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Dural Puncture Epidural & Congenital Heart Disease: A Case and Reappraisal of Labor Complicated by Maternal Tetralogy of Fallot
Abstract Number: RF1AA-138
Abstract Type: Case Report Case Series
BACKGROUND: Congenital heart disease (CHD) presents a challenge to safe delivery of anesthesia to a parturient. Complications such as mechanical ventilation and mortality are reportedly increased in mothers with CHD than those without (1). Adequate peri-obstetric anesthesia is critical to optimizing hemodynamics and minimizing cardiac stress (2, 3). We present an interesting case of a parturient with a history of repaired tetralogy of Fallot (TOF) who underwent forceps-assisted vaginal delivery after successful dural puncture epidural (DPE).
CASE DESCRIPTION: A 25-year-old G2P1 woman at 36 weeks gestation presented to labor and delivery for induction of labor. She had a past medical history of TOF with significant pulmonic regurgitation and right ventricular enlargement status-post Rastelli procedure at age 6 months and bio-prosthetic pulmonic valve replacement at age 21 years. She had a fair functional status with greater than 4 metabolic equivalents and negative cardiac and respiratory review of systems. She was evaluated by cardiology in her first trimester and deemed appropriate for potential vaginal delivery. Pre-operative transthoracic echocardiogram showed a left ventricular ejection fraction of 65%, moderate pulmonary regurgitation and normal left ventricular systolic function; electrocardiogram showed right bundle branch block and sinus bradycardia. The primary obstetric and anesthesia plan consisted of pre-induction of labor arterial line placement, two large-bore peripheral IV lines, continuous telemetry and ICU level monitoring, readily available central access kits and vasoactive agents, and planned vaginal delivery with accelerated second stage of labor. She underwent successful placement of a dural puncture epidural, amniotomy and oxytocin infusion to augment labor, and delivered with forceps assistance in the operating room. She delivered a vigorous female infant with Apgar scores of 4 and 9. She was monitored closely in the ICU following delivery and had no diagnosed complications during her labor hospitalization or postpartum visits.
DISCUSSION: Prior studies have demonstrated safe deliveries of parturients with TOF under general and neuraxial anesthesia - epidural, spinal, or combined spinal-epidural (CSE) (2). The DPE technique has been described to have improved block quality compared to standard labor epidurals and decreased hypotension and uterine hypertonus compared to the CSE technique (4). This case introduces an alternate method to providing adequate analgesia to this population while limiting the stresses of labor and potential suboptimal fluid shifts and hemodynamic fluctuations.
1. Thompson JL, et al. Obstet Gynecol. 2015; 126(2); 346-54.
2. Arendt KW, et al. Anesth & Analg. 2011; 113(2): 307-17.
3. Fernandes SM, et al. Expert Rev Cardiovasc Ther. 2010; 8(3); 439-48.
4. Chau A, et al. Anesth & Analg. 2017; 124(2): 560-9.