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Anesthetic Management of a Super Obese Parturient with Recent NSTEMI
Abstract Number: F-69
Abstract Type: Case Report/Case Series
Successful obstetric and anesthetic management of a parturient who recently suffered a Non ST Elevation Myocardial Infarct (NSTEMI) can be challenging. Considerations include; how long after the NSTEMI should delivery occur, which delivery technique (vaginal or caesarean) is safest for the mother and the fetus, and which anesthetic technique will place the least amount of stress on a recently strained heart. These decisions become more complicated when the patient has concomitant super obesity (BMI>50), severe anxiety and post-traumatic stress disorder (PTSD).
This case presents a 24yo G1P0 at 34 wks gestational age with history of super obesity (BMI 70), PTSD, anxiety and chronic hypertension who presented with SOB, radiating chest pain and elevated troponins. She was diagnosed with NSTEMI and after initial workup the obstetric team decided that she should deliver either vaginally or by C-section in 2 weeks time. During this time frame a cardiac catheterization could not be performed and the patient refused to be on a heparin drip. At the 2 week period when labor was to be induced, a C-section became obligatory due to breech presentation and was successfully performed under a combined spinal-epidural anesthetic technique with mild sedation. Several non-standard tools were either considered or used to make this possible: fluoroscopy and ultrasound were considered to help access the neuraxial space, the Airpal RAMP system was used for positioning, and extra long spinal and epidural needles had to be ordered.
This is an interesting case of a super obese pregnant female with PTSD, anxiety and recent NSTEMI who had a C-section performed after placement of a combined spinal-epidural using a 7.5 inch Gertie Marx needle and mild sedation with midazolam. Ultrasound guidance proved unhelpful and a landmark based approach was used. An arterial line was placed to monitor hemodynamics, and the Airpal RAMP system was used for positioning. In preparation for this case several complex issues related to anesthetic management had to be addressed: the inability to perform a truly emergent C-section if a complication occurred during vaginal delivery, the increased risk of general anesthesia in a patient who may have a difficult airway due to her extreme size, using fluoroscopy or ultrasound to help access the neuraxial space, managing severe anxiety and PTSD, and the patient's inability to tolerate lying supine during the procedure. A multi-disciplinary team approach was used to address and overcome these obstacles.
Tan, T. et al. (2011) Seminars in Perinatology 35: 350-355.
Smith R. et al. (2008) International Journal of Obstetric Anesthesia 17: 46-52
Baysinger Curtis (2010) Anesthesia and Analgesia 110: 863-867