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Management of a parturient with untreated WPW during cesarean section
Abstract Number: F-78
Abstract Type: Case Report/Case Series
A 37 year old G3P1 presented in labor for urgent cesarean section. She had a previous cesarean delivery and desired a repeat cesarean section. The patient’s past medical history was significant for Wolff-Parkinson-White Syndrome(WPW). The patient was diagnosed with WPW during her 7th month of pregnancy. At that time, she had an episode of palpitations and was brought to the emergency room. Her EKG revealed normal sinus rhythm with a WPW pattern. An echocardiogram showed an ejection fraction of 52% and was otherwise unremarkable. The cardiologist's recommendations was to avoid medication treatment at that time due to the pregnancy and then proceed with ablation during the postpartum period. The patient reported no further episodes of palpitations.
To avoid sudden hypotension and need for vasopressors, an epidural anesthetic was planned for the patient. A 1000 cc intravenous bolus of Lactated Ringers was administered. Anti-arrhythmic medications and a defibrillator were immediately available. After placing blood pressure, pulse oximetry and continuous EKG monitoring, an epidural catheter was placed uneventfully at L3-4. The catheter was injected with lidocaine 45 mg to test for a subarachnoid placement and 0.5ccs of air to rule out intravascular placement of the catheter. After a negative test dose was determined, the epidural catheter was bolused with 3% 2-chloroprocaine. Despite bolusing the catheter with 20 cc of 3% 2-chloroprocaine and 8 cc lidocaine 2% with 1:600K epinephrine, the patient’s sensory block remained at T9. The epidural catheter was then removed and another epidural catheter was placed with sterile technique at L2-3. After a negative test dose with lidocaine 45mg and 0.5cc air, the epidural catheter was then bolused with 5 cc of 3% 2-chloroprocaine. A bilateral T4 sensory block was obtained. A cesarean section proceeded uneventfully and a healthy infant was delivered. An oxytocin infusion (20 units/1000ml) was started at 200 cc/hr. The patient’s blood pressure and heart rate remained stable with no need for vasopressors or signs or symptoms of arrhythmia throughout the surgery and postoperative period.
Wolff-Parkinson-White Syndrome(WPW) accounts for most of the supraventricular tachycardia arrhythmias in women of reproductive age.(1) Because the commonly used medications to treat WPW cross the placenta and are only recommended for patients with severe symptoms or sustained arrhythmias(2), the WPW patients that present to labor and delivery are often untreated. We discuss our management of an untreated WPW parturient presenting for urgent cesarean section and review the perioperative goals and recommended anesthetic management.
(1)Palaria U, Rasheed M, Jain G, Sinha AK. Anesthetic management of Wolff-Parkinson-White syndrome in a patient posted for emergency caesarean section. Anesth Essays Res.7:408-410; 2013.
(2)Robins K, Lyons G. Supraventricular tachycardia in pregnancy. Br J Anaesth.92:140-3; 2004.