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Severe Hemodynamic Instability from Aortocaval Compression in a Parturient with Marfan Syndrome
Abstract Number: S-57
Abstract Type: Case Report/Case Series
Introduction: Marfan Syndrome (MFS) in pregnancy is associated with potential challenges for the anesthesiologist including aortic root dilatation, scoliosis and lumbosacral dural ectasia.1 We report a case of severe hemodynamic instability from aortocaval compression after combined spinal-epidural anesthesia (CSE) in a parturient with ascending and descending aortic grafting due to MFS.
Case: A 35 year old G2P1 at 36w6d presenting for cesarean delivery with MFS, hypertension and severe scoliosis. She is status post graft repair of the entire descending aorta and right iliac artery due to Type B dissection followed by valve-sparing root replacement of the ascending aorta. Recent echocardiogram revealed stable grafts and an ejection fraction of 45% with a 4.6 cm native aortic root. Following arterial line and large bore intravenous placement, a CSE technique was performed using 3.5 mg of hyperbaric bupivacaine with fentanyl and morphine in the sitting position with BP 173/80 and HR 72. The epidural was dosed incrementally with 2% lidocaine with epinephrine with the patient in left uterine displacement (LUD) position. Bilateral anesthetic level could not be achieved while SBP fell into the 90’s with normal HR. With reseating for epidural placement SBP increased dramatically to 180-190. Following epidural replacement and LUD positioning, severe hypotension (40’s/20’s,) bradycardia (30’s) and obtundation occurred despite steep LUD and vasopressors. With prompt placement in full left lateral decubitus (LLD) position, hemodynamics and mental status resolved completely. Following induction of general anesthesia, cesarean delivery of a healthy infant was performed in LLD position. Immediately postoperatively, hypertension was treated with esmolol drip.
Discussion: Supine Hypotension Syndrome occurs in 15% of women at term.2 Caval and aortic compression typically occur at < 15% and 35% tilt respectively. Manual uterine displacement or full LLD position will prevent compression.3 In this case, we suspect the graft in conjunction with differences in vascular wall tone contributed to severe compression.
1. Cardiology in Review 2009; Volume 17, Number 6 (Goland et al)
2. Obstetric Anesthesia (Chestnut)
3. Anesthesia Intensive Care 2008; 36: 775-777. (Paech)