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Obstetric Anesthetic Considerations for a Pre-eclamptic Patient with Cardiomyopathy and Limb Girdle Muscular Dystrophy
Abstract Number: FCI-465
Abstract Type: Case Report Case Series
Case Presentation – A morbidly obese 23year old G1P0 at 38 weeks gestation was transferred from an outside facility for induction of labor for pre-eclampsia and with a newly diagnosed cardiomyopathy, and a known history of Limb Girdle Muscular Dystrophy (LGMD). The patient had not previously been diagnosed with cardiomyopathy. However prior to induction an echocardiogram was obtained due to the patient’s history of LGMD because of high association with cardiomyopathy that revealed an ejection fraction of 20%. The patient had significant lower limb swelling that had been progressively increasing over a 2 week period causing increasing difficulty with ambulation. Given her elevated blood pressures and an elevated Urine protein/creatinine ratio of 0.34, the patient fulfilled the criteria of pre-eclampsia. A multidisciplinary approach involving maternal fetal medicine, anesthesiology, nursing and cardiology was convened.
Hospital Course – Because of higher propensity for sudden cardiac death in patients with cardiomyopathy related to LGMD, and associated elevated blood pressures due to pre-eclampsia, a pre-labor induction arterial line and right jugular central venous catheter were placed. Induction of labor was started with misoprostol and followed by Pitocin infusion. Early neuraxial labor analgesia was initiated and continued with infusion of 8ml per hour of 0.08% bupivacaine with 2mcg/ml fentanyl. When her cervix was fully dilated, attempted vacuum for passive delivery failed and patent underwent cesarean delivery. The epidural was used to gradually bring surgical anesthesia level with 2% lidocaine with epinephrine. Healthy neonate was delivered and subsequent postpartum period was uneventful under careful monitoring and supervision. Postoperative analgesia was achieved with epidural morphine.
Discussion - There are several important considerations for a patient with cardiomyopathy at term complicated by pre-eclampsia and LGMD. LGMD is an inherited progressive weakness and wasting of limb, shoulder and hip girdle muscles with accompanying scoliosis and lordosis, arrhythmias, heart block and cardiomyopathy. These patients are at high risk for ongoing congestive heart failure, arrhythmias, and sudden death in the postpartum period. Postpartum patients are further susceptible to congestive heart failure as the intravascular volume remains elevated necessitating careful hemodynamic monitoring. Regional anesthesia is preferred approach. General anesthesia is avoided for several reasons. Succinylcholine and inhalational agents are avoided due to susceptibility to Malignant Hyperpyrexia. Laryngeal reflexes are decreased and gastric emptying time is prolonged. Patients are sensitive to respiratory depressant effects of sedatives. Magnesium therapy for preeclampsia and the use of non-depolarizing muscle relaxants may further complicate the recovery profile from general anesthesia.