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Pulmonary Hypertension and the Parturient: A Case Report
Abstract Number: S 41
Abstract Type: Case Report/Case Series
A 32 year-old G5 P3 at 36 weeks gestation was admitted one day prior to elective repeat Cesarean section. The patient had a history of severe pulmonary hypertension secondary to chronic thromboembolic disease. Despite treatment with an IVC filter and anticoagulation, she developed lower extremity deep venous thromboses on two separate occasions. At the time of initial evaluation she was on therapeutic enoxaparin and a continuous treprostinil infusion. Prior to these events, she had 3 completed pregnancies and one miscarriage. An echocardiogram series showed worsening pulmonary artery pressure (75mmHg) and impaired RV function. On the day of admission, her pulmonologist placed a pulmonary artery catheter for perioperative hemodynamic monitoring. The anesthesia team was made aware of the patient the day of surgery and evaluated her in the intensive care unit. A thrombelastogram obtained showed normal clotting kinetics. Of note, her care was complicated by a history of multiple lumbar back surgeries including debridement for osteomyelitis.
The patient was taken to the OR where an epidural was placed, and an arterial line was placed prior to dosing it. Approximately 15 minutes after administration of 5mL of a 2% lidocaine and 8.4% sodium bicarbonate solution, a T4 level was achieved and she experienced anxiety and shortness of breath along with a drop in systolic blood pressure from 140mmHg to 88mmHg. Administration of 1 unit of vasopressin elicited a good response, and was given throughout the case in place of phenylephrine for blood pressure support to avoid constriction of pulmonary vasculature and worsening of pulmonary hypertension. Her symptoms resolved and the baby was delivered 12 minutes after acquiring adequate surgical level with Apgars 8 and 9. Oxytocin was infused to ensure uterine tone without complication. ABG and pulmonary artery values were followed intraoperatively and the treprostinil infusion was never discontinued for any reason. The patient was transferred to the ICU for postoperative observation. She was discharged 5 days later after restarting anticoagulation and a post-operative echo was performed.
Pregnancy combined with severe pulmonary hypertension carries a maternal mortality of 30-50%.[1,2] The physiologic changes of pregnancy create increasing demands on a cardiopulmonary system already compromised by pathologic changes and a multi-specialty approach is likely to greatly improve outcomes. Epidural anesthesia with incremental dosing has been recently shown to provide good outcomes and provide better hemodynamic stability while avoiding the adverse effects of general anesthesia and positive pressure ventilation. We present our successful approach to this complicated patient in order to contribute to the existing literature on this difficult subject.
1. Anesthesiology. 2005 Jun;102(6):1133-7
2. Medicina (Kaunas). 2012;48(3):159-62
3. BJOG. 2010 Apr;117(5):565-74