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Successful Use of Combined Spinal and Epidural Anesthesia for Intra uterine fetal Thoracentesis due to Evolving Pleural Effusion and Repeat Cesarean Delivery Complicated by Fetal AV Canal Defect with Fixed Bradycardia requiring External Pacing immediately
Abstract Number: SU-07
Abstract Type: Case Report/Case Series
The number of high risk parturients we encounter is on the rise. Advances in invasive intra uterine fetal procedures pose a new challenge to the anesthesiologist. We presents a case of successful use of combined spinal and epidural anesthesia (CSE) for intra uterine fetal thoracentesis due to rapidly evolving pleural effusion (F) and repeat cesarean delivery of an infant with known fetal heterotaxy syndrome with AV canal defect and fixed fetal bradycardia requiring external pacing immediately after delivery.
A 24-year-old G3P2 parturient with previous 2 cesarean section at 30 3/7 weeks gestation presents for repeat cesarean delivery as the baby has multiple cardiac congenital anomalies as a result of fetal heterotaxy syndrome (Left Atrial isomerism, AV canal defect with fixed bradycardia and a heart rate ranging from 40-55, dextro transposition, interrupted IVC with Azygous continuation) with rapidly evolving large right pleural effusion. The baby required external pacing immediately after delivery. The surgical plan was to perform intra uterine fetal thoracocentesis followed by C-section, for effective pacing and ventilation of the infant post-delivery. Our anesthetic plan was to place CSE for this combined procedure. CSE was placed at the L4/L5 level and 12 mg of 0.75% bupivacaine, 20 mcg of fentanyl and 100 mcg of morphine was initially injected into the intrathecal space. The fetus was paralyzed with 160 mcg of vecuronium for thoracentesis resulting in the removal of 30 mL of pleural fluid. Cesarean delivery was performed and baby was handed to the pediatric team. Immediate external pacing was commenced secondary to fixed fetal bradycardia. Since the procedure finished in 1hr 20 minutes, there was no need for re-dosing. The patient was discharged on post-op day 3. The infant remained in the neonatal intensive care unit status-post permanent pacemaker, and awaiting corrective surgery.
As the field of maternal fetal medicine advances, parturients present with a number of rare and complicated fetal anomalies resulting in a plethora of invasive procedures. Epidural, CSE or continuous spinal are the preferred techniques, as repeat dosing is often necessary for intra uterine fetal procedures combined with repeat C-section. In this case we choose to place CSE as the best option for mother and infant.