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Dermatomyositis and Pregnancy: Inflaming An Already Complicated Situation
Abstract Number: RF2BB-222
Abstract Type: Case Report Case Series
We present a 35yo G3P1011 parturient at 26 and 2 GA with decreased fetal movement. Her medical history is remarkable for severe dermatomyositis and myopathy with progressive dysphagia, dysarthria, proximal muscle weakness, restrictive lung disease, asthma and poor functional status, multiple psychiatric illnesses, and cleft palate repair as a child. Her pregnancy was complicated by an acute pulmonary embolism, treated with Lovenox 1mg/kg twice a day. Upon admission for monitoring, she was transitioned to a heparin infusion to treat her pulmonary embolism. Uterine ultrasound exam showed breech fetus, IUGR and absent umbilical artery diastolic flow. Clinical course included category two fetal heart tracings, therefore, on hospital day 3, urgent cesarean delivery was indicated. Heparin was held for four hours in an attempt to allow possibility for neuraxial blockade. General anesthesia was reserved for non reassuring fetal well being. After heparin hold, PTT normalized, and she received a combined spinal epidural as primary anesthetic. The mother tolerated the procedure and delivery without complication. On assessment he was 0.45 kg, APGAR scores were 5 and 8. He was hemodynamically stable and transferred to the NICU. Of note, the mother’s hospital course was complicated by aspiration pneumonia and acute hypoxic respiratory failure not related to anesthesia.
Dermatomyositis is an inflammatory myopathy with systemic effects including esophageal dysfunction, restricted temporomandibular joint and decreased cervical spine mobility. These risks factors combined with pregnancy create the potential for difficult airway and aspiration. Dermatomyositis is associated with prolonged weakness after general anesthesia and there are not contraindications to succinylcholine or volatile agents (1). Our patient’s cleft palate repair, lung disease and concerning fetal status made general anesthesia undesirable. Neuraxial anesthesia was performed, however, anticoagulation in the setting of a pulmonary embolism can be a relative contraindication. The current recommendations advice to hold high dose low molecular weight heparin for 24 hours prior to neuraxial anesthesia and intravenous heparin infusion for 4-6 hours(2). We transitioned our patient to a heparin infusion in order to treat the pulmonary embolism and decrease the wait time in anticipation of an elective procedure(3). We detail a careful balance between anticipating complications and multiple competing risk factors in a multidisciplinary fashion for safe delivery of a compromised infant.
1.J Clin Anes. 2018 Nov;50,59-60
2. A&A. 2017 Aug
3. Current Cardio Vas. 2018 July;20