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Anesthesia for cesarean delivery with a dilated aortic root, severe pre-eclampsia, and acquired von Willebrand disease: a case report.
Abstract Number: T-68
Abstract Type: Case Report/Case Series
We describe the management of a parturient with a dilated aortic root, severe pre-eclampsia (PE), and acquired von Willebrand (vW) disease who underwent a general anesthetic for urgent cesarean delivery (CD).
A 35 yr G2P1 patient at 30 weeks presented with a history of a bicuspid aortic valve status post Ross procedure at age 18. She had a screening echocardiogram and was newly diagnosed with a dilated aortic root (4.8 cm TTE; 5 cm on follow-up MRI).
At 33 weeks + 4 days, she was diagnosed with severe PE. She was started on magnesium and her systolic BPs were maintained below 140. On the third night following admission, she developed recurrent severe range BPs. Given a recent diagnosis of acquired vW disease, one unit of platelets and vW concentrate (Humate-P) were transfused in anticipation of an urgent CD. Post transfusion platelet function testing was consistent with a continued coagulopathy (>300 CollagenADP/EPI).
Arterial line, central line, and large-bore peripheral IVs were established, and cross-matched blood and uterotonics were immediately available. Pre-induction BP management included IV labetalol 5 mg x 2, nitroprusside (0.2-1 mcg/kg/min), and esmolol 50 mcg/kg/min. General anesthesia was induced with rapid sequence induction of propofol 60 mg, etomidate 6 mg, succinylcholine 90 mg, and remifentanil 100 mcgs. She was intubated with glidescope laryngoscopy, and anesthesia was maintained with a mixture of sevofluorane and 50% nitrous/oxygen with a remifentanil infusion (0.05-0.15 mcg/kg/min). Following induction, she became hypotensive requiring down-titration of anti-hypertensives and initiation of a phenylephrine infusion. Delivery of the neonate occurred 16 minutes after intubation and estimated blood loss was 600 ml. Prior to extubation, 15 mg of IV morphine was titrated for post-operative analgesia. Nitroprusside was restarted for BP control 10 minutes before extubation and the remifentanil infusion was continued to minimize stimulus at emergence. She was extubated awake and transferred to the intensive care unit. In the ICU, she was successfully transitioned to oral labetalol, transferred to the floor on postpartum day 2, and discharged to home 4 days postpartum.
Screening of the aortic root should be routinely performed in patients with a history of congenital cardiac repair prior to conception.1 Aortic diameter >40 mm among Marfan patients is considered particularly high risk, and maternal survival in the event of aortic rupture or dissection is dismal.2 The patient’s dilated aortic root and concurrent severe PE necessitated urgent CD and meticulous peripartum BP control. Her vW and associated coagulopathy with limited response to vW factor and platelet transfusions precluded a neuraxial anesthetic technique, however hemodynamic stability during her CD was obtained with remifentanil and appropriate anti-hypertensives.
1. Circulation. 2010;121(13):e266
2. Anesthesiology. 2014;120(4):810-818