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ANESTHETIC MANAGEMENT OF A PARTURIENT WITH SEVERE PULMONARY HYPERTENSION
Abstract Number: S 61
Abstract Type: Case Report/Case Series
This is a case report of the successful anesthetic management of a laboring patient with severe pulmonary HTN. The mortality rates for pregnant women with pulmonary hypertension are 30-56%; a majority of these deaths occur during labor or within one-month postpartum.
Case Report: A 35 years female G5P2 , with PMH of childhood rheumatic heart disease, s/p mitral valvuloplasty for mitral stenosis in 1998 and chronic pulmonary HTN was admitted to the OB unit at 35 weeks for symptomatic and progressing pulmonary HTN. Patient complained of SOB on minimal exertion, orthnopnea requiring two pillows to sleep, and 3 episodes of syncope in the last 3 weeks. She was placed on bed rest, fluid restriction, no medications and scheduled for labor induction at 37 weeks when stable. A Doppler echocardiogram showed severe pulmonary HTN, severe tricuspid regurgitation (right ventricular systolic pressure of 63 mm Hg), moderate mitral stenosis (area of 1.2cm2 with an estimated mean gradient of 21 mm hg), severe dilated left atrium, moderate dilated right atrium, mild left ventricular systolic dysfunction with an EF= 45-50%. Patient was stable at rest although unable to tolerate physical activity. At 37 weeks and 3 days, she was brought to L&D for induction. She was placed in PACU with standard monitoring and given supplemental O2 2l via NC. Preinduction A-line and CSE was inserted by anesthesia team. Duramorph 0.3 mg, fentanyl citrate 25 mcg, and 1mg bupivicaine were injected intrathecally. No test dose performed. 0.1% bupivacaine with 2mcg fentanyl epidural infusion at 6cc/h started three hours later to ensure patient comfort while induction continued with oxytocin. The patient was not given any IV fluids except 10ml/h as a carrier for Oxitocin. She was allowed to have clear liquids up until delivery. Six hours after the patient had NSVD without complications. She was observed postpartum in the telemetry unit with no issues and discharged home 2 days later. 2 months later, patient underwent TVR/ MVR/ AVR cardiac surgery.
Physiologic hypervolemia of pregnancy predisposes women to pulmonary congestion, which is poorly tolerated by patients with preexisting pulmonary HTN. Labor and the early postpartum state puts these patients at the highest risk of hemodynamic catastrophe due to a significant increase of cardiac output secondary to autotransfusion from uterus contractions. Anxiety, pain, hypoxia, and hypercapnea are known to increase pulmonary pressure and should be avoided. We advocate for a pain free, stress free delivery; early CSE with intratechal morphine dose for prolonged analgesia and hemodynamic stability; strict titration of epidural infusion rate of local anesthetics; tight hemodynamic monitoring; continuous oxygen supplementation; avoidance of routine IV fluid use; and 24 h postpartum ICU monitoring. For achievement of these goals, discussion with all medial care teams must take place.