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Slowly Titrated Spinal Anesthesia for Cesarean Delivery (CD) in a Super-Morbidly Obese Parturient with Peripartum Cardiomyopathy
Abstract Number: RF5AH-357
Abstract Type: Case Report Case Series
Peripartum cardiomyopathy and super-morbid obesity are associated with significant morbidity in pregnancy. There are few cases reporting the use of spinal catheters for CD in patients with heart disease or morbid obesity (1-4). We report on the use of slowly titrated spinal anesthesia in a super-morbidly obese patient who presented with peripartum cardiomyopathy at risk for acute decompensation requiring repeat CD.
A 28 year-old G2P1 female, at 36 weeks and 5 days gestation, presented after a fall. The patient had reassuring fetal status, however, she also reported dyspnea over the last month. Medical history included hypertension, asthma, tobacco use, super-morbid obesity (BMI 81), gestational diabetes mellitus type A2, and previous CD for failure to progress. Physical exam was significant for dyspnea, excessive somnolence, snoring, and wheezing. A chest CT showed a massively dilated main pulmonary artery with right heart dilation, concerning for pulmonary hypertension. TTE showed an ejection fraction of 30-34% compared to 60-64% at 28 weeks gestation suggestive of peripartum cardiomyopathy. A multidisciplinary meeting with obstetrics, maternal-fetal medicine, anesthesiology, and critical care teams recommended CD at 37 weeks. A radial arterial line was placed. A spinal catheter was inserted at L3-4 level and confirmed by CSF aspiration. 20mcg fentanyl and 0.1mg morphine were injected intrathecally and 0.25% isobaric bupivacaine was titrated slowly using 0.5mg boluses every minute over 20 minutes (total 10mg) to achieve a T4 sensory level. An additional 1.25mg of 0.25% bupivacaine was injected over 3 minutes 20 minutes later. Phenylephrine and epinephrine infusions were titrated as needed. Total IV fluids were 450ml. Postoperative course was uneventful.
Peripartum cardiomyopathy is defined as development of heart failure between 1 month before delivery and 5 months postpartum in patients without prior heart disease and in the absence of another cause of heart failure. We chose to slowly titrate local anesthetic to avoid spinal-induced hypotension. Phenylephrine and epinephrine were used for hemodynamic and inotropic support and to prevent worsening of pulmonary hypertension. This case presents an alternative method of anesthesia for CD in high risk patients with heart disease and morbid obesity.
1. Velickovic IA, et al. Continuous spinal anesthesia for cesarean section in a parturient with severe recurrent peripartum cardiomyopathy. Int J Obstet Anesth 2004;13:40-3
2. Sakuraba S, et al. Continuous spinal anesthesia and postoperative analgesia for elective cesarean section in a parturient with Eisenmenger's syndrome. J Anesth 2004;18:300-3
3. Velickovic I, et al. Continuous spinal anesthesia for obstetric anesthesia and analgesia. Front Med 2017;4:1
4. Polin CM, et al. Anesthetic management of super-morbidly obese parturients for cesarean delivery with a double neuraxial catheter technique: a case series. Int J Obstet Anesth 2015;24:276-280