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Anesthetic Management of a Pregnant Woman with Pulmonary Stenosis: A Case Report
Abstract Number: SAT-77
Abstract Type: Case Report/Case Series
Management of pregnant women with pulmonary stenosis (PS) is controversial and challenging. PS refers to a dynamic or fixed anatomic obstruction to flow from the right ventricle (RV) to the pulmonary arterial vasculature. During pregnancy, women increase their cardiac output (CO) which increases further during labor and remains elevated after delivery. PS increases RV work and dramatically impairs left ventricular (LV) output. Cardio circulatory changes in PS can lead to RV (systemic) failure or dysfunction resulting in morbidity and mortality. Sudden cardiac arrest can occur during cesarean section (CS) or up to a month after birth.
Understanding of cardiac function, physiological adaptations, events and drugs that can alter the magnitude of RV outflow is required for optimal anesthetic management. Hemodynamic management includes maintenance of LV afterload, and RV preload, avoiding increase in pulmonary and systemic vascular resistance. Hypothermia, hypercarbia, acidosis, hypoxia and high ventilator pressures must be avoided. General anesthesia (GETA) is considered the safest approach for fluid management in patients with PS.
We report on the case of a 29 year-old G2P1 morbid obese female with BMI of 43.3, previous CS under GETA and mild PS of 4.2 m/s peak velocity, LVEF of 60% and RV hypertrophy diagnosed by echocardiogram, who was referred to our service for CS and bilateral partial salpingectomy at 38 weeks gestational age. Patient (pt) was hemodynamically stable, well oxygenated. A left radial artery and two peripheral IV lines were placed. While in sitting position, ASA monitors in place, anatomical landmarks were identified for insertion of an 18G Weiss epidural needle after sterile prep and drape. Clear CSF identified needle placement at subarachnoid space (SAS). No paresthesias occurred. A 20GA epidural catheter was placed and fixed 12 cm into the SAS without complications. Pt was then placed on supine position with an obstetric wedge under right hip. Titrated boluses of 1.5 mg of Bupivacaine 0.75% were administered in a long timely fashion to achieve a sensory level of T6 to pinprick, with careful monitoring of HR and arterial line pressure. A total of 7.5 mg Bupivacaine 0.75% was used. A titrated dose of 20mg oxytocin in 1L NSS was started post-partum. The procedure lasted one hour. Intra-operative BP ranged between 120/65 mmHg and 130/85, HR ranged from 65-97 bpm. Estimated blood loss was 1,100 mL and urine output was 1 mL/kg/hr. There were no major hemodynamic changes during the peri-operative period. Pt was transferred to Post Anesthesia Care Unit then to Obstetrics ward without adverse effects. Morphine 4mg was administered every 4 hours for pain control. Our multidisciplinary team followed the pt for three days until discharged home with no post-operative complications. Ref: 1. Bathia A. Clinical Diagnostic Research. 2016;10:3-4. 2.Sanikop C. Indian J Anesth. 2012;56:66-8. 3.Katsuragi S. Circulation Journal. 2012;76:2249-54.