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Point of care ultrasonography: (POCUS): An efficient tool for maternal cardiac evaluation during operative delivery
Abstract Number: RF4AD-391
Abstract Type: Case Report Case Series
Point of care ultrasonography (POCUS) has proven to be a useful diagnostic tool in the evaluation of an increasing number of obstetric patients with complex congenital heart disease and cardiovascular risk.1-2 We present a case in which a single handheld probe was utilized for neuraxial guidance and for cardiac ultrasonography in a patient with a mechanical prosthetic mitral valve.
A 22-year-old G1P0, with a past medical history of rheumatic heart disease, and mechanical heart valve was admitted for a scheduled cesarean delivery (CD) secondary to fetal malpresentation. At 37 wks, external cephalic version was attempted but proved unsuccessful. At this point, she was transitioned from warfarin to heparin (UFH). A dose of 19,000 Units three times a day was needed to achieve therapeutic goal. After a multidisciplinary meeting between cardiology, maternal fetal medicine and anesthesiology, the plan was to stop anticoagulation 24h before cesarean delivery time.
Given normal coagulation profile the morning of the surgery, spinal anesthesia was deemed safe. The Butterfly iQ ultrasound was utilized to mark the desired interspace at L3-L4 level. A Spinal anesthesia with bupivacaine 0.75% 1.6 ml, fentanyl 15 mcg and preservative free morphine 0.1 mg was performed. In addition, a parasternal long axis, short axis, and an apical view were obtained without needing to bring additional equipment into the operating theatre. The intra-operative course was uneventful. Intravenous UFH was started 6 h after cesarean delivery. Her post-operative course was complicated by the development of bilateral rectus sheath hematoma on post-operative day 3 in the setting of anticoagulation. After adjusting the anti-coagulation regimen, the patient had a satisfactory recovery without further surgical intervention and was discharged home on post-operative day 13.
As cardiovascular disease continues to be a leading cause of maternal mortality1, the addition of a handheld transthoracic echocardiogram (TTE) to our diagnostic toolbox seems opportune. The implementation of POCUS is often limited by a lack of accessibility to training opportunities and the resources necessary to learn new effective skills (i.e. TTE). At our institution, we propose an algorithm in conjunction with cardiology to improve our imaging acquiring and interpreting skills (See Figure below).
1. Int J Obstet Anesth 2018. [Epub ahead of print]
2. Int J Obstet Anesth 2011;20:160–8