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Anesthetic Considerations for a Parturient with Pulmonary Artery Hypertension Medically Managed with Epoprostenol
Abstract Number: F 60
Abstract Type: Case Report/Case Series
Introduction: Pulmonary artery hypertension (PAH) is a disorder in which constriction of pulmonary arteries leads to increased pulmonary artery resistance (1). To prevent decompensation during labor and delivery, medical management of parturients with severe PAH often requires a pulmonary vasodilator. We report the successful anesthetic management of a parturient with a history of congenital PAH medically managed with epoprostenol, a potent pulmonary vasodilator with significant side effects.
Case Report: A 20 year-old G1P0 at 30 weeks gestation was admitted for preterm labor. Past medical history was significant for corrected congenital tetralogy of fallot, pulmonary valve atresia with a pulmonary artery stent. Transthoracic echocardiogram revealed a fenestrated VSD patch with a left to right shunt, and severe PAH with a PAP of 68 mmHg. Because of her history of severe PAH, increased risk for acute decompensation and sudden death during labor and delivery, a multidisciplinary team management labor plan was for ICU admission, early epidural placement, arterial line for blood pressure monitoring and arterial blood gas evaluations, central line for epoprostenol infusion, and assisted forceps vaginal delivery. A CSE was placed at 3 cm cervical dilatation; with 20mcg of fentanyl administered intrathecally and an initial epidural bolus of 5mL 0.08% bupivicaine with 2mcg/mL fentanyl. A PCEA infusion of 0.08% bupivacaine with 2 mcg/mL fentanyl was started at a continuous rate of 4 mL/hr and PCEA dose of 4 mL every 8 mins. Betamethasone was given for fetal lung maturity and a magnesium infusion for preterm fetal neuroprotection. Epoprostenol (2ng/kg/min) was initiated via the central line and later increased to 4ng/kg/min. Over the course of 24 hrs, her cervix became fully dilated. The epidural was re-dosed for delivery with 3cc of 1.5% lidocaine and 100mcg of fentanyl, along with bilateral pudendal nerve blocks performed for an uncomplicated assisted vaginal delivery. A live born infant was delivered, immediately intubated and transferred to the NICU. On postpartum day (PPD)#2, she was started on PO sildenafil (a long-term pulmonary vasodilator) at which time the epoprostenol infusion was titrated and discontinued PPD #4. She was discharged home on PPD#6.
Discussion: Epoprostenol is an IV prostacyclin requiring central administration that has demonstrated improvement in cardiopulmonary function by reducing pulmonary vascular resistance. Epoprostenol is associated with significant side effects necessitating ICU monitoring (2). Abrupt discontinuation of epoprostenol can cause severe rebound hypertension (3). Epoprostenol also inhibits platelet aggregation therefore coagulation studies are needed prior to regional anesthesia and central line insertion.
(1) Int J Clin Pract. 2011 Suppl; 172:6-14
(2) Lung. 2012; 190: 155-160
(3) Pulm Med. 2012; 2012: 709407