Anesthetic management of a parturient with congestive heart failure
Abstract Number: 249
Abstract Type: Case Report/Case Series
Introduction: Peripartum management of a parturient with congestive heart failure (CHF) poses a challenge for the anesthesiologist. Anesthetic considerations include preventing further cardiac depression and avoiding uncontrolled changes in afterload and preload. Early administration of effective labor analgesia is a necessity in order to minimize further cardiac stress associated with pain. We present a case where intermittent delivery of opioids via a spinal catheter successfully controlled labor pain in a patient with severe congestive heart failure undergoing vaginal delivery.
Case presentation: A 34-year-old G2P1 parturient presented at 36 weeks of gestation for elective induction of labor. She had a past medical history of non-ischemic cardiomyopathy NYHA Class III, hypertension, asthma and morbid obesity, weighing 177 kg (BMI 60). Her last echocardiogram showed an ejection fraction of 10%, severe diffuse left ventricular hypokinesis and pulmonary artery pressure of 52 mmHg. Pregnancy course was complicated by worsening dyspnea, orthopnea and two episodes of supraventricular tachycardia that responded to adenosine. On admission she was tachypneic and tachycardic. Invasive hemodynamic monitoring was initiated via a right radial arterial line and right internal jugular pulmonary artery catheter. An epidural catheter was placed intrathecally at L4-L5 interspace using a 17 gauge 7.5 inch Touhy needle. Adequate pain control was achieved and maintained by injecting 20 mcg of Fentanyl every 45 minutes. Patient was hemodynamically stable during the 9-hour labor and she delivered a healthy baby after forceps application. Postpartum she was monitored in the cardiac intensive care unit. Mild CHF exacerbation responded well to oral furosemide. She was discharged home on postpartum day five.
Discussion: Pregnant women with congestive heart failure are at increased risk of cardiac events during labor and delivery. NYHA Class III patients have a maternal mortality rate of 5-15% and a perinatal mortality rate of 20-30%. Pain management is of outmost importance in order to avoid cardiac decompensation. Various neuraxial analgesic techniques have been used. Administration of opioids via a spinal catheter allows maintaining hemodynamic stability since sympathetic blockade is avoided while obtaining effective analgesia throughout the labor. Invasive monitoring is used to guide adequate fluid and pharmacologic therapy. In our case, careful titration of spinal opioids during labor provided effective pain control in a pregnant woman with severe congestive heart failure.
Conclusion: Neuraxial analgesia via a spinal catheter is a safe and effective way of providing pain control in a parturient with severe heart disease.