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Successful use of Epidural Anesthesia facilitated with Invasive monitoring (Pulmonary artery catheter and Arterial line) for cesarean delivery of a parturient in Sickle cell crisis and severe pulmonary Hypertension
Abstract Number: SA-74
Abstract Type: Case Report/Case Series
Parturients with Sickle Cell Disease (SCD) can have serious life-threatening sequelae that make the peripartum care very difficult. Pulmonary hypertension, thrombotic events and pain crises are the challenges places the parturient and fetus at risk for adverse events. We present a difficult case of a parturient with SCD developed severe pulmonary hypertension from chronic pulmonary emboli (PE) presenting for cesarean section was successfully managed with slow, controlled epidural anesthesia and pulmonary artery catheter (PA) for monitoring.
26 yr old G1P0 at 26w1d presented for urgent cesarean section due to severe IUGR with worsening fetal heart tone. Her past medical history includes SCD, pulmonary hypertension from chronic PE, lupus anticoagulant, asthma, OSA on CPAP, type 1 Diabetes, stage 2 renal failure. She is on 2L/min of O2 at home and therapeutic Lovenox for chronic PE and receives exchange transfusions every 3 weeks. Recent echocardiogram revealed moderate pulmonary hypertension (RVSP 66mmHg) with preserved right and left ventricle function. She has shortness of breath (NYHA III) and 3 pillow orthopnea with PND. For the last 8 days she was hospitalized for pain crisis, and dyspnea requiring 5L/min of O2. She received exchange transfusion and treated for pneumonia in the ICU. She was also started on oral sildenafil at 12.5 mg 3 times a day. With multidisciplinary team approach our plan was to do incremental dosing epidural anesthesia and PA catheter and arterial line for monitoring during cesarean delivery. PA catheter was placed prior going to the operating room which revealed PAP 54/18 with mean of 30 and A- line prior to epidural catheter placement. After a negative test dose, 2% Lidocaine was given in 3 cc increments every 5 minutes until T6 sensory level was obtained. C-section performed and viable infant was delivered. Mother remained hemodynamically stable throughout surgery and transferred to ICU for post op monitoring. She was discharged from ICU POD 2 and home on POD 7.
Peripartum management of parturients with severe SCD and pulmonary hypertension can be very challenging. We were able to successfully manage our patient with pre op placement of PA catheter and slow titration of epidural anesthesia. Monitoring the PA pressures helped us to manage the hemodynamic changes that occur during and immediate post- partum period when maternal mortality is at its highest. Multi-disciplinary team (Obstetrician, Hematologist and Cardiologist) approach helped us to have the best outcome when dealing with patients with complex disease.
1. Boga, C., Ozdogu, H., Pregnancy and sickle cell disease: A review of the current literature. Crit Rev Oncol/Hematol (2015),http://dx.doi.org/10.1016/j.critrevonc.2015.11.018.
2. Sahni S1, Palkar AV2, Rochelson BL3, Kępa W4, Talwar A5.Pregnancy and pulmonary arterial hypertension: A clinical conundrum.Pregnancy Hypertens. 2015 Apr;5(2):157-64.