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The Challenges of an Emergency Cesarean Section in a Remote Location in a High Risk Cardiac Patient
Abstract Number: SUN-19
Abstract Type: Case Report/Case Series
Peripartum cardiomyopathy (PPCM) is a rare life threatening entity that affects parturients during the last trimester or first few months in the postpartum period. Some of these patients may require intensive monitoring and treatment to prevent further maternal and fetal morbidity, and possible mortality. Medical management of these cases frequently occurs outside of the labor and delivery suites. This places unique challenges on the obstetric, anesthesia and neonatal teams.
An 18 year old G1P0 at 33+6 week IUP was transferred to our hospital for PPCM with shortness of breath and pre-eclampsia. Echocardiogram revealed an EF 25-30% with bilateral pleural effusions. Cardiology was consulted and she was admitted to CCU for medical management and invasive monitoring. The OB plan was to perform a Cesarean section (CS) approximately 48 hours after admission depending on cardiovascular stabilization and betamethasone administration for the fetus. Anesthesia options included either regional or general anesthesia with invasive monitoring. Due to the patient’s medical status and remote location in the CCU, a multidisciplinary team was prepared for an emergent CS plan with a bedside CS surgical tray, anesthesia and neonatal supplies and equipment. L&D nursing staff, technicians, pediatricians and anesthesiologists were identified for each shift and briefed on equipment and location. Approximately 40 hours after admission at 0450 am, sudden and persistent fetal bradycardia occurred and a decision to perform an emergent CS in the CCU under general anesthesia was made, within 15 minutes from the time of fetal deceleration. General anesthesia included a rapid sequence induction with Etomidate(20mg), Ketamine(50mg) and succinylcholine(100mg) and atraumatic endotracheal intubation and was maintained on100% oxygen and intravenous propofol(40+40mg), fentanyl(100mg+100mg) and midazolam(2mg+2mg) . A complete placental abruption was identified, and a viable infant was delivered with Apgars of 2 and 7, with a birth weight of 2.01 kg.
In addition to concerns regarding optimal subspecialty management of PPCM for either emergent or elective delivery, the major systems aspect of this patients care was the preparation for an emergent C-section outside of the delivery suite. Cultural, quality improvement, and patient safety initiatives instituted over the past few years provided a framework and awareness of the crucial need to rapidly plan for a potential emergent C-section in ICU settings. Systematic training in six sigma principles and the use of root cause analysis tools allowed for the development of an effective plan with each team rapidly deploying the onsite equipment and supplies necessary for an emergency. Preemptive team planning and communication allowed for the rapid and seamless delivery of care in a coordinated fashion during this crisis situation.