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Anesthetic Management for Cesarean Delivery in a Parturient with Unrepaired Coarctation of the Aorta
Abstract Number: RF3AC-388
Abstract Type: Case Report Case Series
Background: A 24 year-old G2P1 female at 39/0 presented to the Labor and Delivery floor of our tertiary care center for a scheduled repeat cesarean delivery. She was diagnosed as a child in the Dominican Republic with coarctation of the aorta (CoA) which was never surgically corrected. Her previous cesarean delivery took place under presumed spinal anesthesia due to failure to progress and without complications per patient.
Case Report: Prior to presentation to the Labor and Delivery floor, the patient was sent by her obstetrician to both cardiology and obstetric anesthesiology for pre-operative consultation. Cardiology noted that she had coarctation of the descending thoracic aorta distal to the takeoff of the left subclavian artery. It was mild with a normal ejection fraction, normal wall motion and no valvular disease. Peak velocity was 4.4 m/sec and mean gradient was 34 mmHg. She did not have a blood pressure differential by Doppler in her upper and lower extremities. Cardiology had obtained records from the Dominican Republic and confirmed that her first delivery occurred under spinal anesthesia. Given their evaluation, Cardiology was in favor of proceeding with regional anesthesia for her repeat cesarean delivery. After an extensive discussion in anesthesiology pre-operative clinic which included both obstetric and pediatric anesthesiologists, the decision was made to proceed with epidural anesthesia for secondary cesarean delivery. On the day of her scheduled delivery, the patient was brought to the operating room and standard monitors were applied. An epidural was placed without issue and slowly dosed to an adequate level while the patient’s blood pressure was frequently measured and supported by low dose phenylephrine. The fetal heart rate was also monitored closely during this time. Once adequate anesthesia was obtained, the cesarean delivery proceeded without complication.
Discussion: CoA accounts for 6 to 8 percent of all congenital heart defects with a reported prevalence of approximately 4 per 10,000 live births (1,2). CoA is frequently corrected prior to childbearing age. When uncorrected in pregnant women they prompt evaluation and discussion between a number of consultants including obstetrics, cardiology and anesthesiology to formulate the safest delivery plan for both mother and baby. In this case, the patient presented with adequate time to obtain appropriate consultation and determine an interdisciplinary plan for a healthy delivery.
(1) Yetman AT, Starr L, Sanmann J, Wilde M, Murray M, Cramer JW. Clinical and Echocardiographic Prevalence and Detection of Congenital and Acquired Cardiac Abnormalities in Girls and Women with the Turner Syndrome. Am. J. Cardiol. 2018 Jul 15;122(2):327-330.
(2) Bjornard, K., Riehle-Colarusso, T., Gilboa, S. M. and Correa, A. Patterns in the prevalence of congenital heart defects, metropolitan Atlanta, 1978 to 2005. Birth Defects Res Part A: Clin Mol Teratol. 2013;97:87–94.