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Challenges in the Management of a Parturient with Takayasu Arteritis: a Case Report and Review of the Literature
Abstract Number: FCH-547
Abstract Type: Case Report Case Series
Takayasu arteritis (TA) is a vasculitis which primarily affects the aorta and its primary branches. Women are affected in 80 to 90 percent of cases, with an age of onset between 10 and 40 years. These patients are at high risk for preeclampsia, refractory hypertension, and miscarriages. Cesarean section is usually performed for obstetric reasons or uncontrolled blood pressures. Analgesic and anesthetic management of such parturient is a challenging task. We present a case report of a parturient with TA who posed unique clinical challenges due to refractory hypertension and pre-eclampsia in the setting of significant pathology affecting the carotid and subclavian arterial vasculature.
35-year old female, G1P1001 with longstanding history of TA complicated by subclavian steal syndrome requiring left subclavian and carotid artery stent placement and two subsequent revascularization procedures. She was admitted at 36 weeks for refractory hypertension and blood pressure lability. Due to the presence of variable pulses, right carotid vascular narrowing and left carotid and subclavian artery neovascularization, blood pressures were monitored with a non-invasive blood pressure cuff on the right calf. Mean BP was same in both right sided extremities, but pulse pressure was wider on the lower extremity. She received labor epidural when she was in L&D and her BP was closely monitored. She stayed on that epidural for 12 hours and then due to constant pain despite multiple top-ups, it was re-sited with CSE technique. After 18 hours of labor, she was taken for Cesarean section which was done under epidural anesthesia top-ups with 2% lidocaine. An arterial line was placed in right radial artery for closed BP monitoring. Her postpartum course was complicated by uterine atony causing significant hemorrhage, as well as pre-eclampsia induced pulmonary edema requiring admission to the intensive care unit.
Discussion: Understanding the pathophysiology of TA and its extent is very important in the optimal anesthetic management of these patients. Closed communication between different teams and a proper plan of care should be in place both for elective and emergency scenarios. Goals should be set for optimal blood pressures.
Iosovich et al."Peripartum anesthetic management of patients with Takayasu's Arteritis. IJOA 2008 Oct;17(4):358-64
IK Grewal et al. “CSE for caesarean section in a patient with Takayasu’s disease”. IJOA 2003 July; 12(3):234-235