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Multidisciplinary Management of a Fontan Patient on the Labor Floor
Abstract Number: F 53
Abstract Type: Case Report/Case Series
The Fontan repair was originally developed in 1971 for children with compromised biventricular circulation. Increasingly, these patients have survived to child-bearing age. The physiologic alterations present unique management challenges in the puerperium. Studies suggest that complications are common, with most being obstetrical rather than maternal.
We present the peripartum planning and management of a 32 year old G2P0 with a history of tricuspid atresia s/p Fontan repair. Despite pharmacological therapy, her repair was complicated by recurrent presyncopal episodes from atrial flutter requiring cardioversion and anticoagulation. She had chronic hypoxemia (baseline room air saturation= 89%) and right to left shunting through an ASD. A multidisciplinary team of providers from High Risk Obstetrics, Obstetric Anesthesia, Cardiology, Critical Care, and Nursing met to discuss physiologic challenges, mode of delivery, and anesthetic plans. Of particular concern was maintenance of adequate preload and vascular access, avoidance of arrhythmias, and management of anticoagulation. The plan was elective induction at 36 weeks with a forceps assisted vaginal delivery under epidural analgesia. LMWH was held and a radial arterial line, large bore peripheral IV and PICC line terminating in the subclavian vein were placed. Optimal epidural analgesia was attained via careful titration to avoid significant decreases in preload. Generous maintenance fluids were administered and baseline antiarrhythmic medications were continued. Soon after an uneventful 36 hour labor and delivery of a healthy fetus, she was monitored in our surgical ICU for 18 hours and then transitioned to a telemetry floor until discharge on PPD #3.
Critical Care Decisions:
Patients with Fontan repair present significant challenges and can require intensive-level peri-delivery care. Although our ICU provides excellent access to critical care and anesthesia resources, this site is more remote from the Obstetric and Neonatology infrastructure. We have developed a system whereby the team of multidisciplinary providers who will actively care for these patients create a detailed plan that maximizes peripartum time on the labor floor when feasible. Key to success is the integration of an ICU nurse into the labor floor team and an ICU back-up plan. In this manner, we can provide cost-effective, high level care in the most suitable locations in the hospital at the appropriate times during these High Risk patients’ labor, delivery, and postpartum periods.
1) Pregnancy and Delivery in Patients With Fontan Circulation: A Case Report and Review of Obstetric Management. Nitsche JF, et al. Obstetrical & Gynecological Survey: Sep. 2009; 64(9):607-14.
2) Pregnancy outcomes after the Fontan repair. Canobbio MM, et al. J Am Coll Cardiol. 1996 Sep; 28(3):763-7.
3) The Fontan Patient. Bailey PD, et al. Anesthesiology Clin 27. 2009; 285-300.