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Preoperative 'bloodletting' in a patient with severe cardiomyopathy presenting for Cesarean delivery
Abstract Number: F-84
Abstract Type: Case Report/Case Series
A 37 year old G3P1 at 37 weeks gestation with a history of cardiomyopathy, LVEF 30-35% and severe global hypokinesis at term, presents for induction of labor. Throughout pregnancy, she was followed closely by cardiology, placed on metoprolol and furosemide, and was instructed to wear a ‘Life Vest’. At term, she complained of shortness of breath and dyspnea on exertion. An early epidural was placed after rupture of membranes without complication. An arterial line was also placed to closely monitor her blood pressures during labor. The patient failed to progress past 5 cm dilation, and due to persistent category II tracings, the obstetric team decided to proceed with Cesarean section.
Concerned about fluid overload immediately postpartum, the anesthesia team decided to place a rapid infusion catheter (RIC) line in the patient’s forearm, which was used to remove 400 mL of blood preoperatively (with storage in sodium citrate in case it was needed postpartum). Defibrillation pads were placed on the patient in the OR, and she underwent an uncomplicated Cesarean delivery via epidural anesthesia. Postoperatively, a CBC was checked, which revealed a hematocrit of 32 (compared to a preoperative value of 34). An echocardiogram was performed, which demonstrated slightly increased RAP (5-10), compared to her exam a week prior. With this information, she was deemed euvolemic, so the patient’s autologous blood was discarded. The rest of her recovery was uncomplicated, and she was discharged home in stable condition on post-op day 3.
In the immediate postpartum period, cardiac output may increase 75% above pre-delivery levels, due in part to auto-transfusion from the contracted uterus (approximately 500 mL), leading to increased venous return, larger stroke volumes, as well as alterations in sympathetic nervous system activity. Cardiac output may also rise with relief of aortocaval compression, diminished lower extremity venous pressure, and a reduction in maternal vascular capacitance (1). With this patient’s severe cardiomyopathy, there was concern for fluid overload and resultant pulmonary edema if she could not tolerate such physiologic changes immediately postpartum. We thus present a novel preoperative ‘bloodletting’ technique, to potentially minimize adverse hemodynamic effects in the immediate postpartum period in a patient with severe cardiomyopathy.
1) Chestnut, David H. Chestnut's Obstetric Anesthesia: Principles and Practice. 4th ed. Philadelphia: Mosby/Elsevier, 2009.