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MEDICAL TERMINATION OF PREGNANCY IN THE PRIMARY PULMONARY HYPERTENSION SETTING: UNIQUE CONSIDERATIONS OF OPIOID-ONLY SPINAL ANESTHESIA
Abstract Number: RF6AI-150
Abstract Type: Case Report Case Series
INTRODUCTION: Pregnancy-induced pathophysiological changes exacerbate a parturient’s pulmonary hypertension (PH) PH, It has significant negative effect on most organ systems but specifically, the patient’s cardiopulmonary well-being.1 This case demonstrates the successful management of a dilation and curettage at 10 weeks of gestation, in a patient with idiopathic PH, which was complicated by uterine atony leading to a significant hemorrhage.
CASE: A 22-year old- G-P- at 10 weeks gestation and a known history of idiopathic PH presented for elective termination of pregnancy. She was diagnosed with idiopathic PH during her previous pregnancy three years back. The patient was prescribed 3 liters. min-1 of home oxygen by nasal cannula at night time and was being considered for eventual heart and lung transplantation. The patient presented with mild to moderate dyspnea and orthopnea. Her vital signs were a heart rate of 70 beats/min, blood pressure of 100/60 mmHg, respiratory rate of 20 breaths/min with an oxygen saturation of 92% on 3L. min-1 via nasal cannula. A spinal anesthetic using just 25mcg of fentanyl was instilled at the L3-4 interspace using a 27-gauge pencil-point needle. She was then placed in stirrups in the lithotomy position and a paracervical block was performed by the obstetrician using 10 ml of 1% Lidocaine, without epinephrine. The surgical procedure was completed within 10 minutes and the products of gestation were completely evacuated. Immediately thereafter, the patient began to hemorrhage secondary to uterine atony. The obstetrician requested for the attending anesthesiologist to administer a bolus of 10 units oxytocin followed by an infusion. A calculated risk/benefit assessment was made, and the authors elected for administering an oxytocin infusion in escalating dosage as opposed to a bolus method. The oxytocin infusion with 60 units in 1 liter of lactated ringer’s solution was carefully titrated to an infusion rate of 500 ml.hr-1, until the bleeding subsided. At this time, the estimated blood loss was noted to be 600 ml. The patient remained hemodynamically stable throughout the 15-min event of increased uterine bleeding and had an uneventful recovery.
DISCUSSION: Our observations reveal that spinal opioids, in conjunction with a paracervical block, are an effective and safe anesthetic approach during elective termination of pregnancy in the parturient with pulmonary hypertension in need of stringent hemodynamic control.2 Furthermore, the use of oxytocin infusion in escalating doses was successful in terminating the uterine atony.3 In case of PH patients, the physician should always anticipate and have a therapeutic algorithm in place for every complication that may occur in the perioperative period.
1. Tuder RM et al. J Am Coll Cardiol 2013;62(25 suppl.): D4–D12.
2. Craig M et al. Anesthesiology 1998;88(2):355-361.
3. Steinauer JE. Obstet Gynecol 2008; 111:881–9.