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Cesarean section in parturient with prosthetic mitral valve: challenges of safe neuraxial block management.
Abstract Number: S 60
Abstract Type: Case Report/Case Series
Incredible progress in the field of cardiac surgery has guaranteed survival and prolonged normal life of many children and young adults, with cardiac defects both congenital and acquired. Prosthetic valve replacement is a common option for surgical repair in young patients. The benefit of durability of prosthetic valves comes at the price of lifelong anticoagulation treatment. During pregnancy patients must switch from warfarin to Low Molecular Weight heparin (LMWH), due to teratogenicity of warfarin. They present an extra challenge for peripartum obstetric and anesthetic management. Usual approach is limited to general anesthesia for cesarean section, due to substantial risk of catastrophic epidural hematoma after neuraxial block . We present a case of cesarean section realized under spinal anesthesia guided by Thromboelastogram (TEG) as a tool for safe management of neuraxial block.
A 29 year old G2P1 parturient at 39 weeks was scheduled for induction of labor, but found to be in breech presentation. Cardiology service was consulted and recommended that she be switch from LMWH to heparin infusion, to be discontinued 4-6 hours prior to vaginal delivery. Cesarean section was indicated after fetal distress during induction of labor. During consent, the patient expressed preference for regional anesthesia. In addition to routine platelet count (169K) PT(12.6), INR(1.0) and PTT(38), TEG was also drawn before surgery (Without heparinase: R-2.2 min, K-0.8 min, Angle-78.4 deg, MA-75.9mm. With heparinase: R-2.2 min, K-0.8 min, Angle-77.9 deg, MA-5.1 mm). Blood was noticed at initial attempt during spinal placement. Considering normal TEG, the decision to proceed with spinal anesthesia was made and was successfully performed with clear CSF. Cesarean section was uneventful with delivery of a healthy baby. Two hourly follow up for 24hours showed no neurological deficit and patient met all post-partum recovery goals. Heparin infusion was restarted in the postpartum period. She was switched to LMWH and later to warfarin as per cardiology service recommendations.
Performing TEG with and without heparinase is an indispensable tool when considering neuraxial block for peripartum anesthetic management in high risk obstetric patients receiving heparin anticoagulation.
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2. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, Brown DL, Heit JA, Mulroy MF, Rosenquist RW, Tryba M, Yuan CS. Reg Anesth Pain Med. 2010 Jan-Feb;35(1):64-101.