Urgent Cesarean Section in a Single Ventricle Parturient
Abstract Number: T 61
Abstract Type: Case Report/Case Series
Increasing numbers of children with congenital heart disease (CHD) are surviving to adulthood. Resultantly, they are presenting to the operating room for non-cardiac surgeries at increasing
rates—obstetrical procedures not being excluded.
We present the case of a 22 year old G1P0 diabetic female at 36 weeks gestational age who presented in labor in need of an urgent cesarean section due to variable decelerations seen on fetal heart tracing. Additionally, the parturient had been born with a single ventricle and congenital pulmonary atresia which was previously surgically corrected. After having a bidirectional cavo-pulmonary shunt (Glenn procedure) at age 1 followed by a complete Fontan operation at age 4, her cardiac output was heavily dependent upon elevated CVP and preload. With coexisting moderate ventricular dysfunction, she was a NYHA Class 1 controlled with furosemide, spironolactone, and digoxin prior to and during pregnancy. A developmental delay in the patient further complicated her peripartum care. An arterial line was placed pre-operatively and IV access was obtained via two peripheral veins. Due to the urgency of the cesarean section and the lack of heart failure symptoms in the parturient, a central line was not placed pre-operatively. However, necessary equipment including an ultrasound for central line placement was checked and made available if central access became necessary. A cardiac anesthesiologist with TEE experience was available to assist with cardiac monitoring if necessary. An epidural catheter was placed in the OR without difficulty. A sensory level to T4 was accomplished via slow titration of 2% lidocaine and fentanyl with careful monitoring of the parturients vital signs and with administration of IV fluids as necessary. No significant hemodynamic instability developed with our neuraxial technique. However, following delivery of the fetus, the patient developed hypertension with autotransfusion followed by moderate hypotension, bigeminy, and multiple PVC's secondary to increased preload in concordance with her pre-existing ventricular dysfunction. Since the uterine tone was adequate, oxytocin infusion (20 units/L in LR) was transiently stopped with improvement in her hypotension. The dysrhythmias continued, however, and she was transferred to the ICU for postoperative monitoring.
In patients with single ventricle CHD with previous surgical palliation, epidural anesthesia can be safely administered with slow titration and without detrimental effects to mother or fetus. Because of the hemodynamic alterations associated with delivery and the potential associated problems such as dysrhythmias, tachycardia, pulmonary edema, hemorrhage, and embolism, peripartum care should be managed in a multidisciplinary ICU setting. In a parturient with more symptomatic heart failure, general anesthesia with intensive intraoperative monitoring such as TEE and central access with continual measuring of CVP would be beneficial.