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Caesarian Section in a Parturient with Recurrent Peripartum Cardiomyopathy and Left Ventricle Ejection Fraction of 10%
Abstract Number: SAT-74
Abstract Type: Case Report/Case Series
Introduction: Peripartum cardiomyopathy (PPCM) is defined as left ventricular systolic dysfunction of unknown cause in the final month of pregnancy or the first five months post-partum1. Management includes preload and afterload reduction as well as ionotropic support2. The ideal anesthetic technique for CS with PPCM is unknown. We present the successful use of slow-dosed epidural anesthesia as part of a multi-disciplinary approach to CS complicated by recurrent PPCM.
Case Report: A morbidly obese 33 year old G4P1 at 26 weeks gestation with history of prior CS and PPCM was admitted for acute pulmonary edema and worsened left ventricular ejection fraction (LVEF) from 40% to 16%. LVEF further deteriorated to 10% with evolution of pulmonary hypertension in the ICU. A multi-disciplinary team of OBGYN, OB and CT anesthesia, cardiology, neonatology, CT surgery, ICU, and perfusion was assembled for repeat CS and bilateral tubal ligation at 30 weeks gestation with standby VA ECMO.
The anesthesia team placed a central line, arterial line, PA catheter, and epidural which was dosed with 200 mcg fentanyl and 40 mg (2%) lidocaine boluses every 5 minutes to achieve a T6 level. A norepinephrine infusion was used to maintain MAP and a right femoral arterial catheter was placed for possible VA ECMO. Low dose epinephrine infusion was started at incision until delivery 8 minutes later. 200 mcg IM Methylergonovine and 3 units oxytocin were administered. CVP and PA pressures rose with auto-transfusion but systemic hemodynamics remained stable. Pressors were weaned prior to 48 hr post-op ICU stay. Mother and infant were discharged home without complication.
Discussion: Anesthetic management for CS complicated by PPCM requires meticulous preoperative preparation in a multi-disciplinary setting. Plans for circulatory support are necessary given the risk of cardiovascular collapse2. Few, if any, case reports exist documenting a successful delivery of anesthesia for CS in a parturient with LVEF 10%. This report demonstrates the utility of the slow-dosed epidural in minimizing acute hemodynamic change in the setting of PPCM.
Conclusion: Slow-dosed epidural is a good option for CS complicated by PPCM.
References: 1) Dutt et al. Anesthetic management for caesarean section in a case of peripartum cardiomyopathy. Anesth Essays and Res. 7(2): 273-275. 2013 2) Wolff et al. Management of acquired cardiac disease in the obstetric patient. Semin Cardiothorac Vasc Anesth. 13(3): 85-97. 2011