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Goal Directed Therapy in a Parturient with Double Outlet Right Ventricle for a Vaginal Delivery
Abstract Number: T-69
Abstract Type: Case Report/Case Series
Double outlet right ventricle (DORV) is a rare congenital heart disease accounting for less than 1% of congenital heart defects. It is even rarer to encounter a patient without palliative surgical procedure in the obstetric population. We report successful management of a parturient with DORV during vaginal delivery.
A 30 year old G3P1101 with a DORV and mild pulmonary stenosis had induction of labor at 33(6/7) weeks due to headaches, vomiting, epigastric pain and increasing transaminases. Two previous vaginal deliveries were uncomplicated. Magnetic resonance imaging (MRI) of the chest showed dextrocardia with situs ambiguous, inversion of the origin and position of aorta and pulmonary artery, mild pulmonary stenosis, a large subaortic VSD with left to right shunt (L to R). Flow calculations on MRI showed a pulmonary to systemic blood flow ratio (Qp:Qs) of 2.5. Her SpO2 was 80% on room air.
A multidisciplinary team of MFM, obstetrics, obstetric and cardiovascular anesthesiology and adult congenital heart disease experts managed the peripartum patient care. A right radial arterial catheter was placed and connected to a pulse contour cardiac output monitoring device. The left Internal Jugular vein was cannulated with an oximetric catheter and the central venous oxygen saturation (ScvO2) was monitored. Oxygen delivery was titrated with an air-oxygen blender via a nasal cannula to avoid pulmonary vasodilation. A combined spinal-epidural (CSE) was performed for labor analgesia. Intrathecal narcotics alone were used during early first stage of labor. Analgesia during the late first stage was achieved with an epidural infusion of 0.125% bupivacaine with 2 mcg/ml of fentanyl. An intravenous phenylephrine infusion was titrated to maintain blood pressure at baseline to counteract the sympathectomy from the epidural infusion.
A male neonate was delivered and estimated blood loss was 900 ml. The ScvO2 decreased from a baseline of 83 to 76%, concurrent with the decreased cardiac output (CO). An appropriate response of increased ScvO2 and CO was seen with transfusion of packed red blood cells (PRBCs).
The successful management of this complicated patient warranted the collaborative efforts of a multi-disciplinary team. The consensus goals were to prevent PVR and SVR changes to maintain enough pulmonary blood flow to oxygenate, but to prevent increases in pulmonary blood flow that would lead to pulmonary edema and congestive heart failure. The oxygen supplementation was used cautiously in this patient as pulmonary vasodilation could worsen the L to R shunt decreasing systemic circulation and the utero-placental blood flow. Good outcome was achieved with the judicious use of CSE. Real time hemodynamic monitoring with pulse contour cardiac output and ScvO2 guided the therapy. We were able to provide early intervention via careful titration of IV fluids, vasoactive agents, cautious supplemental oxygen and PRBCs.
Ref:E Lockhart et al;Anesthesiology 1999;90(1213-5)