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Anesthetic Management of A Parturient With Wolff-Parkinson-White Syndrome (WPWS) With History of Two Cardiac Arrests with Two Previous Pregnancies
Abstract Number: S-07
Abstract Type: Case Report/Case Series
Wolff–Parkinson–White syndrome (WPWS) is a pre-excitation reentrant arrhythmia caused by an aberrant conduction pathway between atria and ventricles (bundle of Kent), bypassing the normal atrioventricular (AV) conduction predisposing patients to supraventricular tachycardia, atrial fibrillation and ventricular fibrillation. As anesthetic drugs and techniques influence the physiology of AV conduction, perioperative management of WPWS is challenging. We present the successful anesthetic management of a patient with WPWS who presented in active labor with history of two previous cardiac arrests.
A 30-year old gravida 3 para 1 female presented in active labor at 40 weeks gestation and anesthesiology was consulted for labor analgesia. Past medical history was significant for WPWS diagnosed after cardiac arrest at 32nd week of her first pregnancy ten years ago, following which she underwent ablation. Four years ago, she had a second cardiac arrest secondary to hypotension from excessive vaginal bleeding from spontaneous abortion. The patient was asymptomatic at time of presentation, although she had intermittent palpitations and syncopal episodes earlier in pregnancy. Physical examination was unremarkable with regular heart rate of 66/min, NIBP 128/66 mmHg. EKG revealed short PR interval, wide QRS duration, delta waves, premature atrial complexes. 2D Echocardiogram showed normal right and left heart function with LVEF (65%). Avoiding tachycardia was pivotal and labor analgesia with combined spinal-epidural (CSE) early in labor was planned. A defibrillator, crash cart with cardiac medications (procainamide, adenosine, diltiazem, amiodarone, lidocaine, ionotropes) and telemetric EKG monitoring was made available in the labor room. A CSE was successfully performed with 25mcg intrathecal fentanyl followed by patient-controlled epidural analgesia with epidural infusion of 0.1% bupivacaine, 2mcg/ml of fentanyl at 6ml/hour with 5ml bolus every 20 minutes. Anesthetic principles involved avoidance of epinephrine containing solutions and AV nodal blocking agents throughout the labor. The patient had an uneventful vaginal delivery 3 hours later requiring only one epidural bolus dose. She was monitored for post-partum hemorrhage and off telemetric monitoring 30 hours post-delivery with stable vital signs and discharged on the second postpartum day.
The anesthetic goal in perioperative management of WPWS is to circumvent any factor that increases sympathetic activity such as pain, anxiety, stress response, and hypovolemia. The CSE in this patient ensured reliable, rapid onset, and prolonged analgesia with stable hemodynamics throughout labor. The emphasis on thorough preoperative evaluation, meticulous intraoperative monitoring for arrhythmias, and preparedness to manage untoward incidents cannot be overstressed.
1.Liu A, et al. BMJ case rep.2011:1-4
2.Sahu S, et al. Ind J Anes.2011;55(4):378-80