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Anesthetic Management for Cesarean Section of a Patient with Severe Preeclampsia and Aortic Dissection
Abstract Number: F 75
Abstract Type: Case Report/Case Series
Introduction: We present our management of a patient with severe preeclampsia and aortic dissection for cesarean section (C/S).
Case Report: A 40 year old G10P9 female presented at 37 weeks gestation with severe range blood pressures. The patient was a poor historian and a thorough review of previous visits was conducted.
Her past medical history was significant for chronic hypertension (HTN). She admitted to noncompliance with her medications. Blood pressure (BP) now was 170s/100s.
A review of records found a CT scan from the previous pregnancy which demonstrated a Type A aortic dissection at 34 weeks gestation. Intraoperative TEE at that time revealed the dissection was actually Type B and the patient was discharged for medical management after her cesarean section. The Type A appearance on CT was attributed to scatter from the patient’s body habitus. The patient was lost to follow-up.
Past Surgical History: C/S x 3
Meds: unknown anti-HTN medication, daily albuterol
Social: daily alcohol and tobacco use, frequent cocaine use (last smoked 2 days prior; no signs or symptoms of acute intoxication or withdrawal)
On physical exam: Height: 67 inches. Weight: 300 pounds. VS: Temp 36.4, Pulse 94, Resp 24, BP 188/120. Airway: Mallampati 2, poor dentition with multiple missing upper and lower teeth. Lungs: Clear to auscultation bilaterally. Heart: S1S2 normal. (+) systolic murmur. Hemoglobin 10.7 g/dL. Platelets 202 x 10^9/L.
CT Scan: Type A dissection extending beyond the renal arteries. Infrarenal abdominal aortic aneurysm measuring 4 cm maximally.
Severe preeclampsia was suspected. Blood pressure control was with labetalol and lorazepam. Magnesium was used for seizure prophylaxis. Multidisciplinary conversations were held involving MFM, anesthesiology, cardiology, trauma surgery, and vascular surgery. It was decided to deliver the patient via C/S, monitor patient in the ICU in the postoperative period, and once stable transfer to a nearby hospital for management by vascular surgery.
By the time the patient was ready to the OR her BP had been slowly decreased to 140/75. Bypass equipment was in the OR. An epidural was placed at L4-L5 and slowly dosed with 2% lidocaine to achieve a T4 block. The patient did not tolerate the pulling and pressure sensations as the surgeons worked through adhesions. In order to allow for optimal control of BP, GA was induced. The remainder of the case and postoperative course was uneventful. EBL was 800 ml. Epidural preservative free morphine was given for postoperative pain control.
Discussion: Type A dissection involves the aorta proximal to the origin of the left subclavian artery. Type B dissection is confined to the descending aorta. Type A dissections are usually managed surgically and Type B are usually managed medically. Anesthetic goals involve minimizing aortic root shear forces and wall stress. This involves slowly decreasing blood pressure and preventing catecholamine release secondary to pain.