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PDPH Management in Patient with Ebstein’s Anomaly
Abstract Number: SU-77
Abstract Type: Case Report/Case Series
Ebstein’s anomaly is a rare congenital heart disease (CHD). As medical advances continue, we expect a growing population of CHD patients living to reproductive years, presenting unique management considerations for the obstetric anesthesiologist. We report the case of post-dural puncture headache (PDPH) in the Ebstein’s anomaly parturient and decision for early epidural blood patch (EBP).
A 32-year-old G1P0 at 40w with history of Ebstein’s anomaly presented in active labor. Most recent echocardiogram demonstrated normal left ventricle (LV) systolic function, atrialization of the right ventricle (RV) and apical displacement of the septal leaflet of the tricuspid valve, and globally reduced RV systolic function. The patient complained of past palpitations, mostly associated with caffeine consumption, which correlated with sinus tachycardia on a Holter monitor. The patient was a New York Heart Association (NYHA) class I. Upon presentation, the patient was placed on telemetry with defibrillator nearby. The Cardiology team was consulted. An epidural was placed at the L3-4 interspace using an 18-g Tuohy needle. Unintentional intrathecal puncture occurred and Tuohy was removed immediately. An epidural was then placed at the L2-3 interspace. The patient was started on a low continuous rate of 6mL/hr of 0.055% bupivacaine-1mcg/ml sufentanil. The patient remained on telemetry during her hospital admission. Postpartum day 3 the patient reported a severe, unremitting, positional headache concerning for PDPH. An early EBP was chosen, avoiding fluid boluses and caffeine. Her headache improved immediately and post-EBP day 3 she remained without headache.
The peripartum management of Ebstein’s anomaly includes the following three hemodynamic goals: maintaining cardiac output, minimizing right to left shunt, and avoidance of atrial tachyarrhythmias (1). Early epidural placement to blunt the sympathetic response to pain is helpful in decreasing right heart strain (2). A Cochrane review and Pubmed search did not yield any data regarding risk: benefit profile for therapy of PDPH in the parturient with Ebstein’s anomaly. Due to the risk of supraventricular tachycardias and Wolff-Parkinson-White, caffeine can be dangerous. These patients often have RV dysfunction as well, especially after delivery-associated autotransfusion, therefore large fluid boluses to treat a PDPH may not be tolerated. We conclude that PDPH should be managed early with epidural blood patch while caffeine and fluid boluses should be minimized.
1. Donnelly JE, Brown JM, Radford DJ. Pregnancy outcome and Ebstein’s anomaly.Br Heart J 1991;66:368-71.
2. Andropoulos, Dean B.; Stayer, Stephen A.; Russell, Isobel A.; Mossad, Emad B. Anesthesia for Congenital Heart Disease. Hoboken: Wiley, 2011. Ebook Library. Web. 31 Aug. 2015.