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Anesthetic management for cesarean delivery in a patient with evolving acute myocardial infarction (AMI).
Abstract Number: S3C-9
Abstract Type: Case Report/Case Series
Background: Cardiovascular disease is a rare but significant complication of pregnancy, with an incidence of 0.6-1 per 10,000 births, and mortality rate of 5.1-37%. Mortality is highest in the peripartum period. The most common cause of AMI in pregnancy is spontaneous coronary artery dissection (SCAD), occurring in 15-27% of pregnancy-associated AMIs. Here, we describe peripartum anesthetic management for cesarean delivery (CD) of a pregnant patient with recent atherosclerotic AMI.
Case features: Our patient was a 34-year-old gravida 2 para 1 with known coronary artery disease (CAD) and previous percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) 3 years ago. She presented to a community hospital at 35+5 weeks with chest and back pain. She was diagnosed with a non-ST elevation myocardial infarction (NSTEMI) and admitted to the coronary care unit (CCU) at a tertiary care centre to undergo PCI.
Medical history included hypertension, dyslipidemia, and smoking. Her pregnancy was complicated by gestational diabetes, intrauterine growth restriction, and footling breech presentation. In CCU, she was hemodynamically stable and did not require vasopressors. A multidisciplinary team (cardiology, obstetrics, and anesthesia) opted for delivery prior to PCI to avoid anticoagulation. External cephalic version without anesthesia was attempted but unsuccessful and, 6 days after presentation, the patient was scheduled for CD.
In the operating room, a radial arterial catheter was placed. A low-dose combined spinal-epidural (CSE) was performed with 7.5mg of 0.75% bupivacaine, 15mcg fentanyl, and 150mcg morphine. Thirteen minutes later, despite prophylactic phenylephrine infusion, the patient developed hypotension (77/35mmHg) and bradycardia (49bpm). The patient was resuscitated with phenylephrine, ephedrine, atropine, and a rapid fluid bolus. She stabilized within 5 minutes and no ECG changes or chest pain were noted. Surgical anesthesia was obtained with titration of epidural 2% lidocaine (total 160mg). The remainder of the CD was unremarkable. Serial post-operative troponins were not elevated from pre-operative values. The patient and newborn were transferred to CCU and neonatal ICU, respectively. The patient underwent successful PCI the next day, receiving 2 drug-eluting stents to her right coronary artery. She was discharged home on postpartum day 4.
Discussion: Anesthetic management of CD in a patient with evolving AMI includes adequate surgical block, which can be achieved with neuraxial anesthesia, and titration of vasoactive agents for hemodynamic maintenance. In review, norepinephrine infusion and intra-operative transthoracic echocardiogram could offer additional means to assess and stabilize hemodynamics.
Semin. Perinatol. 38, 304–308 (2014).
Can. J. Cardiol. 26, e185–e189 (2010).
J. Am. Coll. Cardiol. 52, 171–180 (2008).