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Anesthetia for an Obstetric Patient with Postural Orthostatic Tachycardia Syndrome
Abstract Number: T-39
Abstract Type: Case Report/Case Series
Postural orthostatic tachycardia syndrome (POTS) is an autonomic disorder of orthostatic intolerance. This syndrome is subdivided into 2 groups. Type 1, which comprises 90% of cases, is called partial dysautonomia. It manifests as tachycardia in the upright position with symptoms of orthostatic intolerance, such as lightheadedness, nausea, chronic fatigue, dependent edema, and acrocyanosis. The second type, representing the remaining 10% of cases, is the hyperadrenergic form, which manifests as increased serum norepinephrine levels (>600 pg/mL), tremulousness, anxiety, and an exaggerated response to β-adrenergic stimulation (1). Diagnostic criteria for POTS include an increase in heart rate of ≥30 bpm or an absolute heart rate of ≥120 bpm within 10 min of standing or head-up tilt, combined with symptoms of orthostatic intolerance and the absence of other known causes of autonomic neuropathy. The etiology of this syndrome is unclear but immune-mediated and genetic abnormalities are proposed in the pathogenesis of POTS (2). POTS usually occurs between the ages of 15 and 50 years with a female: male ratio of 5:1 (3). The optimal anesthetic management for an obstetric patient with POTS is uncertain and based only on a few published case reports. We present a successful regional anesthetic for an obstetric patient with POTS undergoing a cesarean section.
Our patient is a 28 year old G1 P0 with POTS Type 1 and gestational diabetes but no other co-morbidities, who was admitted to our hospital at the 38th week of pregnancy. Her pregnancy was complicated by gestational diabetes, polyhydramnios, breech presentation and macrosomia. After counseling regarding delivery options, the patient decided to proceed with cesarean section. The anesthesiologist recommended regional anesthesia, which might reduce the likelihood of hemodynamic instability compared to general anesthesia. A combined epidural spinal anesthetic using bupivacaine, fentanyl, and duramorph was performed. Her blood pressure and heart rate were well controlled with minimal variability during surgery. She had an uneventful delivery and hospital stay, and was discharged home on the second postpartum day.
Regional anesthesia is regarded as a beneficial choice for cesarean section for both mother and fetus. Regional anesthesia remains a reasonable anesthetic option for the obstetric patient with POTS. Adequate volume loading beforehand, careful titration of local anesthetic and judicious use of vasopressors can improve hemodynamic stability. In comparison, general anesthesia may create greater hemodynamic instability due to light anesthesia levels, airway manipulation and the rapid switch from an inhalational to intravenous-based technique after delivery.
1.Kanjwal Y et al. The postural orthostatic syndrome: definitions, diagnosis and management. Pacing Clin Electrophysiol 2003; 26:1747–57.
2.Schondorf R et al. I