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Management of a Patient with Pulmonary Hypertension
Abstract Number: 225
Abstract Type: Case Report/Case Series
INTRODUCTION: Maternal mortality in women with pulmonary hypertension (PH) is estimated to be 30 – 56%. The highest risk is at labor/delivery and the immediate postpartum period. We present the case of a woman with PH secondary to severe mitral regurgitation and describe our approach to her care.
CASE REPORT: A 27 year old female G2P1 32 weeks gestation presented for consultation. Past medical history was significant for mitral stenosis as a result of rheumatic fever at age 9 and a mitral valve annuloplasty in 2005 performed in Puerto Rico. Her previous pregnancy, 1 year after her valve annulopasty, was complicated by severe pre-eclampsia and resulted in a caesarean section (C/S) under general anesthesia.During this pregnancy, she had been hospitalized twice for episodes of supraventricular tachycardia. The patient reported dyspnea and palpitations with exertion that had worsened during pregnancy, but she was able to climb 3 flights of stairs. Echo one month prior noted severe mitral regurgitation, LVEF 65%, and an estimated pulmonary pressure of 54 mmHg. At 37 weeks gestation she presented for an elective repeat C/S and bilateral tubal ligation as scheduled. On arrival her vitals were: BP 116/74, HR 120, 100% O2 sat(RA). Nitric oxide was set up in the OR. 2 large bore IV’s and an Aline were placed. A CSE was introduced into L3-L4. Fentanyl 20 mcg was injected into the intrathecal space. An 8.5 FR introducer/CVP line was placed into the right internal jugular vein under ultrasound guidance. Milrinone and Epinephrine infusions were readily available. Baseline CVP was noted to be 10-15mmHg. 20ml of 2% Lidocaine was bolused through the epidural catheter in 4 ml increments to obtain an adequate level of anesthesia.Following delivery the CVP was noted to rise to 25mmHg, while the rest of the vitals remained stable. A male infant APGARS 9/9, was delivered. Pitocin 30 units was infused slowly.Preservative free morphine 3 mg was injected epidurally for postoperative analgesia.The patient was transferred in stable conditioned to the ICU. She was discharged home on postop day 7 uneventfully.
DISCUSSION: Recent literature reports a lower mortality rate using various approaches to the pregnant patient with PH. C/S is preferred as it may decrease acute increases in pulmonary vascular tone that can be seen with vaginal delivery. Regional anesthesia avoids increased pulmonary arterial pressures during laryngoscopy, and effects of positive pressure ventilation on venous return. slow onset epidural is recommended. CSE may provide superior anesthesia, but a low dose or narcotic only spinal is suggested. Nitric oxide and/or milrinone may be beneficial. Since deterioration of PH may occur early in the 3rd trimester, C/S is recommended as early as possible.It is imperative that these patients be monitored in an ICU immediately postpartum.
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J Am Card 1998;31:150-7
Br J Ob Gyn 2010;117:565-574
Cur Op Anaes 2008;21:467-72