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Point of Care Transthoracic Echocardiography for Peripartum Hypotension
Abstract Number: SA-68
Abstract Type: Case Report/Case Series
Introduction: Hypotension following epidural placement is a common clinical scenario encountered in the obstetric population. Sympathectomy resulting in decreased vascular tone is the primary etiology. Hypotension in this setting is commonly managed with intravenous fluids (IVF) and vasopressors. We report a case of post-epidural hypotension refractory to IVF and vasopressors and the usefulness of point of care (POC) echocardiography in its management.
Case: A 35-year-old parturient (G4P3) at 41 weeks of gestational age with no significant past medical history was admitted to the labor and delivery floor for induction of labor. The patient was noted to have an episode of variable decelerations. On day 2, a lumbar epidural at L3-4 level was placed without any complications. Three boluses of 5 mL of a mixture of 0.125% bupivacaine with 2 mcg/mL fentanyl were administered over 15 minutes, and an infusion was continued at the rate of 6 mL/h. The baseline systolic blood pressure (SBP) was noted to be around 110mmHg. Minutes after the last bolus, the patient became comfortable; however, the SBP was noted to be in the 90s mmHg which was treated with 1L IVF and intermittent doses of vasopressors. One hour after the epidural, late decelerations were noted and the anesthesia team was called for evaluation. SBPs were noted be 80s-90s mmHg . At this time, oxytocin infusion was stopped by the obstetric team. Given the persistent hypotension despite fluid bolus and vasopressors, a POC bedside transthoracic echocardiogram (TTE) was performed to evaluate volume status. The TTE was notable for preserved left ventricular function, well filled ventricles, and the absence of inferior vena cava (IVC) respiratory variations. At this time, the decision was made to not administer additional IVF and to treat with vasopressors. The blood pressure returned to baseline shortly thereafter as well as a reassuring fetal heart tracing. Oxytocin was subsequently resumed at a lower dose. The patient was surgically delivered 12 hours later for recurrent decelerations.
Discussion: With advances in image quality and availability, ultrasound has now become ubiquitous in clinical practice. It is a valuable tool that can be used to evaluate cardiac parameters such as systolic function, valvular function, volume status via left ventricular end diastolic volume and IVC fullness. We have presented a case of persistent hypotension in a parturient with an epidural. The POC TTE allowed us to rule out life threatening pathologies through an efficient and non-invasive modality. It also facilitated in tailoring the clinical management of such patients with intriguing clinical presentations by sparing them from unnecessary treatment with additional IVF. POC TTE can be be used to better manage common clinical scenarios like this encountered by the obstetric anesthesiologist.
Lee A. Semin Perinatol 2014;38(6):349-58.
Khasawneh FA, Smalligan ED. Postgrad Med 2010;122(3):230-7.