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Low-Dose Spinal with Epidural Volume Extension (EVE) for Management of Very Advanced Maternal Age Parturient with Significant Medical Comorbidities and Placenta Previa During Urgent Cesarean Delivery
Abstract Number: T-74
Abstract Type: Case Report/Case Series
Introduction: In high income countries, pregnancy in women of advanced maternal age (AMA) is becoming increasingly common. There is a paucity of data describing women of very advanced maternal age (>45). They are more likely to suffer from pre-existing medical conditions (cardiovascular, respiratory, metabolic) and peripartum complications. In conjunction with hemorrhage risk factors, this accounts for important causes of potentially preventable maternal morbidity. Obstetric anesthesia delivery strategies for this patient cohort require multidisciplinary planning. Low dose spinal with epidural volume extension (EVE) is a technique that has been used in parturients with complex cardiac or respiratory disease for cesarean delivery in whom avoidance of general anesthesia is desirable. We report the successful use of low dose spinal with EVE to facilitate an urgent cesarean delivery of an obese parturient of very AMA with COPD, OSA, SVT, pulmonary edema, and placenta previa.
Case: Patient is a 49yo G4P1 at 32 weeks gestation who presented with placenta previa in the setting of obesity (BMI 44), COPD on chronic oxygen, OSA, and medically treated SVT. Because this was her second bleeding episode with concomitant pulmonary edema, a multidisciplinary meeting was formed to discuss the delivery plan. Anesthetic goals included avoidance of hemodynamic instability, limiting accumulation of extravascular fluid in the lungs, patient comfort, and placement of a reliable neuraxial anesthetic that would obviate the need for general anesthesia. A pre-neuraxial arterial line with cardiac output monitoring was placed, and 7.5 mg of hyperbaric bupivacaine was injected intrathecally as part of a CSE. After the patient was placed in Semi-Fowler’s position (due to baseline orthopnea), a T5 level was achieved with EVE of 3mL 1.5% lidocaine. Delivery of the fetus was uneventful, and IV furosemide was administered. Surgical blood loss (1.7L) was treated with preferential colloid and PRBC transfusion. Due to the risk of postoperative apnea, neuraxial opioids were withheld, and an epidural infusion was maintained in the ICU for pain control. Discharged home on POD 3 after an uneventful postoperative course.
Discussion: Women of very AMA presenting for cesarean delivery may pose clinical challenges to the obstetric anesthesiologist due to their pre-existing medical and obstetrical complications. In addition to multidisciplinary planning, choosing an appropriate but safe anesthetic plan is paramount to achieving a safe outcome. Low dose spinal with EVE has been described in parturients with advanced cardiovascular or respiratory disease, but often not with multiple diseases in one patient. We describe a successful case of low dose spinal with EVE in a medically and obstetrically complex patient.
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