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Emergency Cesarean Delivery in a Patient with Severe Pulmonary Arterial Hypertension (PAH): A Major Dilemma
Abstract Number: S-22
Abstract Type: Case Report/Case Series
Pulmonary arterial hypertension (PAH) in pregnancy is associated with a prohibitive maternal mortality of 30-56% and thus, pregnancy is strongly discouraged in these patients. Physiologic pregnancy changes compound the compromised hemodynamic state in PAH. Although new advances in medical management of PAH offer improved prognosis, maternal mortality remains high. We describe the anesthetic management of a patient with severe PAH for emergency cesarean delivery.
A 25-year old (G3P1) female presented at 35 weeks gestation with progressive dyspnea at rest, and fetal tachycardia. Past medical history was significant for severe PAH (Echo: RVSP 96 mmHg, dilated PA, enlarged RV). Physical exam was notable for RR of 32 breaths/min, pan systolic murmur(TR), SpO2 of 91% on 10L O2. Her platelet count was 37,000/cmm, with active epoprostenol infusion. After consultation with a multi-disciplinary team, an emergent cesarean section with postoperative ICU care was planned. With a pre-induction arterial line and IABP 120/70, HR 120; cardiac index (CI) of 2.1 L/min/M2 (Edward FloTracTM) and epoprostenol infusion(1ng/kg/min), a rapid sequence induction with lidocaine, etomidate and succinylcholine was performed. After delivery of a viable male neonate with Apgar scores of 91 and 95 and initiation of oxytocin infusion, there was acute hypotension and marked drop in CI which responded to phenylephrine, ephedrine and slowing of oxytocin infusion. The hemodynamics were stabilized with loading dose of milrinone and patient was transferred sedated and intubated to the ICU, where her vital signs were stable and she was following commands. The first 16 hours in the ICU were uneventful except for vaginal bleeding which resolved with treatment. However, on POD 1, she had sudden desaturation and hypotension which prompted an increase in epoprostenol rate with addition of nitric oxide, dopamine and eventually norepinephrine. Despite aggressive therapy, the patient continued to deteriorate and finally succumbed on POD 3.
The majority of deaths among parturients with PAH occur in the peripartum period due to the exaggerated hemodynamic changes which may exacerbate pre-existing hypoxia, leading to further PA vasoconstriction, hypercarbia and acidosis with further increase in PAH and right-sided heart failure. This case demonstrates the challenging management in a patient with severe PAH that presented late in pregnancy with acute deterioration requiring an emergent cesarean section under general anesthesia, and subsequent demise in postoperative period. Although no one mode of delivery or type of anesthesia may be superior in these patients, the importance of early intensive monitoring and treatment during gestation with a multidisciplinary team and a controlled approach to delivery cannot be over emphasized.
1.Kiely D, et al. BJOG 2010;117(5):565-74.
2.Bonnin M, et al. Anesthesiology 2005;102(6):1133-37.