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Trends in the management of parturients with Fontan circulation
Abstract Number: F-59
Abstract Type: Case Report/Case Series
Parturients with Fontan physiology provide unique challenges to anesthesiologists and anesthetic/analgesic management of these patients is complex. Much has been written about obstetrical management of these patients; however, there is a paucity of information regarding detailed intrapartum anesthetic management. We therefore sought to perform a systematic review of the available case reports in the literature to determine the best practice for the management of parturients with Fontan circulation.
PubMed and Ovid/Medline databases were searched systematically using the keywords anesthesia; obstetrical, general, epidural, spinal; congenital heart disease; Fontan procedure and Pregnancy. Further, examining citations by the previous publications discovered additional cases. The case reports were restricted to the English language. Only reports that provided detailed anesthetic management were included. The endpoints examined included type of repair, age of patient, gestational age, mode of anesthesia, method of delivery, monitors used, NYHA classification, and any complications noted.
Mean patient age was 25.7 +/- 3.0 and mean gestational age was 33.5 +/- 3.9 weeks. Anesthesia/analgesia management was provided using epidural analgesia in 7/11 of the cases (see table). Cesarean section was the method of delivery in 7/11 of the patients. Indications for cesarean delivery were purely obstetrical, except for one patient who had atrial flutter and another who was deemed not able to tolerate labor. Vaginal delivery was the method of delivery in 4/11. Most of patients were NYHA I-II; an arterial line was used in 8/11 of patients and was independent of the NYHA class. Conversely, CVP was performed in only 3/11 of the patients. Complications noted were postpartum hemorrhage, hypotension, and supraventricular arrhythmias.
Based on the results of this review, there seems to be a trend towards using regional anesthesia techniques despite the implications of sympathectomy and a decrease in preload. Use of invasive monitoring in the form of an arterial line was independent of NYHA classification in parturients with Fontan circulation. Cesarean section was the modality used in most cases. Indications for cesarean section were purely obstetrical in nature except for in one patient where it was deemed necessary due to maternal causes.