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Labor Management of a Parturient with a Subaortic Membrane in the Setting of Severe Preeclampsia
Abstract Number: T-65
Abstract Type: Case Report/Case Series
A pubmed search yielded no articles describing the management of a parturient with a subaortic membrane. We describe a case of successful vaginal delivery with epidural anesthesia for a patient with a severe stenotic subaortic membrane and severe preeclampsia.
A 20-year-old primigravida with a subaortic membrane that had been surgically corrected at age 13 was admitted at 31 4/7 weeks with systolic blood pressures in the 190s and 4+ proteinuria with a diagnosis of severe preeclampsia. An echocardiogram at that time showed left ventricular hypertrophy, an ejection fraction of 65%, advanced diastolic dysfunction, moderate aortic regurgitation, and left ventricular outflow obstruction (70-75 mm Hg gradient that increased to 85 mm Hg with valsalva) consistent with subaortic membrane regrowth.
At 32 4/7 weeks the patient was induced for increasingly labile blood pressures, a rising creatinine, and intermittent headaches. In order minimize fluid shifts associated with surgery the patient was induced for planned vaginal delivery. Arterial line placement and tight fluid control were implemented to prevent fluid overload while ensuring adequate preload and afterload. An L4/L5 lumbar epidural was placed prior to induction, and tested without epinephrine or atropine and bolused slowly with 0.25% bupivicaine with a goal to prevent both pain induced catecholamine release and valsalva with delivery. Heart rate and blood pressure were controlled with beta 1 selective beta blockers. The patient was counseled that her highly stenotic membrane limited the speed by which either IV induction or epidural bolus could be given for fetal distress potentially increasing the chances of a poorer outcome for her baby. After successful instrument-assisted passive 2nd stage delivery of a healthy infant the patient lost 350 mL of blood secondary to uterine atony which was responsive to misoprostal. Despite fluid shifts the patient remained stable and was discharged from the ICU on postdelivery day 2.
This case describes the first reported use of an epidural in a parturient with severe preeclampsia and severe subaortic stenosis secondary to a subaortic membrane. In the absence of precedent or guidelines a delivery plan was made via close collaboration between obstetrics, cardiology, and anesthesia. ACC/AHA guidelines for the management of patients with aortic stenosis were consulted as subaortic membranes function as fixed left ventricular outflow obstructions. As the first known description of the management of a parturient with a subaortic membrane it is our hope that this abstract may help guide future providers in the care of these challenging patients.
Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the ACC/AHA Task Force on Practice Guidelines. Circulation 2008;