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Anesthetic Management of a Parturient with Eisenmenger Syndrome
Abstract Number: S4D-9
Abstract Type: Case Report/Case Series
30-yr-old G1P0 Hispanic woman at 19 weeks was referred to our institution for further evaluation of hypoxemia secondary to Eisenmenger syndrome with pulmonary hypertension secondary to congenital uncorrected ventricular septal defect. On presentation, she was noted to have digital clubbing and a saturation of 70%. Continuous O2 therapy improved saturations to 90% at rest. Right heart catheterization showed RV pressure of 116/5, PA pressure 118/43, Ao pressure 121/60, and SVC, PA, and Ao saturations of 71%, 72% and 88% respectively. Pulmonary vascular resistance was 42 woods units. Echo showed moderately dilated RV, with RV hypertrophy, mild TR, flattened septum and a bidirectional shunt. She was placed on sildenafil, treprostinil and oxygen and continued to tolerate her pregnancy well. At 30 weeks’ gestation, she was admitted to the medical ICU for transition from inhaled treprostinil to IV epoprostenol. At 33 weeks’ gestation a radial arterial line, lumbar epidural, and femoral double lumen central line and arterial line were placed in case the need for ECMO arose. A slow induction of labor was performed around 8:00 am and initially was tolerated well. Around 10:30 pm, her membranes were artificially ruptured. Unfortunately, the umbilical cord prolapsed with resultant bradycardia in the fetus. Cord was reduced and the epidural was bolused with bupivacaine followed by chloroprocaine to obtain an adequate level. Cesarean delivery was performed successfully with stable hemodynamics except for some transient tachycardia during fetal delivery. EBL was 800 ml and the patient tolerated the procedure well. She was continued on IV epopostenol for 1 week and then transitioned back to inhaled treprostinil. She tolerated her transitioning well and ultimately was discharged on hospital day 37. The baby was 1508 grams with Apgar’s of 7 and 7. Echo revealed a PFO with a small PDA which closed spontaneously. The baby had normal oxygenation on room air and was discharged home at 3 weeks of life after an uneventful hospital stay.
Multiple meetings were held between pulmonology/critical care, high risk obstetrics, adult congenital cardiology, neonatology, and anesthesiology during the delivery planning for this patient. Recent evidence suggests that some patients with Eisenmenger syndrome benefit from aggressive pulmonary arterial vasodilator therapy. We instituted this approach and followed the patient carefully with serial echocardiograms to optimize RV function. This approach also helped us determine appropriate timing for delivery of the infant. Although the projected mortality is close to 50% in these patients, a multidisciplinary approach with subspecialty expertise can be helpful for a successful delivery and recovery.