///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

ANESTHETIC CONSIDERATIONS FOR A PARTURIENT WITH PULMONARY HYPERTENSION

Abstract Number: RF2AB-176
Abstract Type: Case Report Case Series

Julie F Harvey MD1 ; Ayse O Kula MD2; Steven Ropers MD3

Case: A G2P1001 woman at 32 weeks gestation with obesity, OSA, asthma, thrombocytopenia, and severe pulmonary hypertension (PH) secondary to ASD requiring 2.5 L O2 via nasal cannula presents for delivery planning. Her prior right heart catheterization and echocardiograms demonstrated a D-shaped septum, systolic pulmonary artery pressure (PAP) up to 92 mmHg, and right ventricular hypertrophy. Given the 30-50% risk of mortality for parturients with PH, providing a safe anesthetic required extensive pre-delivery planning. Ultimately, we placed a central line, arterial line, and an epidural for cesarean delivery. Anesthesia included slowly titrating 2% lidocaine via epidural. Her intra- and post-operative courses were uncomplicated.

Discussion: Anesthesia for a parturient with PH included many considerations. Overall, the goal was to avoid increased pulmonary vascular resistance leading to right heart overload and possible cardiac collapse. To prepare for possible cardiopulmonary compromise, we involved cardiac anesthesiology and CT surgery. We had the OR set up for ECMO and TEE if needed. Choice of anesthetic method was highly debated. Spinal was ruled out as it is contraindicated due to associated hemodynamic instability. Therefore, we debated epidural vs general anesthesia (GA). Both methods may lead to undesirable physiologic changes. The disadvantages of GA included increased PAP with positive pressure ventilation, decreased contractility, and the possibility of a difficult airway in a patient with OSA, obesity, and pregnancy-related airway edema. To avoid those issues, epidural was chosen for this patient. However, we also debated the practicality of an epidural given the inability of our patient to lie flat, platelet count of 89, and possible need for intra-op TEE and/or heparinization for ECMO. Given those possibilities, we had to plan for possible conversion to GA. In that case, induction would need to be slow to minimize hemodynamic changes and difficult airway cart would be available. Monitoring and vascular access were additional considerations of pre-delivery planning. We chose to admit the patient to the ICU the day prior to delivery for line placement and further optimization. Arterial line is standard so blood pressure changes can be avoided or addressed quickly. Given the high chance of hemodynamic compromise, central line was placed to facilitate rapid fluid infusions and vasopressors. Because patients with PH have an increased risk of PA rupture and thrombosis, it is reasonable to forgo PA catheter placement as we did. Overall, due to such high mortality, and because several aspects of management for PH parturients are still debated, pre-delivery planning is a crucial process to create an individualized plan and provide the safest anesthetic.

1. Bonnin, M. et al. (2005) Anesthesiology 6:102, 1133-1137

2. Pieper, PG and Hoendermis, ES. (2011) Neth Heart J. Dec; 19(12): 504-508

SOAP 2019