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Marfan's Syndrome, PTSD, and Cesarean Delivery: Getting to the Root of the Problem
Abstract Number: F1D-8
Abstract Type: Case Report/Case Series
Introduction: PTSD after exposure to a traumatic event may be exacerbated by pregnancy and lead to tocophobia (fear of childbirth), and maternal request for C/S. Marfan’s syndrome (MFS) is an inherited connective tissue disorder complicated by progressive aortic root dilation. We present peripartum management of a woman with MFS, aortic root dilation, dural ectasia, and severe PTSD.
Case Presentation: A 44 yr old G5P3 6’3” 259 lb female presented at 37 5/7 wks requesting C/S and PPTL. PMH included IDDM, HTN, MFS, and PTSD from sexual assault. ECHOs demonstrated progressive aortic root dilation (3.7 to 4.1 cm, fig 1), trace MR, and dural ectasia (MRI). C/S was performed in a CT OR under spinal (bupivacaine, fentanyl, hydromorphone). Verbal reassurance and communication controlled PTSD and a healthy baby was delivered.
Discussion: Psychiatric disorders are associated with high risk maternal behaviors, ectopic pregnancy, spontaneous abortion, lower birth weight babies, and preterm delivery (1). PTSD is treated with psychotherapy and antidepressants but we used reassuring communication and multimedia in the OR (2) to calm our patient without sedatives.
Aortic root dilatation may progress from increased blood volume and CO during gestation. When the aortic root dilates > 4 cm, risk of aortic dissection is 10% (3). Most dissections occur in the 3rd trimester or immediately postpartum so our patient delivered in a CT OR and recovered in the ICU. Since beta blockade may slow aortic root dilation, reduce AI, and risk of dissection, metoprolol was continued in the perioperative period. We avoided calcium channel blockers which can accelerate aneurysm expansion and rupture.
Both GA and neuraxial anesthesia are safe for C/S in patients with MFS and aortic root dilation provided hemodynamic stability is maintained. Although dural ectasia is present in 90%, we chose a spinal because the block is dense and her dural ectasia was minimal. Aortic root dilation persists after pregnancy so parturients should be monitored for 6 months.
MFS is inherited; transmission may be 50%. Neonatal ECHO demonstrated a redundant thickened mitral valve but no aortic root dilation. Arachnodactyly, commonly seen in newborns with MFS, was noted.
Conclusion: Peripartum management of a patient with MFS, aortic root dilation, and PTSD requires a multidisciplinary care approach.
1. J Affect Disord 2007;102:137-43
2. Br J Anaesth 2010;104:369-74
3. Eur Heart J 2003;24:761-81