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Anesthetic Management for Cesarean Delivery in a Parturient with Severe Dilated Cardiomyopathy: A Case Report
Abstract Number: S-06
Abstract Type: Case Report/Case Series
Introduction: Significant physiologic changes in CV system during pregnancy may lead to cardiac decompensation, arrhythmia and maternal death in those with limited cardiac reserve.1 We present a case of anesthetic management for cesarean delivery (CD) in such a patient.
Case: A 44 yr-old G4P1, immigrant from Mongolia was referred at 36 wks due to worsening heart failure (HF). She had been diagnosed with DCM (EF<30%) at OSH, 2 wks prior to referral. Her HF was diagnosed in Mongolia 10 yrs ago, on metoprolol and furosemide then. She became non-compliant and came to the U.S. She had primary CD 5 yrs ago under spinal anesthesia at 37 wks. During current pregnancy, she developed chest pain at 34 wks, which prompted echo to show EF <30 % and severe global hypokinesis. She was started on heparin and referred to us. On admission, she was NYHA class III, and echo showed DCM with EF <30% and mod MR. ECG showed NSR with LBBB. She was given furosemide for 2 days and taken to the OR for repeat CD. Preop Hgb was 12 gm%. A-line and PA catheter were placed preoperatively. Vitals were BP 125/80 mmHg, HR 98/min, RR 20/min, SpO2 95% (RA), PAP 32/18 mmHg. Sequential combined spinal-epidural (CSE) anesthesia was administered at L3-4 with initial spinal doses of hyper-baric bupivacaine 4.5 mg, fentanyl 20 mcg and PF-morphine 200 mcg. Dobutamine was started. Sensory level was slowly increased to T4 in next 30 min with epidural lidocaine 2% total 7 ml, after test dose. Her BP was stable with dobutamine, which was stopped 40 min after delivery. Furosemide 10 mg was given at immediate pp. Oxytocin infusion (40 U/L) was started to facilitate uterine contraction. Surgical duration was 1hr 55min. Total IVF was 1.8L, EBL 850 ml and u/o 650 ml. She was transferred to CCU. She had uneventful recovery and underwent cardiac catherization on POD#5, which showed EF 20% and no CAD. She was discharged home on POD #6 in stable condition with medications including enalapril, furosemide, metoprolol and albuterol. Her cardiac function continued to deteriorate and BIV-ICD was implanted at 3 mo pp.
Discussion: Among pregnant women with DCM, cardiac complication is most considerable, approaching 65%, in women with moderate or severe LV dysfunction and/or NYHA functional class III or IV.2 Early medical intervention leads to better maternal and fetal outcome in these patients.3 Management principles are to reduce preload and afterload, and to increase myocardial contractility. Invasive hemodynamic monitoring helps guide fluid management, measurement of cardiac parameters and administration of inotropes. Judicious use of neuraxial anesthesia has been increasingly reported in these patients.4-6 Sequential CSE anesthesia is most suitable due to its solid quality, slow titration, and low incidence of PDPH.
References: 1. Heart 2009;95:680-6 2. J Am Coll Cardiol 2010;55:45-52 3. Arch Gynecol Obstet 2013;287:195-9 4. IJOA 2000;9:189-92 5. IJOA 2007;16:68-73 6. Masui. 2008; 57:187-900