///2012 Abstract Details
2012 Abstract Details2019-08-02T19:38:42-06:00

Multidisciplinary Team Management ensured Uneventful Vaginal Delivery of High Risk Pregnancy in Patient with Moderate Pulmonary Hypertension secondary to Broncho-Pulmonary Dysplasia

Abstract Number: T-66
Abstract Type: Case Report/Case Series

Arvind Srirajakalidindi MD1 ; Deepak Gupta MD2; John Haddad MD3; Sra Paruchuri MD4; Vitaly Soskin MD, PhD5

22 year old gravida-1-para-0 presented to labor and delivery at 33-3/7 weeks with new onset pregnancy induced hypertension (HTN). Her past medical history was untreated moderate pulmonary HTN (50-65 mmHg) secondary to prematurity-induced-bronchopulmonary dysplasia and bronchiectasis. She had required home-based mechanical ventilatory support via tracheostomy till the age of 5 years. She was on 2-4 liters of home oxygen therapy and bronchodilators. Initial echocardiography demonstrated ejection fraction 55-60% with right ventricle dilatation with right ventricular pressure overload from pulmonary HTN. Fetal ultrasound estimated fetal weight at 13-14 percentiles secondary to pulmonary HTN induced chronic maternal hypoxia. Multidisciplinary team management was initiated with inputs and support from pulmonary, anesthesia, adult and pediatric cardiology consult teams as well as maternal special care and medical intensive care units. The patient understood informed risks of high maternal-fetal mortality-morbidity related to the progress of pregnancy and labor-delivery. Initial pre-partum management was intensive monitoring for progression of new-onset systemic HTN. As the patient developed atypical HELLP syndrome, she was transferred to intensive care unit. The plan was induction of labor with cervical priming at 34 weeks. The goals were vaginal delivery with shortened second stage of labor. Low-level epidural labor analgesia was initiated. Right radial artery catheter with Vigileo hemodynamic monitoring and triple lumen catheter through cordis were placed. Cardiac output and central venous oxygenation were continuously monitored. Daily echocardiograms were performed for assessment of the right ventricular ballooning or dilatation. A trial of 3-day sildenafil 30-60 mg daily for management of pulmonary HTN failed secondary to ventilation-perfusion mismatch. She was initiated on epoprostenol titrated infusion. At bedside, inhaled nitric oxide and ventilator were available in standby for eventuality of clinical worsening requiring non-invasive or invasive supplementation of inhaled nitric oxide. Labor analgesia was maintained with 6-8 ml per hour of 2.5 mcg/ml fentanyl in 0.125% bupivacaine epidural solution. The first stage of labor was 54 hours long and second stage was shortened by forceps-assistance; a female baby weighing 1820 g was born with APGARS 7/6/9 at 1, 5 and 10 minutes. Swan-Ganz catheter for pulmonary artery pressure (40-55 mmHg) monitoring was only required in post-partum period due to hemodynamic instability secondary to auto-transfusion as well as blood loss (400 ml) during delivery; she received 2 units of red blood cells. Thereafter, she and her baby were uneventfully discharged home on post-partum day 5. She was advised to follow up outpatient pulmonary clinic for sleep studies and right heart catheterization. She also decided to follow up with obstetrician for permanent sterilization as an outpatient surgery.

SOAP 2012