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Anesthetic Management of a 38 year old G3P0 Woman with a History of Mechanical Heart Valve, Third Degree Heart Block Treated with a Biventricular Pacemaker, and Paroxysmal Atrial Fibrillation and Atrial Flutter who Presents for Induction of Labor
Abstract Number: RF1AA-75
Abstract Type: Case Report Case Series
Introduction: The American Society of Regional Anesthesia and Pain Medicine has guidelines to determine when it is safe to perform neuraxial anesthesia after cessation of anticoagulation. A clinician caring for a parturient with a mechanical heart valve must weigh the risks and benefits of stopping anticoagulation in the peripartum period with the benefits of labor analgesia; an issue often managed by a multidisciplinary team.
Case: A 38-year old G3P0020 woman with a history of aortic valve replacements in 2005 and 2017, third degree heart block managed with a biventricular pacemaker, and paroxysmal atrial fibrillation and atrial flutter was admitted to a telemetry monitored floor at 36w5d gestation prior to induction of labor for medical optimization. A multidisciplinary team consisting of Maternal Fetal Medicine, Cardiology, and Obstetric Anesthesiology formulated a management plan prior to admission. At 37w0d, she was transferred to the Medical Intensive Care Unit where an arterial line was placed for improved monitoring of blood pressures. Cervical ripening was begun with misoprostol and eventually a foley balloon. A heparin infusion was initiated after the last scheduled dose of therapeutic enoxaparin and was stopped six hours after initiation of an oxytocin infusion. It took ten hours for the activated partial thromboplastin time to reach a level (below 40 seconds) that was safe for neuraxial anesthesia after the heparin infusion was stopped; fentanyl and remifentanil patient-controlled anesthesia were employed for labor analgesia in the interim. A labor epidural catheter was placed and dosed in 3 ml increments to ensure hemodynamic stability. A pudendal block was performed just prior to delivery and a forceps-assisted vaginal delivery was performed in the MICU with neonatal intensive care unit team members in attendance. APGAR scores were 7 and 8 at 1 and 5 minutes, respectively.
The patient expressed desire for permanent sterilization and a postpartum tubal ligation was performed immediately after delivery and the labor epidural was successfully activated for surgical anesthesia. The patient was discharged from the hospital in good condition on the fourth postpartum day and anticoagulation was resumed with warfarin.
Discussion: Due to our patient’s cardiac arrhythmias, she had continuous telemetry monitoring throughout her hospitalization; this required coordination between telemetry, MICU, and labor and delivery nursing staff as our labor and delivery unit was not capable of telemetry monitoring. We were aggressive about minimizing the amount of time without anticoagulation and it unexpectedly took ten hours after stopping the heparin infusion for the aPTT to normalize; delayed neuraxial labor analgesia was an unintended consequence. We extended our resources to provide the patient a timely postpartum tubal ligation during the late evening hours due to her comorbidities and the burden another pregnancy would cause.