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Epidural Analgesia in a Parturient with Supravalvular Pulmonary Stenosis
Abstract Number: T4D-3
Abstract Type: Case Report/Case Series
Intro: Obstetric patients with cardiac disease are a challenge for the anesthesiologist to manage. These patients are less tolerant of physiological changes associated with pregnancy, let alone the hemodynamic changes seen during delivery and within the immediate postpartum period. Anesthesia can further compromise their cardiovascular stability.
Case: Our patient is a 35-year-old G9P6025 female who was referred to our cardiology department for dyspnea on exertion in the setting of a known cardiac murmur present since childhood. Medical history was questionable for pulmonary hypertension (HTN).
Transthoracic echocardiogram showed severe supravalvular pulmonary stenosis with a peak transpulmonary gradient of 62mmHg and mild pulmonary HTN of 41mmHg. Left and right ventricular functions were preserved, although her functional status was consistent with NYHA Class III symptoms. A six-minute walking test was attempted, but after two-minutes the patient developed pre-syncopal symptoms with a severely blunted cardiac response.
Her case was reviewed by our multidisciplinary team; it was agreed she would undergo induction of labor at 37 weeks. She received an epidural for analgesia which could be converted to a surgical anesthetic if needed. She was started on 0.125% bupivacaine with 2mcg/mL of fentanyl at 5cc per hour with a PECA of 3mL and 30 minute lockout. The patient was hemodynamically stable and did not require an arterial line. She delivered vaginally without complication.
Discussion: We were unable to find another case in the literature such as ours and therefore extrapolated our case based on other right ventricular outflow obstructive lesions (RVOO). No one anesthetic technique was superior to another. [1,3] General anesthesia (GA) is associated with an increased sympathetic response due to endotracheal intubation, decreased systemic vascular resistance (SVR) due to induction and volatile agents, and thermodysregulation. In patients with RVOO this can lead to a vicious cycle of hemodynamic derangements. [2,4] Neuroaxial anesthesia is associated with decreased SVR, which can be more prolonged and difficult to manage than GA. The development of the ideal anesthetic plan for these patients should be individualized and formulated by a multidisciplinary team in advance.
1.Hamlyn EL, et al. Low dose sequential combined spinal epidural: an anaesthetic technique for caesarean section in patients with significant cardiac disease. Int J Obstet Anesth 2005;14:355–61.
2.Pieper, P, et al. Pregnancy and pulmonary hypertension. Best Practice and Research: Clinical Obstetrics and Gynecology. 28(4); 579-591. 2014.
3.Privartsky, JR, et al. Anesthetic management of patriuent with uncorrected Tetrology of Fallogy undergoing c-section. International Journal of Obstetric Anesthesia. 88.90. 2014
4.Rex, S, et al. Anesthesia for pregnant women with pulmonary hypertension. Current Opinion Anesthesiology. 29(3); 273-281. 2016.