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Management of Pregnant Patient with History of Tetralogy Of Fallot (TOF) Repair
Abstract Number: F-73
Abstract Type: Case Report/Case Series
Introduction: The prevalence of cardiac disease in pregnancy has not changed over the past few decades although congenital heart disease (60-80%) has replaced rheumatic heart disease. Maternal outcome correlates well with New York Heart Association functional status. Class III and IV patients have a mortality rate between 5%-15% and perinatal mortality between 20%-30%. Exceptions are patients with pulmonary hypertension, severe left ventricle dysfunction and severe cases of Marfan’s syndrome. These lesions are high risk and may contraindicate pregnancy regardless of the classification. However, when patients present with uncorrected lesions, or partially corrected lesions, the obstetric and anesthetic management becomes more challenging.
Case Report: We present a case of a 34 years female, at 31 weeks for anesthesia consult. Patient had past history of Tetralogy of Fallot repaired at 6 years of age and stroke at 3 years with residual left sided weakness, contracture of left hand and forearm, and Barrets esophagus. Patient’s exercise tolerance was poor; dyspnea after walking up 1 flight of steps. Echo showed moderately enlarged RV, severe pulmonic valve regurgitation, mild pulmonic stenosis, normal LV function EF 60%. As per cardiologist patient was cleared for pregnancy and vaginal delivery. Prophylactic antibiotics recommended.
Prior to delivery, a multidisciplinary meeting was held with Anesthesia, Obstetrics, neonatology and Cardiology. At 36 weeks patient was admitted for pre-eclampsia. Cardiology and Anesthesia were immediately notified. A CCU nurse was present to monitor the patient. Patient was placed on magnesium and induction of labor was started. Epidural catheter was placed. Decision was made to perform C-Section for worsening preeclampsia. Epidural was loaded with 0.5% Ropivicaine. C/S was uneventful and patient was transferred to PACU.
Discussion: Tetralogy of Fallot is the most common congenital cyanotic heart disease. Very few women reach child bearing age without corrective surgery. Surgical correction involves closure of the VSD and widening of the pulmonary outflow tract. Majority of times the surgery is successful and patient remains asymptomatic. However, overtime some residual lesions can manifest . Pregnancy may unmask symptoms. Patient should have a recent echocardiogram prior to and during pregnancy.
Anesthetic management includes continuous monitoring during labor to detect ventricular arrhythmias. Care must be taken not to decrease SVR which will increase right to left shunt. Intravascular volume and venous return should be maintained. Early neuraxial block is recommended to prevent sympathetic stimulation and increase in pulmonary vascular resistance. For cesarean delivery, regional anesthesia should be administered slowly to avoid abrupt decrease in SVR. Careful planning and multispecialty collaboration is essential for optimal outcomes.
Chestnut, D. Obstetric Anesthesia