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Anesthetic Management of Parturients with Pulmonary Hypertension Undergoing Cesarean Deliveries
Abstract Number: S3D-8
Abstract Type: Case Report/Case Series
Introduction: Pulmonary hypertension (PH) in pregnancy is associated with high mortality and can lead to worsening of PH due to hemodynamic changes that take place during pregnancy, presenting unique clinical challenges. We present anesthetic management of cesarean section (CS) in two patients with PAH. One of the cases involved an added complexity of Von Willebrand disease (VWD) requiring general anesthesia (GA) and another involved an autoimmune and hypercoagulability disorders utilizing neuraxial anesthesia (NA.)
Case 1: A 22-year-old G1P0 with history of VWD was found to have a severe PH on an echocardiogram during a cardiomegaly work-up at 30 weeks gestational age. At 34 weeks, she was admitted to cardiac care unit where a Swan-Ganz catheter was placed to titrate the epoprostenol infusion to an improved mean PA Pressure (mPAP) prior to a planned CS. Cardiothoracic surgery was consulted for a back-up Extracorporeal Membrane Oxygenation. The patient received GA due to VWD. A rapid sequence induction was achieved with propofol, remifentanil, and succinylcholine using a video laryngoscope. Anesthesia was maintained with propofol, remifentanil infusion, and hydromorphone. IV epoprostenol infusion was continued and Nitric Oxide (iNO) was initiated intraoperatively. She required a low dose Vasopressin infusion which was weaned off. The patient was extubated uneventfully, iNO was weaned off, and she was transferred to CCU hemodynamically stable.
Case 2: A 19-year-old G1P0 with history of Systemic Lupus Erythematosus (SLE), Anti-phospholipid Syndrome, pulmonary embolism on heparin, and a known PH underwent an unplanned pregnancy. At 33 weeks, the patient was admitted to CCU where a Swan-Ganz catheter was placed for a titration of epoprostenol infusion prior to a planned CS. The patient was continued on immunosuppressants for SLE and heparin drip for APLS and PE. For CS, the patient received a combined spinal epidural (CSE) block. A platelet count coagulation labs were within acceptable ranges. The patient received bupivacaine, fentanyl, and morphine via spinal. The patient tolerated the procedure well. Epoprostenol infusion was continued through the procedure. The epidural was removed at the end of the procedure without complication. The patient returned to CCU hemodynamically stable and was discharged home on epoprostenol infusion.
Conclusion: The two cases of management of CS in women with PAH illustrate a complexity in peri-operative management with a need for multidisciplinary approach. The two cases are highlighted by planned, timely deliveries by CS with a pre-op optimization of hemodynamics guided my invasive monitors and involvement of cardiac and obstetric anesthesia services. The two cases illustrate that both GA and NA can be successfully implemented with careful considerations of the co-morbid conditions that allowed for individualized approach to the anesthetic management.
Reference: McLaughlin et al. 2009. Circulation.119:2250-2294