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Pulmonary Hypertension and Instrumented Scoliosis in Pregnancy
Abstract Number: T 54
Abstract Type: Case Report/Case Series
Pulmonary hypertension may worsen during pregnancy due to cardiovascular and pulmonary changes, with recent reported mortality of 25-30%. Most studies report successful management of these patients with neuraxial anesthesia. We describe a parturient with instrumented scoliosis who presented with new onset severe pulmonary hypertension (pHTN) in the third trimester.
We present the case of a 28-year-old G1P0 parturient with history of repaired congenital diaphragmatic hernia, left lung hypoplasia, instrumented scoliosis, and released tethered cord. She presented at 37 weeks with a 2-week history of severe dyspnea and SpO2 85%. Pulmonary CT scan was negative for embolism. Echocardiogram revealed right ventricular dysfunction. Cardiac catheterization confirmed severe pHTN with mean PAP 56 mmHg (78/45).
Harrington rods from T2 to sacrum and tethered cord release precluded neuraxial anesthesia. With multidisciplinary team, elective cesarean delivery under general anesthesia with cardiac team and CPB on stand-by was planned. In addition to routine monitors, a 5-lead ECG, 16G intravenous, 20G arterial radial canula, and 7F right internal jugular cordis were placed. Baseline vitals were BP 132/81, HR 80-90, SpO2 95% 2L/min O2, with respiratory acidosis (pH 7.34, pCO2 63, pO2 152, HCO3 34), and haemoglobin (Hb) 117 g/L. Rapid sequence induction consisted of midazolam 1mg, fentanyl 150mcg, propofol 40mg, ketamine 40mg, and succinylcholine 140mg, maintaining hemodynamic stability. Three minutes after intubation, delivery occurred with concurrent blood loss of 600 ml. This resulted in hemodynamic instability lasting 60-90s with hypotension (SBP 60 mmHg), bradycardia (37-40 bpm) and CVP 2 mmHg. This was aggressively managed with IV ephedrine (25+25 mg), atropine 0.6 mg and 1L colloid volume resuscitation. Transesophageal echocardiogram determined normal right ventricular systolic function and CVP improved to 12 mmHg. The remainder of the intraoperative course was uneventful. The patient was transferred intubated, stable to cardiovascular intensive care (BP 135/65 mmHg, HR 75 bpm, SpO2 100% (FiO2 100%), Hb 78 g/L, mPAP 25 mmHg, CVP 10 mmHg).
Postpartum investigation revealed restrictive lung disease due to scoliosis and left lung hypoplasia, reversible obstructive lung disease, and nocturnal hypoventilation. She was discharged four weeks postpartum with fluticasone/salmeterol and home BiPAP with oxygen. Three-month follow-up showed clinical improvement and better saturation at rest (SpO2 94%).
This patient was previously asymptomatic and presented in late pregnancy with decompensated pHTN. Pregnant patients with pHTN poorly tolerate peri-partum fluid shifts. Mortality is four times higher in those who receive general anesthesia rather than neuraxial anesthesia. Neuraxial anesthesia was not possible and this highlights the importance of multidisciplinary management in these complex obstetric cases.
Eur heart 2009; 30: 256-65
Anesthesiology 2005; 102: 1133-7