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CSE for Cesarean Section in a Parturient with Ebstein’s Anomaly
Abstract Number: RF4BD-48
Abstract Type: Case Report Case Series
Case Presentation:33 yo G2P1 female at 39 weeks gestation with Ebstein’s anomaly(EA) presents for a repeat cesarean section (c/s) and bilateral tubal ligation.Patient was diagnosed with EA during her first pregnancy at 27 weeks gestation. During this current pregnancy she experienced intermittent episodes of SOB which resolved on their own.TTE showed 3.1 cm apical displacement of the tricuspid valve, RVSP was 40-45 mmHg during the first trimester. Third trimester TTE showed RVSP of 30 mmHg and EKG showed RBBB.We placed two large bore IVs and an a-line preoperatively. A low dose combined spinal epidural (CSE) with 7.5 mg bupivacaine, 25 mcg fentanyl, and 0.2 mg morphine was administered for the c/s.A phenylephrine gtt was started at the time of intrathecal injection. We monitored her cardiac function intraoperatively during the c/s with TTE.Overall, both patient and her baby did well and no long-term complications were identified postoperatively.
Discussion: EA consists of an anatomically abnormal tricuspid valve, which results in atrialization of the right ventricle with concomitant tricuspid regurgitation(1).Associated abnormalities include ASD, PFO, and tachyarrhythmias(1).Clinical presentation varies by age and degree of symptoms; diagnosis is made by echocardiography.Patients with EA have an assorted clinical course and many women who attain childbearing age desire pregnancy.Vaginal delivery is recommended, however there is a higher risk for these patients to require cesarean section(2). There is limited data regarding anesthetic techniques for obstetric patients with EA undergoing cesarean section. We showed low dose CSE to be safe and effective; CSE may be favorable for these patients, especially when a shorter onset is desired. Of note, our patient did not have an ASD.Patients with both EA and an ASD develop right to left shunt and subsequent hypoxemia with decreases in afterload. CSE may be tolerable in that subset of patients, but as of now it is unknown.
1.Ross FJ, Latham GJ, Richards M, Geiduschek J, Thompson D, Joffe D. Perioperative and Anesthetic Considerations in Ebstein’s Anomaly. Seminars in Cardiothoracic and Vascular Anesthesia 2016;20(1):82–92.
2.Lima FV, Koutrolou-Sotiropoulou P, Yen TYM, Stergiopoulos K. Clinical characteristics and outcomes in pregnant women with Ebstein anomaly at the time of delivery in the USA: 2003–2012. Archives of Cardiovascular Diseases 2016;109(6–7):390–8.