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Successful use of Epidural Anesthesia for Cesarean Delivery in a Parturient with Unrepaired Coarctation of the Aorta and Post Ductal Aortic Aneurysm
Abstract Number: SU-06
Abstract Type: Case Report/Case Series
The number of parturients with congenital heart disease is growing, which presents unique challenges for the anesthesiologist. These patients normally do well, but during pregnancy there is increased risk to the mother and fetus. We present the successful use of slow controlled epidural anesthesia in a parturient with unrepaired coarctation of the aorta and post ductal aortic aneurysm (F) for cesarean delivery.
A 26-year-old G2P1 at 37 weeks gestation presents for primary cesarean section due to fetal malpresentation. She has a history of unrepaired coarctation of the aorta, chronic hypertension and asthma. Her first pregnancy was complicated by pre-eclampsia. The patient was referred to our hospital for palpitations during pregnancy and was found to have undiagnosed significant coarctation of the aorta associated with post ductal aneurysm (5x4cm). Our anesthetic plan was to do slow, controlled epidural for her cesarean delivery. Epidural was successfully placed at the L4/L5 level. Following a negative test dose, epidural catheter was dosed with 3cc of 2% Lidocaine with fentanyl every 5minutes till T6 level of analgesia was reached. A non-invasive blood pressure cuff was placed both in the right upper and lower extremity, and blood pressures were taken every 2 minutes. She had a successful cesarean delivery, resulting in a healthy female infant with Apgar of 7 and 9. 2 months after surgery she underwent repair of her coarctation of aorta and descending aortic aneurysm with cardiac bypass for distal arch augmentation and discharged home uneventfully.
Ninety percent of children with congenital heart disease survive into adulthood, due to advances in cardiothoracic surgery. It is crucial for anesthesiologist to understand the physiology of congenital heart disease during pregnancy to manage these patients for obstetric and non-cardiac surgeries. Our anesthetic goal in this parturient was to maintain hemodynamic stability by avoiding severe hypotension which will compromise the fetus because of the coarctation and to avoid hypertension which may rupture the aneurysm. Proceeding with slow dosing epidural anesthesia minimized the effect of the rapid sympathectomy associated with spinal anesthesia and avoided the hypertension associated with induction of general anesthesia. Slow dosing of epidural anesthesia allowed us to keep the patient hemodynamically stable and successfully manage this complex patient.