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Anesthetic Management of Parturient with Heart Failure and Mechanical Mitral Valve Requiring Therapeutic Anticoagulation
Abstract Number: S4D-1
Abstract Type: Case Report/Case Series
This is a report of successful management of labor and delivery of a parturient requiring therapeutic anticoagulation for a mechanical mitral valve with ejection fraction of <20%.
A 32 year-old, Gravida 2 Para 1, 1.49 meters, 64kg, with a BMI of 28.8 kg/m2. The pregnancy was complicated by history of mitral valve replacement (MVR) 7 years prior due to rheumatic heart disease on warfarin, LVEF 15-20%, chronic atrial fibrillation, and dual chamber pacemaker/defibrillator (AICD). Care was further complicated by noncompliance with antenatal appointments, and necessity to communicate via an interpreter. An antepartum, multi-disciplinary delivery planning conference included maternal fetal medicine, obstetric anesthesiology, and cardiology. Critical care and cardiac surgery were consulted in case ECMO became indicated.
At 36/6 weeks gestation, patient was admitted for induction of labor due to IUGR with plan for vaginal delivery with passive second stage. On admission, warfarin was discontinued and she was bridged with a heparin infusion until INR reached 1.1. The heparin was then discontinued. When PTT was in normal range, invasive monitors (arterial line, PA catheter) and epidural were placed. Telemetry monitoring was initiated; AICD was inactivated. Labor analgesia was provided with patient-controlled epidural analgesia (PCEA; bupivacaine 0.0625%, fentanyl 2mcg/ml at 6ml/hour and 6ml bolus every 10 minutes). After establishing a bilateral T8 sensory level, labor was induced with misoprostol (25mcg x 1) followed by oxytocin infusion per institutional protocol.
After 36 hours off anticoagulation with vaginal delivery remote, the decision was made to proceed with cesarean delivery due to high risk for thrombotic event. For cesarean delivery (CD), the epidural was dosed gradually (lidocaine 2%, 120 mg total) for a surgical T8 block. Delivery was uncomplicated; vitals remained stable, estimated blood loss 600ml, intravenous fluid 500ml, and urine output 125ml. Female neonate with weight of 2361 grams and Apgar’s 9 and 9.
Postoperative analgesia included epidural morphine 1mg, acetaminophen 1 gram and ibuprofen 600mg every 6 hours each, with oxycodone 5 or 10mg, as needed.
Postoperatively, a planned admission to the intensive care unit (ICU) occurred. Six hours after delivery, a heparin infusion was initiated and warfarin started the following day. She remained in the ICU for two days and then transferred to postpartum care. The neonate was admitted to the NICU as planned and treated for hypoglycemia. Both mother and child were discharged on postpartum day eight.
Goldszmidt E, Macarthur A, Silversides C, et al. Anesthetic management of a consecutive cohort of women with heart disease for labor and delivery. IJOA 2010; 19:266
Berg CJ, Callaghan WM, Syverson C, et al. Pregnancy-related mortality in the United States, 1998 to 2005. Obstetric Gynecology 2010; 116:1302