dosed slowly with continuous CVP tracing and frequent non-invasive blood pressure monitoring. The epidural was adequate for cesarean section. Soon after delivery, the patients CVP and systemic blood pressure dropped to 80s/50s. The patient was asymptomatic, and the CVP and systemic blood pressure returned to normal after 500 mL of IV fluids. No vasoactive medications were required. The patient was transferred to the ICU for monitoring and was discharged from the hospital four days after delivery.

Discussion

Literature states that mortality of PAH in pregnancy ranges from 30-50%, with greatest risk in the postpartum period.1-3 Secondary causes of PAH appear to confer higher risk, but the patient group is more heterogeneous than with primary PAH,3 and it appears that exercise tolerance and right heart function have some correlation to prognosis.1 Our patient had decreased exercise tolerance and O2 dependence due to her lung disease, but she had borderline normal RV function with moderate PAH. Future studies are needed to delineate mortality risk, but current literature supports specialist involvement and invasive monitoring of preload and right heart function to guide care.1-3

References

1.Madden BP. IJOA 2009;18:156-64

2.McMillan E, et al. Lupus 2002;11:392-8

3.Weiss BM, Hess OM. Eur Heart J 2000;21:104-15

SOAP 2010