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Perioperative Management of Cesarean Delivery in a Parturient with Single Ventricle Physiology
Abstract Number: F1C-4
Abstract Type: Case Report/Case Series
A 24yo G4P1 at 32 weeks was admitted for preterm labor. She had history of tricuspid atresia s/p bilateral Glenn and Fontan procedures. Recent echocardiogram showed normal left ventricular systolic function with baseline oxygen saturation in the mid-high 80s. Delivery was indicated due to worsening fetal hydrops with large fetal pericardial effusion. After a multidisciplinary meeting with MFM, pediatric cardiology and obstetric anesthesiology, plan was to proceed with cesarean section and fetal pericardiocentesis before cord clamping. Monitoring included invasive blood pressure (IBP), minimally invasive cardiac output (CO) monitor (EV 1000TM) and central venous pressure (CVP) obtained through a PICC line. A combined spinal epidural anesthetic was performed with intrathecal injection of 3.75 mg hyperbaric bupivacaine, 15 mcg fentanyl and 150 mcg morphine. Slow incremental epidural boluses totaling 200mg 2% lidocaine, 60 mcg epinephrine and 0.8 mEq bicarbonate were needed to achieve a T4 sensory level. At administration of the spinal anesthetic, 300 mL of crystalloid co-load and phenylephrine infusion at 25mcg/min were started. The patient’s cardiac index (CI) and BP were stable and phenylephrine was discontinued after 10 minutes. Delivery of the fetus was followed by fetal pericardiocentesis performed in 70 seconds. Following cord clamping, an oxytocin infusion was started at 300 milliunits/min and maintained for 40 min to completion of case. In PACU, it was decreased to 62.5 miliunits/min for 1h before discontinuation. The CI ranged 3-5.5L/min/m2, CVP 18-27mmHg and stroke volume 71-138mL. The peak values corresponded to first 10 minutes following delivery and nadir values were at the end of the procedure. Albumin 5% 250mL was administered for volume expansion when CVP decreased with an increase after administration. Estimated blood loss was 1 L. IBP and telemetry were maintained for 24h while patient remained in L&D unit for close observation. Postop analgesia was provided by epidural infusion of bupivacaine 0.0625% + fentanyl 2mcg/mL for 24h. The postop course was uneventful.
Discussion: Corrected single ventricle physiology is becoming more common in the obstetric population. The peripartum period is associated with high morbidity. Nearly 1/4 of patients experience cardiovascular (CV) complications. Filling of the LV occurs passively in these patients; thus, maintenance of SVR and preload is required to maintain CO. Neuraxial blockade reduces both, so a low dose and slow anesthetic induction is safest. IBP monitoring can allow early detection and treatment of hemodynamic changes. Prophylactic initiation of vasopressors can help prevent such changes. CVP trends can be useful to help direct fluid resuscitation. Close monitoring should be continued after surgery since CV complications often present postpartum.
Conclusion: Coordinated care and careful planning of perioperative period is important for an optimal outcome in such complex cases.