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Dural Puncture Epidural Technique for Cesarean Delivery in Parturient with Postural Orthostatic Tachycardia Syndrome
Abstract Number: RF5BH-382
Abstract Type: Case Report Case Series
A 23-year-old nulliparous patient at 39w0d gestation with complex medical history including debilitating postural orthostatic tachycardia syndrome (POTS) with associated daily episodes of vertigo and syncope presented for scheduled cesarean. Past medical history includes hypermobility type Ehler-Danlos (ED), platelet storage pool deficiency, severe asthma and nighttime hypoxia, mitochondrial disease, and gastroparesis with recent requirement for TPN and enteral feeding access. Despite mild-range HTN, her day of surgery labs were reassuring. Per hematology recommendations for her platelet disorder, she received DDAVP 1 hour prior to case and TXA during her hospitalization.
Dural puncture epidural (DPE) with 25-g spinal needle was performed without issue with simultaneous normal saline and IV phenylephrine infusions, with frequent noninvasive blood pressure monitoring (every 1-2 minutes). Eight minutes later, after epidural was dosed with 8 mL of 2% lidocaine with epinephrine, the patient became symptomatically hypotensive with systolic blood pressure of 50 mmHg. This was treated with additional phenylephrine and the epidural was successfully dosed to a T4 level for the case. Surgery was typical with the delivery of a healthy neonate, and mother and infant were discharged to home as expected after planned postoperative observation.
Postural orthostatic hypotension syndrome includes a heterogeneous group of conditions without clear definition and is often associated with underlying conditions. Annually 500,000 Americans are diagnosed, with a strong predominance for females aged 15-50. Diagnostic criteria include a heart rate increase of 30 bpm or to >120 bpm within 5-30 minutes of standing, and may include the presence of hypotension. Other reasons for tachycardia should be excluded, and tilt-table testing or measurement of upright plasma norepinephrine concentration may be utilized for diagnosis(1). Preferred treatment of hypotension in obstetric patients is IV phenylephrine, and this appears to be useful therapy for patients with POTS and hypotension(2).
We focus on the anesthetic selection for cesarean delivery in severe POTS and using DPE technique, and include discussion of the perioperative management of the patient’s comorbidities. We predicted that hemodynamic changes would be minimized by avoiding spinal anesthesia, while improving the density of analgesia and speeding the onset of surgical blockade as described for labor analgesia(3). While the patient did develop hypotension soon after dosing epidural, careful monitoring of blood pressure allowed for rapid detection and treatment, and the remainder of the operative courses was uneventful.
1. J Cardiovasc Electrophysiol. 2009 Mar; 20(3): 352–358
2. A&A. 2007 Jan; 104(1): 166-7
3. A&A. 2008 Nov; 107(5):1646-51