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Anesthetic Management of a Parturient with a large ASD and Marfan Syndrome
Abstract Number: T3C-2
Abstract Type: Case Report/Case Series
Intro: Given the significant hemodynamic changes associated with pregnancy, maternal cardiac disease is an important cause of morbidity and mortality. Cardiac complications of unrepaired atrial septal defects(ASD) include paradoxical embolism, supraventricular arrhythmias, pulmonary hypertension and Eisenmenger syndrome. In addition, parturients with Marfan syndrome have an increased risk of aortic dissection or rupture. We describe a successful forceps assisted vaginal delivery of a healthy infant in a patient with a large ASD and Marfan syndrome using neuraxial anesthesia.
Case: 25yo F with Marfan Syndrome and large ASD, previously lost to follow up, presented 6wks pregnant to initial OB appointment. For the remainder of her pregnancy she was followed by cardiology and maternal fetal medicine(MFM) and underwent surveillance transthoracic echocardiography(TTE) every 3 months. TTE showed dilated aortic root (3.5cm), RA/RV dilation with increasing pulmonary pressures, and an ASD with worsening left to right shunt (Qp/Qs from 1.9 to 3.2). A multidisciplinary meeting was held with MFM, cardiology, and anesthesiology 1 week prior to scheduled forceps assisted vaginal delivery. The patient presented as scheduled at 38.3 weeks gestation and was placed on continuous telemetry, pulse oximetry, and an arterial line was placed. Air eliminating filters were added to all IV lines and supplemental O2 and SCDs were placed. A slowly titrated continuous spinal anesthetic technique was chosen and a catheter was placed through a 20G pediatric Tuohy. 0.2% ropivacaine with 2mcg/ml fentanyl infusion was started at 1.5ml/hr and titrated to achieve a bilateral anesthetic level of T9. The patient remained comfortable with minimal variation in heart rate and blood pressure. Ten hours after induction, with forcep assistance, the patient delivered a healthy infant (APGARS of 9/9). EBL was 500ml and the patient was transfused 1 PRBC. The spinal catheter was pulled 6 hours after delivery and the patient was transferred to the cardiac care unit for 48h postpartum (PP). Heparin was started for DVT prophylaxis given the increased risk of paradoxical embolism. On PP day 1, the patient complained of symptoms consistent with post dural puncture headache which resolved within 24 hours with conservative management. The patient and her child were discharged on PP day 4 without further complications.
Discussion: The goal of this presentation is to discuss the specific pathophysiology and anesthetic concerns in parturients with Marfan syndrome and unrepaired ASDs, highlight the importance of a multidisciplinary approach to care, and to review the American Heart Association (AHA) statement on pregnancy and congenital heart disease(CHD).
Ref: "Management of Pregnancy in Patient with CHD." Prog Cardiovasc Dis. 2011; 53(4); 305-311
"Management of Pregnancy in Patients with Complex CHD: A Scientific Statement for Healthcare Professionals from the AHA." Circulation 2017; 135;00-00