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Management of SVT in a Parturient with a Thyroid Goiter
Abstract Number: F-40
Abstract Type: Case Report/Case Series
29 years female a history of thyroid tumor, currently in euthyroid status, with tracheal deviation and s/p neck injury resulting in instrumentation and fusion of C3-4 and C4-5 cervical vertebrae, presented in active labor. Fetal heart rate decelerations were noted in triage, but recovered, and the patient was admitted to delivery room. The anesthesia team was consulted for placement of an epidural. On examination, the patient was noted to be tachycardic with a heart rate of 180 bpm and blood pressure of 105/65 mm of. Cardiology was consulted, and a STAT EKG was ordered. As the patient has a difficult airway and a high likelihood of needing a C-Section, the decision was made to place an epidural catheter for pain control. An epidural catheter was placed under aseptic pre-cautions and as the EKG was being obtained, it was slowly loaded with a solution of bupivacaine 0.1% and fentanyl 2mcg/mg, 3ml every 5 minutes to a total of 10ml. The patient had adequate pain relief, however, she continued to be tachycardic to 180s with blood pressure of 101/54. EKG (Figure1)was suggestive of AVnRT. Patient reported episodes of rapid heart rate which were relieved by Valsalva maneuver which did not relieve her tachycardia this time. The patient was successfully cardioverted, first with 6mg of adenosine and then with 12mg of adenosine IV. Later on, patient underwent an emergent C-Section for nonreassuring fetal heart rate under epidural anesthesia. An arterial line was inserted for close hemodynamic monitoring. Multiple doses of esmolol were administered for control of tachycardia. There were no further complications. She underwent catheter ablation after the delivery.
Pregnancy predisposes patients to tachyarrhythmias. As intravascular volume increases, so does the atrial and ventricular size, and an increase in the resting heart rate both of which may contribute to arrhythmogenesis. A-fib and AF can occur in pregnant women, however these are extremely rare and is usually associated with structural heart disease. Treatment guidelines for pregnant patient with SVT are the same as those for non-pregnant patients. As there is a paucity of large randomized trials looking at effects of anti-arrhythmogenic drugs on fetuses, the benefits of pharmacologic treatment must be weighed against the uncertain side effects. Therefore, only symptomatic SVTs are usually treated.
The decision to proceed with neuraxial anesthesia is a challenge since it is known to cause sympathectomy, vasodilation and a decrease in the preload and afterload; in the presence of a tachyarrhythmia with limited cardiac output, this may produce hemodynamic collapse. However, not proceeding with these measures can exacerbate tachyarrhythmia through increased adrenergic stimulation due to pain and leave the providers to deal with a difficult airway in a patient needing an emergency C-Section. Vigilance and careful monitoring are essential for optimal outcomes.