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The Successful Approach to Perioperative Management of a Parturient with Unrepaired Truncus Arteriosus and Cyanotic Congenital Heart Disease for Cesarean section
Abstract Number: T-61
Abstract Type: Case Report/Case Series
Introduction: Major advances in the treatment of women with congenital heart disease (CHD) have enabled them to survive to childbearing age without surgical correction and this number is rising by 5% per year. However, the hemodynamic demands of pregnancy are associated with a 50% maternal mortality (with pulmonary hypertension) and increased fetal mortality(1).
Case Presentation: Despite heart lung transplant refusal, numerous miscarriages, and preconception counseling, a 30 year old G4P0030 at 25 weeks with cyanotic CHD presented to her cardiologist with worsening dyspnea. She had a known history of unrepaired Type II Truncus Arteriosus, type B Interrupted Arch, VSD and Eisenmenger’s syndrome with PAP 115/64.
She was admitted, loaded with intravenous Treprostinil, and her medications optimized to include ASA, Enoxaparin, and Sildenafil. A team of obstetric and cardiac anesthesiologists, obstetricians, cardiologists, cardiac surgeons, neonatologists and intensivists was formed for perioperative planning for cesarean section. Specifics were delineated: the utility of left sided arterial line (mean arterial pressure) versus right (cerebral perfusion pressure), TEE, and CVP. Options for uterine tone post delivery were explored.
At 29 weeks, fetal umbilical artery Doppler revealed reversal of end diastolic flow confirming worsening growth restriction requiring delivery.
Preop vitals included an oxygen saturation of 85% on room air, blood pressure 100/60, heart rate 118, height 66 inches, and weight 84 kg. Arterial and central lines were placed preop with platelet infusion. Goal hemodynamics included maintaining preload, sinus tachycardia, and saturations of 85%. Induction was performed with Fentanyl, Rocuronium and Etomidate. Anesthesia was maintained with Remifentanil infusion, Midazolam and Desflurane. The neonate was delivered 7 minutes later with APGARs 5/6. Oxytocin infusion was started, prophylactic mesoprostil was placed, and intrauterine oxytocin was additionally administered for uterine contractility. The patient was extubated and taken to recovery.
Hours later, she required a hysterectomy due to bleeding. Edema from resuscitation prevented abdominal closure and extubation. After 2 weeks of meticulous intensive care, her abdomen was closed and she was extubated.
Discussion: There are now 1 million patients with CHD that survive to adulthood. The most important predictor is functional status and problems relate to arrhythmias and heart failure. A multidisciplinary approach involving preconception risk counseling as well as careful perioperative planning is necessary to improve both maternal and fetal outcomes(3). Optimal care for parturients with unrepaired CHD remains at specialized centers that offer centralization, consistency, and expertise in complex physiology management.
1) NEJM 2000;342(4):256-63;
2) J Am Coll Cardiol 2007;49:2303–11;
3) Anesth Analg 2011;113(2):307-17.