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Cesarean Delivery after Bilateral Orthotropic Lung Transplant and Acute Rejection
Abstract Number: SA-77
Abstract Type: Case Report/Case Series
Introduction: Management of a parturient with cystic fibrosis and a history of bilateral lung transplant poses unique challenges to the obstetric anesthesiologist.
A 26 year old G1 was referred for anesthesia consultation at 36 weeks gestation with past medical history significant for cystic fibrosis s/p a bilateral orthotropic lung transplant. She had 1 episode of acute rejection in the past year; chronic CMV infection, a history of pseudomonas aeruginosa infection, poorly controlled diabetes, chronic hypertension, chronic kidney disease stage 1, and anemia. Pulmonary function tests were stable, FEV1/FEV 84 and FEF 25-75% 2.38. A recent bronchoscopy revealed well healed anastomosis sites with moderate narrowing of the right main bronchus. Echocardiogram revealed normal LVEF and good ventricular function. The patient refused vaginal delivery despite counseling about the risks of cesarean delivery and insisted on receiving a general anesthetic (GA) for the procedure. She received extensive counseling from the anesthesia team about risks of GA in all parturients, in addition to the extra risks specific to her condition including aspiration, infection and problems with mechanical ventilation. The patient then agreed to neuraxial anesthesia only if sedated. For her cesarean delivery, five 4mcg boluses of dexmedetomidine were given for anxiolysis. A combined spinal epidural was placed using 12mg of hyperbaric bupivacaine with 15mcg fentanyl and 150mcg morphine. A phenylephrine infusion was used for hemodynamic support. The cesarean delivery proceeded uneventfully. Apgar scores were 7 and 9.
GA was purposely avoided in this parturient. Her condition escalated the risk of aspiration secondary to pancreatic dysfunction, poorly controlled diabetes and gastric atony.  Pneumonia after endotracheal intubation is feared in the immunosuppressed. Ventilation can be challenging in transplanted lungs and barotrauma, bronchospasm, volume overload and postoperative atelectasis should be anticipated. Anorexia from malabsorption and chronic adrenal suppression causes difficulty in extubation and prolonged ventilation. Due to severe anxiety, sedation was needed for block placement. We chose dexmedetomidine since it has been shown to provide analgesia and anxiolysis while maintaining respiratory drive . The use of neuraxial anesthesia with dexmedetomidine sedation allowed for successful management of this challenging parturient.
1. Ahluwalia, M., et al., Cystic fibrosis and pregnancy in the modern era: a case control study. J Cyst Fibros, 2014. 13(1): p. 69-73.
2. Goneppanavar, U., et al., Intravenous Dexmedetomidine Provides Superior Patient Comfort and Tolerance Compared to Intravenous Midazolam in Patients Undergoing Flexible Bronchoscopy. Pulm Med, 2015. 2015: p. 727530.