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Extracorporeal Life Support for Anticipated Right Heart Failure at Cesarean Delivery in a Parturient with Severe Pulmonary Arterial Hypertension
Abstract Number: T-45
Abstract Type: Case Report/Case Series
Introduction: Pulmonary hypertension can lead to significant morbidity and mortality in parturients and management during delivery is both difficult and controversial. We report a case of a parturient with severe pulmonary hypertension who had a complicated peripartum course requiring extracorporeal life support (ECLS).
Case Description: A 35-year-old Para 1001 at 37.1 weeks gestation was admitted after a new diagnosis of severe pulmonary hypertension detected by echocardiogram performed for a heart murmur on exam. As a non-English speaking refugee from East Africa, she had limited prenatal care. Right heart catheterization revealed a pulmonary artery pressure of 106/35 (62) mmHg. IV epoprostenol was started and uptitrated over 6 days, which she tolerated well. A multidisciplinary planning group agreed on a scheduled cesarean delivery.
The patient was brought to the operating room where an arterial line was placed followed by an epidural catheter. Epidural anesthesia was initiated via slow titration of local anesthetics with vasopressor use (maximum vasopressin 0.04 U/min, norepinepherine 0.05 mcg/kg/min) to maintain hemodynamic stability. Prior to incision, cardiac surgeons placed femoral arterial and central venous lines in case ECLS was required. The surgery proceeded uneventfully with delivery of a healthy infant. Immediately after delivery of the placenta, the patient had sudden hemodynamic collapse. General anesthesia was emergently induced and the patient was intubated while simultaneously being placed on veno-arterial ECMO. Intraoperative TEE showed biventricular failure with an EF of 10%. She stabilized on ECMO with vasopressor support. Over the next 3 days, she was able to be weaned from vasoactive agents, decannulated and extubated. Her hospitalization was complicated by a DVT, but she continued to progress and was discharged on postoperative day 30.
Two months postpartum, she remained on vasodilator therapy with treprostonil. Echocardiography revealed normal biventricular function and a right ventricular systolic pressure of 90 mmHg. After a thorough workup, the cause of her pulmonary hypertension remains unclear.
Discussion: Due to a high mortality rate, women with pulmonary hypertension are generally counseled against pregnancy. The optimal mode of delivery and anesthesia are debatable. In this case, ECMO was used to emergently stabilize a patient with severe pulmonary arterial hypertension who decompensated during cesarean section. The autotransfusion of blood that occurs after delivery likely led to right heart failure precipitating hemodynamic collapse. Despite this, the extensive preparation by a multidisciplinary team enabled a rapid response to her deterioration and a favorable outcome.
Reference: Maxwell BG, El-Sayed YY, Carvalho B. Peripartum outcomes and anaesthetic management of parturients with moderate to complex congenital heart disease or pulmonary hypertension. Anaesthesia. 2013 Jan;68(1):52-9.