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Desaturation after Cesarean Delivery in a Parturient with a Single Ventricle
Abstract Number: F-17
Abstract Type: Case Report/Case Series
A 23 year old G2P0010 presented for anesthesia preoperative evaluation due to a history of hypoplastic right ventricle, tricuspid valve atresia, and pulmonary valve atresia. After several congenital heart surgeries, she had a bidirectional Glenn Shunt (superior vena cava venous return directly to pulmonary artery) and a Fontan palliation (conduit from inferior vena cava directly to pulmonary artery). At 22 weeks gestation, her EF was 40%. A multidisciplinary meeting with her obstetrician, obstetric anesthesiologists, a pediatric cardiac anesthesiologist, and a pediatric cardiothoracic surgeon determined that although she was medically managed and asymptomatic throughout her pregnancy, if she were to present in spontaneous labor or need emergency cesarean delivery, the subspecialists needed for her care would not necessarily be immediately available. Therefore, an elective cesarean delivery at 37 weeks gestation was planned.
The case was performed in a cardiac operating room with a pediatric cardiac surgeon and perfusionist on standby. A pediatric cardiac anesthesiologist and obstetric anesthesiologist were present during surgery. An arterial line was placed prior to neuraxial anesthesia. A neuraxial technique was elected for anesthesia to maintain hemodynamic stability. An epidural catheter was placed and 2% lidocaine was dosed slowly until an adequate anesthetic level was obtained. The patient’s blood pressure remained stable throughout epidural dosing, surgery, and delivery. Transesophageal echocardiogram was available if the patient were to decompensate.
During closure, the patient began to complain of nasal congestion and began to sneeze uncontrollably. She was initially stable but then began to desaturate to the low 90s. She was promptly given supplemental oxygen, furosemide, and her head was elevated. The symptoms resolved. Her postoperative course was uncomplicated and she was discharged on postoperative day 3.
Due to the widespread success of pediatric cardiac surgery, the prevalence of parturients with prior corrective cardiac surgery for congenital heart disease is increasing. In 2000, 49% of people living in the United States with severe congenital heart disease were adults, and 57% of adults with severe congenital heart disease were women.1 Understanding both the congenital heart defect as well as the palliative correction, and the resultant influences on blood flow, preload and afterload, is essential to the care of these patients during delivery and in the postpartum period. Neuraxial techniques have been successfully performed for cesarean delivery for parturients with single ventricles when done judiciously.2 Evaluation of the patient early in gestation, as well as multidisciplinary planning among subspecialists, is essential in providing safe and successful patient care.
1. Marelli, et al. Circulation. 2007;115:163-72.
2. Koraki E, et al. Eur J Anaesthesiol. 2009;26:788-90.