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43 Years Old, Mechanical Heart Valves, Anticoagulation with a Complete Placenta Previa---Really?
Abstract Number: F-67
Abstract Type: Case Report/Case Series
Intro: Placenta previa is a leading cause of third trimester hemorrhage, which can lead to morbidity and mortality to mother and fetus. Our case was complicated by a history of rheumatic fever with subsequent mechanical heart valve replacements, necessitating strict anticoagulation.
Case: A 43 year old female with a history of rheumatic fever requiring a mitral and aortic valve replacement and tricuspid repair 2 years earlier was admitted @ 33+4 week gestation, for conversion from warfarin to intravenous heparin prior to an elective cesarean section due to a complete placenta previa. The patient’s symptoms included shortness of breath and orthopnea. The patient was in atrial fibrillation and echocardiogram revealed moderate aortic stenosis, moderate pulmonary hypertension with dilated atria and right ventricle and normal LV function with an EF of 50%. Thirty-six hours prior to the scheduled procedure, the patient began bleeding. The heparin infusion was stopped, the patient was transfused 2 units of PRBC’s, and an urgent cesarean section was performed under general anesthesia (GA). After placement of an arterial line, the patient underwent a modified rapid sequence induction with etomidate, fentanyl and succinylcholine. The patient’s blood pressure ranged from 120-150 systolic to 60-85 diastolic; a transesophageal echo (TEE) was placed and demonstrated a LVEF of 45-50%, dilated atria and moderate pulmonic and tricuspid regurgitation. A viable female infant was delivered weighing 1.63 kg, with Apgars 8 and 8, and was sent to the NICU. Fortunately, the placenta separated easily and the blood loss was only 700 ml. The patient was extubated at the end of the procedure in stable condition. Unfortunately, while converting her back to warfarin in the postpartum period, her PTT became markedly prolonged on the 4th postpartum day and she was taken to the OR for an intra-abdominal hemorrhage that required packing and subsequent removal of packs and closure on the 6th postpartum day.
Discussion: This case involving a complete previa was complicated by significant heart disease and the need for anticoagulation. Either a GA or a neuraxial anesthesia (RA) is a viable option for cesarean section for placenta previa (1). A RA was originally planned with electively stopping the heparin infusion for 4 hours, assuming a normal PTT. However with the acute hemorrhage, a GA was the only option but it afforded the opportunity for TEE placement and monitoring her cardiac status for the duration of the case. Despite planning for an elective procedure, an acute hemorrhage necessitated a change in plans and despite the urgency, the ongoing cooperative and communicative efforts among the sub- specialties, obstetrics, cardiology, anesthesia, neonatology and nursing, facilitated this difficult situation.
Ref: Parekh N,Husaini SW,Russell IF:Caesarean section for placenta praevia:a retrospective study of anaesthetic management.Br J Anaesth 2000;84:725