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Cesarean in a Parturient with a Complicated Tetralogy of Fallot Repair
Abstract Number: RF2AB-257
Abstract Type: Case Report Case Series
Congenital heart defects (CHD) are susceptible to complications such as arrhythmias, endocarditis, heart failure, pulmonary hypertension and valvular disease. In this case report we discuss a 28-year-old female with a history of Tetralogy of Fallot (TOF) repaired with right ventricle (RV) to pulmonary artery (PA) valve conduit complicated by stent re-stenosis.
The patient is a 28 yo G2P1 with history of TOF complicated by pulmonary atresia repaired with a Blalock-Thaussig shunt followed by three sternotomies including a RV to PA valve conduit. This conduit stenosed and required balloon valvuloplasty with stent placement during her first pregnancy nine years prior.
During this pregnancy, at 20 weeks EGA she reported dyspnea with minimal exertion and was found to have moderate to severe RV outflow obstruction with RV hypertrophy and preserved systolic function on echocardiogram. Pulmonary transcatheter valve replacement was deferred at that time and a Holter monitor noted no significant arrhythmias. At 31 weeks EGA she was evaluated by obstetric anesthesiology with a plan for admission at 37 weeks EGA for a repeat cesarean section at our tertiary care facility.
For delivery, an epidural catheter and radial arterial line were placed. 8mL of 1.5% lidocaine with 1:200,000 epinephrine and 100mcg of fentanyl were then administered slowly via epidural over 10 minutes. Hypotension was treated with phenylephrine and an uneventful delivery occurred 13 minutes after incision. Blood loss was 1100mL and the patient received 800mL of lactated Ringer’s. She was admitted to the surgical intensive care unit and discharged on postop day 3. She is now being evaluated for potential intervention of the re-stenosed valve conduit.
Cardiovascular events in pregnant women with corrected TOF occur at a rate of 12%, most commonly arrhythmias1. Maternal use of cardiovascular medication is the best predictor for cardiovascular events2. Our patient did not experience a heart failure exacerbation during her pregnancy, most likely attributed to her valve conduit stenosis being compensated by right ventricular hypertrophy and preserved systolic function.
Previous case reports show that elective cesarean sections can be performed safely with a slow sequential CSE or gradual epidural dosing3. This avoids sharp decreases in SVR caused by spinal or general anesthesia, however phenylephrine should be available to treat decreases in SVR. Patients need close fluid management for optimal preload to the right ventricle and a vigilant eye must be kept on blood loss. Continuous blood pressure monitoring allows the anesthesiologist to respond quickly to hemodynamic changes.
Communication between provider teams is essential. Cases should be performed at an institution where obstetric anesthesiology, cardiology, maternal fetal medicine, critical care, and neonatology teams are readily available.
1 Meijer 2005
2 Balci 2011
3 Baidya 2012