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"Cesarean Section in a Parturient with Cardiac Tamponade Physiology from Systemic Lupus Erythematosus"
Abstract Number: T 67
Abstract Type: Case Report/Case Series
INTRODUCTION: Cardiac tamponade is a rare but serious complication observed in patients with Systemic Lupus Erythematosus (SLE). In patients with SLE, the incidence of tamponade is reported to be between <1%-1.23%. (1,2) We present a case of anesthetic management of a parturient with tamponade requiring cesarean section.
CASE REPORT: A 19yo G2P1 at 30 weeks GA presented with a history of dyspnea and chest pain. The woman had a PMH significant for SLE with mostly skin and joint manifestations and asthma. She presented with anemia, an equivocal EKG, and CXR with cardiomegaly. TTE revealed a large pericardial effusion with early diastolic collapse of the right ventricle and exaggerated respiratory variation, suggestive of elevated intrapericardial pressure. The patient had stable vital signs but an exam consistent with tamponade. We discussed draining the effusion, but the posterior location would be technically challenging, and we were hesitant to use fluoroscopy in the parturient.
On hospital day 8, the parturient developed signs of severe preeclampsia. In a multidisciplinary consultation, the team decided to go to OR for delivery. The patient had a poor airway exam and limited neck extension. After establishing arterial line and two IVs pre-operatively, we placed an epidural catheter and carefully titrated ropivacaine 0.5%. The CT surgeon remained in the OR for possible emergent intervention. We used crystalloid and phenylephrine infusion to preserve hemodynamics. Vital signs were within acceptable ranges. Successful cesarean delivery was achieved without further intervention. Apgars were 8 and 8 at 1 and 5 minutes.
Postoperatively the patient’s course was complicated, but after several weeks the effusion resolved and she was discharged to home in stable condition on four new anti-hypertensives.
DISCUSSION: Cardiac tamponade in the setting of pregnancy presents an enormous challenge. Accepted goals in managing non-pregnant patients with tamponade physiology include maintaining preload and afterload, sinus rhythm, and avoidance of positive pressure ventilation (PPV) and bradycardia. Slow induction of surgical epidural anesthesia with an infusion of phenylephrine prevented the need for general anesthesia with PPV that may have led to cardiovascular collapse. While in the OR, cardiac anesthesia, CPB, and TEE remained on standby. There was no guarantee that epidural anesthesia would be successful, but we felt it was a better initial plan than inducing GA with the potential for airway issues and CV collapse. Although her early postpartum course was complicated, it is possible that early delivery and avoidance of GA prevented the need for drainage of her effusion.
1) Castier MB, et al. Cardiac tamponade in systemic lupus erythematosus. Report of four cases. Arg Bras Cardiol. 2000 Nov: 75(5):446-8.
2) Ketata W, et al. Postpartum pericardic tamponade revealing systemic lupus erythematosus. Rev Pneumol Clin. 2009 Oct: 65(5