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Combined Spinal-Epidural Anesthesia for Vaginal Delivery in a Patient with Takayasu's Arteritis
Abstract Number: T-59
Abstract Type: Case Report/Case Series
Takayasu’s arteritis is a form of large vessel granulomatous arteritis that results in stenosis and aneurysms of the aorta, its branches, and the pulmonary arteries. It predominantly affects asian females, with onset between 15-30 years.
The course of the disease is generally unaffected by pregnancy, however these patients present unique anesthetic considerations that have thus far only been discussed in a few case reports. Evaluation of the extent of carotid involvement, cardiac function, and baseline blood pressure is necessary, but no consensus exists on the management of pain throughout the peripartum period.
A 27 yo G4P0 Asian female presented to University Hospital at 35 weeks gestation for anesthesia evaluation prior to planned vaginal delivery. She had been followed in the high-risk pregnancy clinic secondary to her severe Takayasu’s artertitis; all three of her prior pregnancies had resulted in spontaneous miscarriage.
Her rheumatologist at an outside facility had discontinued her prednisone, as she had not had an acute exacerbation in a few years. Her only current symptom was hip girdle claudication, which was stable. Nevertheless she was pulseless in three out of her four extremities; and non-invasive blood pressure monitoring was only possible on her left leg. The lumen of her infrarenal aorta was narrowed to 7 mm, with normal diameter being 12 +/- 1.6 mm. Additionally she had high grade stenosis of both common iliacs.
Given the risk of congestive heart failure in this disease, a cardiology consult was requested. Her transthoracic echo showed no evidence of heart failure or valvular abnormality, with a left ventricular ejection fraction of 62%.
At 37 weeks gestation, the patient presented in labor with an initial exam showing 3 cm dilation and effacement of 75 %, and a pain score of 6/10. A combined spinal-epidural was performed, with 25 mcg of fentanyl in the spinal and an infusion rate of 6 mL per hour of 0.1% bupivacaine with 3 mcg per mL of fentanyl. This brought her pain score from 10/10 immediately prior to the epidural to 0/10 immediately after. Her blood pressure changed from 145/90 to 125/60. Her baseline blood pressure was 120’s/70’s.
Her pain remained well controlled throughout her labor, and her systolic blood pressure ranged from the 110’s to 150’s. To avoid prolonged pushing, she had a vacuum assisted delivery that was devoid of complications.
Maintaining hemodynamic stability is the primary goal in these patients. Both hypotension and hypertension are poorly tolerated by both mother and fetus; cerebral and placental bloodflow are often compromised.
By combining an opioid spinal with a low infusion rate of epidural local anesthetic, we met this goal while also providing adequate pain control. Given the lack of consensus on management of this disorder in the peripartum period, this method could be utilized in the future to safely provide analgesia to similar patients