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Pericardial effusion and morbidly adherent placenta: a delicate balance
Abstract Number: FCB-131
Abstract Type: Case Report Case Series
Perioperative management of patients with pericardial effusion presents many anesthetic challenges (1). While increased blood volume in pregnancy may offset tamponade physiology, administration of anesthesia may favor it. Further, hemorrhage may provoke cardiovascular collapse.
A 40 y.o. G2P1 at 38 wks with chronic pericardial effusion (PE) was scheduled to have repeat cesarean delivery (CD) for twins (one viable, one fetal demise with accreta). Her PE was incidentally diagnosed 6 y. prior during workup of ovarian mass and she had percutaneous drainage (PD) of 660mL of pericardial fluid for concern of early tamponade physiology seen on transthoracic echo (TTE). Partial re-accumulation (RA) was followed conservatively.
In her first pregnancy, RA of a large PE was followed with TTE with no PD. She underwent primary CD for previa with epidural anesthesia without event. An interim TTE showed a marked decrease in PE.
This 2nd pregnancy was complicated by suspected accreta of the demised twin and evidence of RA of a large PE on serial TTE during pregnancy. Delivery was planned in the hybrid OR. On admission she was tachycardic to 130s. She received 5% albumin. Pre-procedure TTE showed a moderate effusion with right atrial inversion but no evidence of tamponade (Figure). With an arterial line in place, a co-load of 5% albumin was given and a dural puncture epidural technique was used to achieve a level of T4 with epidural 2% lidocaine with epinephrine. Surgical prep was extended to the xiphoid. After CD, the placenta was morbidly adherent requiring hysterectomy. Blood loss was substantial (6L) and she had massive transfusion (Figure) with intermittent phenylephrine infusion to maintain blood pressure. Epidural anesthesia was maintained for the procedure with minimal sedation at time of closure. Recovery was stable and she continues to be monitored for chronic PE.
While PD of large PE is controversial, detecting and treating early tamponade is paramount. Both cardiovascular instability from anesthesia and hemorrhage can contribute to tamponade physiology in patients with large PE. A controlled neuraxial technique with colloid loading allowed for stable onset of surgical anesthesia. Preparations for massive blood loss were in place. Multidisciplinary planning is essential and discussions should include location of delivery, availability of cardiac personnel and preparation for potential adverse events.
1. European Heart Journal (2015) 36, 2921–2964