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///2016 Abstract Details
2016 Abstract Details2019-07-15T10:10:51-05:00

Cesarean Section and Congenital Pulmonary Artery Stenosis: A Case Report of the Anesthetic Management

Abstract Number: SU-69
Abstract Type: Case Report/Case Series

Ryan M Noska M.D., B.S.1 ; Andrea Girnius M.D.2; Lesley Gilbertson M.D.3

Pulmonary hypertension (PH) in pregnancy can compromise the health of both mother and fetus. Despite advances in medical therapy, reported maternal mortality is 30-56%. (1) Patients with PH are often counseled against pregnancy given this high mortality risk. We present the case of a pregnant woman with congenital pulmonary artery stenosis and pulmonary hypertension. A 22 year-old G2P1 presented with a history of congenital bilateral branch pulmonary artery stenosis. She had stenting of her right and left PA as a child with residual stenosis of the LPA. Her first pregnancy was complicated by symptomatic increased right ventricular systolic pressure (RVSP) requiring IV treprostinil. She delivered by c-section at 37 weeks under epidural anesthesia without complications. During her second pregnancy, she remained asymptomatic but her RVSP increased throughout the pregnancy. She was electively admitted at 34 weeks for medical optimization with IV epoprostenol. Admission echocardiogram revealed LVEF of 65-70%, RVH, RVSP 70 mmHg, and normal RV function. After optimization, she had a cesarean section under combined spinal-epidural (CSE). She received intrathecal opioids (15 mcg fentanyl and 0.2 mg morphine). Her epidural was dosed incrementally with 2% lidocaine with 1:200,00 epinephrine and bicarbonate. An arterial line and central line were placed for monitoring. During surgery, she was hemodynamically stable, required no vasoactive medications and had approximately 600 cc of blood loss. She received TAP blocks for post-operative analgesia. She was transferred back to the ICU in stable condition. Management goals for PH patients include avoiding hypercarbia, hypoxia, acidosis, and fluid overload. After delivery, large fluid shifts may cause right heart failure and decreased cardiac output. Uteroplacental blood flow shifts to the intravascular space, causing an increase in both cardiac output and stroke volume. (1)There is a high potential for decompensation at this point. Hemodynamic effects of the chosen anesthetic technique should be carefully considered. Risks of spinal anesthesia include decreased preload and hypotension. Epidural or CSE allow careful titration of the anesthetic level and provide excellent anesthesia.(2) General anesthesia can depress cardiac contractility and increase pulmonary vascular resistance, leading to increased pulmonary artery pressure. (3) Extracorporeal membrane oxygenation (ECMO) is proposed as an option in a decompensated mother, but evidence is limited. Medical therapies include prostacyclin analogs, inhaled nitric oxide, Bosentan, and PDE-5 inhibitors. We describe a c-section performed with a high-risk maternal co-morbidity. With careful titration of anesthetic and appropriate hemodynamic monitoring, these patients can be successfully managed during c-section.

1.Obican et al. Semin Perinatol 2014;38:289-94

2.Bonnin M et al. Anesthesiology 2005;102:1133-7

3.Bedard E et al. European Heart Journal 2008;30:256-265

SOAP 2016