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Anesthetic Management of Primiparous Sexagenarian undergoing Cesarean Delivery complicated by Uterine Atony
Abstract Number: FCB-218
Abstract Type: Case Report Case Series
Though rare, pregnancy at very advanced maternal age (AMA) is becoming more frequent in high-income countries.(1) Assisted reproductive technology (ART) now allows post-menopausal women to conceive, but has been associated with increased risk of adverse maternal and neonatal outcomes.(2) Anesthetic literature addressing pregnant women of extreme AMA is sparse.
A 64 year-old G1P0 healthy female presented for elective cesarean delivery (CD) at 36+1 weeks. She had undergone in-vitro fertilization with embryo donation and returned to Canada for prenatal care. Though her pregnancy was uncomplicated, it was felt by obstetrics that CD was preferred due to concern regarding vaginal elasticity, uterine tone, and risk of spontaneous intrauterine fetal death.
Anesthetic management consisted of two 18g peripheral intravenous catheters and a spinal anesthetic with hyperbaric bupivacaine, fentanyl, and morphine. The patient was co-loaded with lactated Ringers and phenylephrine infusion was started. The patient developed second degree heart block and bradycardia shortly after introduction of the spinal anesthetic that responded to glycopyrolate.
Following delivery (APGARS 9,9), poor uterine tone was noted despite oxytocin infusion. A bolus of oxytocin was given; then with no improvement, it was followed by carboprost and ergonovine. Given the failure of uterotonics and possible postpartum hemorrhage, tranexamic acid was administered. Uterotonics and tranexamic acid were given without adverse effect. On closure of the hysterotomy, the myometrium was noted to be unusually rigid and tore easily. Estimated blood loss was 1000 ml. The patient remained hemodynamically stable, holding her infant. She had an uneventful postoperative course and breastfed. The neonate was later admitted to the NICU due to possible transient pulmonary hypertension of the newborn which resolved without intervention.
CD in a healthy parturient over 60 years of age may safely be performed with standard spinal anesthetic technique. Though hyperbaric bupivacaine may result in a higher level of block and increased latency to maximal level of spread with increasing age(4), a high block was not observed in this patient. Baroreceptor reflex sensitivity decreases, risk of conduction defects increases with age; therefore an elderly parturient’s response to phenylephrine infusion may be unpredictable. It is not known how a uterus of this age would respond to these uterotonic agents. The risk of postpartum hemorrhage has been found to be increased with advanced maternal age(5), however it is unclear whether this patient’s advanced age contributed to the uterine atony.
1. UN, Department of Economic and Social Affairs, Population Division (2017)
2. Obstet Gynecol 2004;103:551
3. Fertil Steril 1997;67:949
4. Br J Anaesth. 1988;60:187
5. J Mat Fetal Neo Med 2015; 28:1,59