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Neuraxial Anesthesia for Vaginal and Cesarean Delivery in Patients with Complex Congenital Heart Disease: A Case Series
Abstract Number: F2B-6
Abstract Type: Original Research
Parturients with complex congenital heart disease present multiple challenges including balancing the preload, afterload, and cardiac output. We describe the neuraxial anesthetic (NA) management and outcomes of parturients with complex congenital heart disease to expand the available anesthetic literature regarding these patients.
Following Institutional Review Board approval, we performed a retrospective cohort analysis of parturients with complex congenital heart disease, repaired or uncorrected, undergoing vaginal delivery (VD) or cesarean section (CS) over an 8yr period. Demographic data, cardiac pathology, pre-pregnancy and peripartum cardiac status, pregnancy course, method of anesthesia/analgesia, operative details, and postoperative complications were described. Zahara and Carpreg Risk scores were also calculated.
Data from 54 cases (48 parturients) was collected between 2010 and 2018 with varying pathologies including primarily left- or right-sided obstructive lesions, defects in septation, Tetralogy of Fallot, congenital pulmonary hypertension, transposition of the great vessels, and complex lesions resulting in single ventricle physiology.
There were 22 (42%) VDs among 20 patients. NA was performed for 100% of VDs as either a combined spinal-epidural (CSE) with intrathecal fentanyl followed by epidural infusion of 0.2% ropivacaine, or epidural infusion only. Complications occurred in 4 patients and included postpartum hemorrhage requiring transfusion and subsequent fluid overload (n=1), postpartum arrhythmia (n=2), and worsening heart failure symptoms (n=1).
There were 32 CS performed among 26 patients. One patient had 2 CSs under general anesthesia due to thrombocytopenia, and the remaining cases were performed using NA. Specifically, 5 had CSEs, 7 had dural-puncture-epidurals (DPE), 9 had slowly-dosed epidurals, and 7 had spinal anesthesia. Complications occurred in 7 patients and included worsening heart failure symptoms (n=2), cardiogenic shock requiring pressor and inotropic support (n=3), low hematocrit and cardiac output requiring transfusion (n=2), and neonatal complications (n=2). All patients with cardiac complications had a Zahara Risk Score ≥2.5.
In addition to our increasing adoption of DPE and CSE techniques in these complex cases, other strategies are also employed in these patients. For example, epinephrine-containing test doses are avoided in patients at risk for arrhythmia or otherwise sensitive to increased heart rate. Uterotonics are also tailored to the patient - oxytocin is often avoided when hypotension can be harmful, being replaced by carefully titrated intravenous Methergine® in such cases. Most importantly, the risks/benefits of NA are carefully discussed with the obstetric and cardiac teams, and the patient, taking into account the underlying pathology. With a carefully executed approach we believe NA results in favorable maternal and neonatal outcomes.