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///2013 Abstract Details
2013 Abstract Details2019-08-02T16:57:45-05:00

Induction of labor in a parturient with chronic abdominal aortic dissection and superimposed severe preeclampsia

Abstract Number: F 62
Abstract Type: Case Report/Case Series

Bhavi Mehta MD1 ; Jonathan Wilks MD2; Ashutosh Wali MD3

A 20 year old G3P2001 at 33 weeks gestation, presented with abdominal pain and breech presentation. The patient had a history of cesarean delivery (CD) and a vaginal birth after CD. She also had a significant medical history of chronic hypertension, Takayasu's arteritis, supra renal aortic stenosis, status post angioplasty with subsequent type IIIb aortic dissection. The patient was non-compliant with anti-hypertensive medications and the chronic aortic dissection was managed conservatively. Cardiology was consulted and she was admitted to the labor and delivery unit for close observation and blood pressure (BP) management. On admission, BP and heart rate were 166/94 mmHg and 105/min respectively. On day two, fetal heart tones were reassuring and metoprolol 25 mg daily, PO, was started for a target BP of 100-140s/70-90s. For close monitoring and vascular access, a left radial arterial line and two large bore peripheral intravenous catheters were placed. On day three, severe superimposed preeclampsia was diagnosed after 24 hour urine protein was greater than 300mg and blood pressure lability was observed, 110-174/64-110. Metoprolol was increased to 50 mg twice a day, PO, and magnesium sulfate infusion was initiated. Secondary to blood pressure lability, superimposed severe preeclampsia, and the chronic aortic dissection, a repeat CD was scheduled. The patient adamantly refused a CD. In preparation for induction of labor and vaginal delivery, a left dorsalis pedis arterial line was placed (for pressure gradient comparison) and the cardiothoracic surgical team was consulted to be on standby. On day four, a nicardipine infusion was initiated at 2mg/hr for tight blood pressure control and a combined spinal and epidural technique was used for labor analgesia. An intrathecal bolus of 150 mcg of duramorph, 5 mcg of fentanyl, and 1.25 mg of bupivacaine was administered, followed by 0.0625% bupivacaine with 3mcg/ml fentanyl via an epidural catheter at a rate of 20 ml/hr, with 5 ml boluses for breakthrough pain. The patient was taken to the operating room for vaginal delivery at 9 cm cervical dilatation when she described perineal pressure and discomfort. During delivery, she was encouraged to resist the temptation to bear down. Analgesia was augmented with incremental epidural doses of 3% chloroprocaine. Nicardipine was titrated to a goal systolic pressure of 120s to 140s. A forceps assisted vaginal delivery was carried out and the neonate was admitted to the neonatal ICU. Postoperatively, the patient’s BP was invasively monitored for hemodynamic shifts. On day five, the patient was weaned off the nicardipine infusion to oral nifedipine, invasive monitoring was discontinued, the epidural catheter was removed, and she was discharged to the wards. The patient refused permanent sterilization despite extensive discussion of the risks and benefits.

SOAP 2013