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MANAGEMENT OF PULMONARY HYPERTENSION IN PREGNANCY USING NITRIC OXIDE
Abstract Number: SU-70
Abstract Type: Case Report/Case Series
CASE PRESENTATION: A 26 y/o G3P1011 at 36w2d with medical history significant for HFpEF, sickle cell disease, HIV, and pulmonary hypertension (pHTN) presented with diffuse pain typical of a vaso-occlusive crisis; and worsening dyspnea concerning for heart failure exacerbation. A CT chest PE protocol ruled out pulmonary embolus, but noted enlargement of the pulmonary artery. A TTE done on admission estimated RVSP of 62mmHg with an enlarged RV. The patient was started on inhaled nitric oxide (NO) at 40 ppm via NC. A diagnostic right heart catheterization (RHC) was done while the patient was on NO the following day showing moderate pHTN with mean PAP of 41mmHg. The patient’s hospital course was also complicated by preeclampsia without severe features, with delivery planned once the patient was medically optimized. Given results of the RHC, the decision to proceed with a planned C-section was made.
The patient was transported to the OR with NO at 40ppm, which was continued throughout the case. A right IJ cordis with a continuous cardiac output Swan–Ganz catheter was still in place from the RHC. In discussing the anesthetic options, a lumbar epidural was planned and placed in the L3-4 space with no complications. The PAP, SVO2 and CI/CO were monitored while the epidural was placed in the sitting position. A radial arterial line was placed for continuous BP monitoring prior to testing and dosing the epidural. The lumbar epidural was slowly titrated to a T4 level. A norepinephrine drip was started and patient’s baseline BP maintained. The patient’s intraoperative course was uneventful, with delivery of a baby girl with APGARs of 5 and 9 at 1 and 5 min. Blood loss was estimated to be 500ml with 550ml of crystalloid administered.
DISCUSSION: pHTN is defined as a mean PAP of greater than 25mmHg at rest in the absence of any demonstrable cause. pHTN is tolerated very poorly in pregnancy and carries a high risk of mortality ranging from 30-56%(1). Prior studies have shown the use of NO in the pre and post delivery management of pHTN in pregnancy with reductions in PAP(2). The primary goals in the anesthetic management of pregnant patients with pHTN includes: avoiding increases in pulmonary vascular resistance, avoiding a marked decrease in venous return, avoiding a reduction in SVR, and avoiding myocardial depression(4). Our case demonstrates the use of NO through the perioperative period to reduce PAP; in combination with epidural anesthesia in the management of a pregnant patient with pHTN.
SOURCES: 1) B. M. Weiss, et al. “Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996,”Journal of the American College of Cardiology, vol. 31, pp. 1650–7, 1998. 2) Robinson JN, et al. Inhaled nitric oxide therapy in pregnancy complicated by pulmonary hypertension. Am J Obstet Gynecol 1999;180:1045–6. 3) Mangano DT. Anaesthesia for the pregnant cardiac patient. Anaesthesia for Obstetrics, 3rd Ed,1983; 502–8.