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Obstetric Anesthetic Considerations for a Patient with a Fontan Repair of Tricuspid Atresia
Abstract Number: T-44
Abstract Type: Case Report/Case Series
Case Presentation: We present a 19yo nulliparous patient with a history of congenital tricuspid atresia/pulmonary atresia and hypoplastic right heart syndrome s/p Glenn procedure at 8 months of age followed by a lateral tunnel fenestrated Fontan baffle at 19 months of age who was referred to the Obstetric Anesthesiology service for consult early in her pregnancy. The patient was asymptomatic and was maintained on labetalol for prevention of hypertension. This patient's care was discussed at several multidisciplinary meetings including Obstetricians, Pediatricians/Neonatologists, Cardiologists, and Anesthesiologists all of whom had been involved in her prenatal care. At 18 weeks, an echo showed an unobstructed Fontan baffle into the pulmonary arteries, mild mitral regurgitation and normal left ventricular systolic function. An echo repeated at 32 weeks showed a mildly depressed LV systolic function.
Hospital Course: The patient presented to the Labor and Delivery Unit in active labor with spontaneous rupture of membranes. A Fetal Scalp Electrode was placed and the patient requested an epidural for labor analgesia. Labor analgesia was induced with subarachnoid fentanyl via combined spinal/epidural technique. An arterial line was placed and then the epidural catheter was bolused with 6ml of bupivacaine 0.25%. Shortly after obtaining an analgesic level the patient was fully dilated and after a very short second stage of labor delivered an infant with Apgars of 9 and 9. The patient remained on the Labor and Delivery Unit for 24 hours after delivery for continuous vital sign monitoring.
Discussion: Important considerations for a patient with a Fontan repair of a congenital heart defect include the high risk of congestive heart failure and atrial arrhythmias, the existing right to left shunt and the maintenance of CVP for passive lung perfusion. Our plan included avoiding abrupt changes in SVR/PVR, placing air traps on all IV lines, using a pediatric central venous catheter to avoid disruption of the existing repair and having furosemide and milrinone available for fluid overload and cardiac output support as needed. These patients are candidates for a vaginal delivery with early epidurals to avoid increasing catecholamines and pain mediated increases in SVR or PVR. The obstetricians planned for a predominantly passive second stage of labor with cesarean section reserved for obstetric indications. Management of postpartum hemorrhage can be difficult because methylergonovine and prostaglandin F2alpha should be avoided due to the increase in SVR and PVR respectively. During the postpartum period, these patients are at risk for congestive heart failure as the intravascular volume remains elevated while the parallel circuit of the placenta has been removed, potentially overwhelming the central circulation. Extensive multidisciplinary planning is required to ensure their care is carefully coordinated during the peripartum period.