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PERIPARTUM ANESTHETIC MANAGEMENT IN A PARTURIENT WITH TAKAYASU’S ARTERITIS
Abstract Number: F-44
Abstract Type: Case Report/Case Series
Introduction: Takayasu’s arteritis(TA) is a rare inflammatory disease resulting in vasculitis of medium and large arteries. It commonly affects women of child bearing age, and the hemodynamic changes of pregnancy can have detrimental effects. Complications during pregnancy such as preeclampsia, refractory hypertension, or miscarriage are seen in many patients.
Case: A 27 y/o G3P1 with TA, pulmonary hypertension(HTN), and chronic HTN presented for induction of labor(IOL) at 39 weeks gestation due to worsened HTN. TA was diagnosed in 2004 after her first pregnancy, requiring stenting of her distal aortic arch and left pulmonary artery. She also had left common carotid and subclavian stenosis without intervention. In this pregnancy, her 3rd trimester echo showed increased tricuspid regurgitation, worsened pulmonary HTN, and decreased velocity across the aortic stent. She was treated for chronic HTN with caution not to compromise systemic and placental circulation. An arterial line was placed despite the rare risk of aneurysm formation. Then an epidural was placed and incrementally dosed with bupivacaine 0.125%. It was maintained with an infusion of bupivicaine 0.0625% with fentanyl 2mcg/ml. Due to progression to severe preeclampsia, she was bolused with magnesium(Mg), however an infusion was not started due to decreased urine output. After 17 hours of labor the patient was taken for cesarean section because of fetal intolerance. An attempt was made to dose the epidural; however an adequate level of anesthesia could not be achieved. After noting reassuring fetal heart tones, the epidural was replaced. The neuroaxial anesthetic allowed for monitoring the patient’s neurologic status to assess for cerebral hypoperfusion. Blood pressure was controlled with a nicardipine drip for quick titration. Near the conclusion of surgery, the patient became unresponsive and started to have seizure like movements which resolved after propofol 30mg and midazolam 2mg IV. She remained unresponsive and was therefore intubated for airway protection. The patient was loaded with Mg and started on an infusion. A stat CT of the head was negative for acute changes. On Postpartum day 1 she was extubated and did not have neurological deficits. Based on the EEG, CT and MRI of head, it was concluded that the etiology of the seizure was likely eclampsia.
Discussion: An understanding of the anesthetic management of patients with TA in the peripartum period is very important. Prenatal multidisciplinary planning allows for optimal patient care and safety. It is essential to be aware of the potential complications of this disease and patient specific hemodynamic goals in order to prevent morbidity and mortality of the mother and fetus.
1. A. Iosovich et al."Peripartum anesthetic management of patients with Takayasu's
arteritis. Int J of Obstet Anes 2009, 17:358-364
2. E. Hauanstein et al.”Takayasu's Arteritis in pregnancy. J Perinat Med 2010, 38:5