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Cesarean Delivery in Mothers with Corrected Transposition of the Great Arteries: Is a Code Cart Available?
Abstract Number: SU-40
Abstract Type: Case Report/Case Series
Congenital transposition of the great arteries (TGA) confers >90% risk of mortality in the first year of life without corrective surgery. Two procedures are used for correction: intra-atrial baffle (atrial switch) and arterial switch. Atrial switch baffles oxygenated blood to the right ventricle, which becomes the systemic ventricle, leading to potential right (systemic) heart failure, arrhythmias, and baffle leaks. The newer arterial switch procedure transposes aortic and pulmonary trunks, and reimplants coronary arteries, to establish normal circulation. This procedure risks aortic root dilation, aortic regurgitation, and early coronary artery disease. We present anesthetic management of cesarean delivery (CD) in 3 parturients with corrected TGA.
Case details are tabulated (chart). Patient #1 developed a prolonged fetal heart rate deceleration during induction of labor, prompting a stat CD. Immediately after delivery, the mother had an episode of bradycardia with hypotension (nadir 98/52, HR 39), treated with incremental epinephrine doses (70 mcg total). Postoperatively she had persistent episodes of bradycardia, and is now being evaluated for a pacemaker. Patient #2 presented with bleeding placenta previa with abruption and underwent urgent, uneventful CD with spinal anesthesia. Patient #3 underwent scheduled CD with epidural anesthesia, after failed combined spinal/epidural anesthesia. As with patient #1, she too had immediate post-delivery bradycardia and hypotension, but much more severe (nadir 28/13, HR 8). Carotid pulse and a-line tracing were lost transiently, and epinephrine 50 mcg was administered. Just before initiating chest compressions, return of spontaneous circulation occurred. She recovered uneventfully in the cardiac intensive care unit.
Few studies have compared pregnancy outcomes between atrial and arterial switch operations. Although arterial switch has replaced atrial switch as the corrective surgery of choice, a generation of atrial switch patients are now presenting with pregnancy. This small series demonstrates the risk of acute decompensation in atrial switch patients, with potential RV (systemic) failure immediately after delivery. Full preparation for treatment of cardiovascular collapse is warranted. A multidisciplinary team approach (including Cardiology) to planning is recommended.
Guédès Am Coll Cardiol 2004;44:433
Tobler Am J Cardiol 2010;106:417
Metz AJOG 2011;205:273.e1