Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Journal of Obstrectic Anaesthesia and Critical Care
Search articles
Home Print this page Email this page Small font size Default font size Increase font size Users Online: 332

 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 92-94

Postural orthostatic tachycardia syndrome: Anesthetic management in the obstetric patient


Department of Anesthesiology and Intensive Care, Souissi Maternity, Ibn Sina University Hospital; Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco

Date of Web Publication7-Oct-2016

Correspondence Address:
Dr. Youssef Motiaa
Department of Anesthesiology and Intensive Care, Souissi Maternity, Ibn Sina University Hospital; Faculty of Medicine and Pharmacy, Mohammed V University, Rabat
Morocco
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.191599

Rights and Permissions
  Abstract 

Postural orthostatic tachycardia syndrome (POTS) is an autonomic disorder which is characterized by postural tachycardia and orthostatic symptoms without associated hypotension. We report a case of a parturient, after her consent, with POTS, who underwent a cesarean section under spinal anesthesia. The anesthetic implications are also discussed.

Keywords: Postural orthostatic tachycardia syndrome, spinal anesthesia, tachycardia


How to cite this article:
Motiaa Y, Doumiri M, El Ouadghiri N, AnasTazi S. Postural orthostatic tachycardia syndrome: Anesthetic management in the obstetric patient. J Obstet Anaesth Crit Care 2016;6:92-4

How to cite this URL:
Motiaa Y, Doumiri M, El Ouadghiri N, AnasTazi S. Postural orthostatic tachycardia syndrome: Anesthetic management in the obstetric patient. J Obstet Anaesth Crit Care [serial online] 2016 [cited 2019 Dec 14];6:92-4. Available from: http://www.joacc.com/text.asp?2016/6/2/92/191599


  Introduction Top


Postural orthostatic tachycardia syndrome (POTS) is defined as the development of orthostatic intolerance symptoms accompanied by an increase in heart rate of at least 30 beats/min (or a rate that exceeds 120 beats/min), within the first 10 min of standing or head-up tilt, which occurs in the absence of other chronic debilitating disorders, prolonged bed rest, or medications that impair autonomic reflexes.[1],[2] Such patients complain of exercise intolerance, extreme fatigue, dizziness, diminished concentration, tremulousness, nausea, headache, near-syncope, and occasionally, syncope.[1] Mechanisms of POTS are uncertain, but some authors suggest adrenergic receptor hypersensitivity and partial dysautonomia as the likely causes.[3] It affects patients between 15 and 50 years of age and is seen predominately in young females (with a female:male ratio of 5:1).[1],[4] Treatment of patients with POTS is based on increasing their fluid and sodium intake. Medical therapies that can treat adrenergic symptoms include mineralocorticoid therapy, adrenoceptor agonists (midodrine), acetylcholinesterase inhibitors, and β-blockers.[5] Few publications have evaluated the specific anesthetic implications of POTS. In obstetrical patients, the tachycardia during labor and after a spinal anesthetic can simulate the symptoms of POTS.


  Case Report Top


A 23-year-old G1P0 parturient presented at 38 weeks gestation with spontaneous labor. Her medical history included POTS, for which she received mineralocorticoid (fludrocortisone 13 mg/day per os) and β-blockers (labetalol 100 mg/day). She was clinically stable with this treatment during a 2 years before the present pregnancy. Fludrocortisone was stopped at the beginning of the pregnancy; labetalol was also discontinued at 28 weeks due to hypotension. She weighed 68 kg and was 160 cm tall (body mass index = 26.56 kg/m 2).

On admission, the parturient was conscious, blood pressure was 100/63 mmHg, pulse rate was 90 beat per min (bpm), and she was in spontaneous labor and an obstetric ultrasound done at admission was normal. Thirty minutes after her admission, she had severe fetal distress for which a category one cesarean section was indicated. She was shifted to the operating room where basic monitoring – electrocardiogram, noninvasive blood pressure, and pulse oximetry were instituted.

Her basal blood pressure at this time was 116/80 mmHg and the pulse rate was 100 bpm. After infusion of crystalloid solution (500 ml isotonic saline), a spinal anesthesia was conducted in the L3–L4 level with 10 mg of bupivacaine, 0.1 mg of morphine, and 25 µg of fentanyl. During anesthesia, our objective was to anticipate blood volume change and to ensure good analgesia.

Blood pressure varied between 89–119 and 45–70 mmHg and her pulse rate between 70 and 95 bpm, with one episode of hypotension 85/45 mmHg treated by 200 ml of isotonic saline and 6 mg of ephedrine. A live female infant was delivered with Apgar scores of 9 at 1 min and 10 at 5 min.

After surgery, the patient was admitted to Intensive Care Unit, analgesia provided by paracetamol, nonsteroidal anti-inflammatory drugs, and morphine. The postoperative period was uneventful.

Fludrocortisone and labetalol were resumed on the following day, and the patient was discharged home on postpartum day 3.


  Discussion Top


Cesarean section in parturients with POTS under epidural anesthesia with or without necessity to convert to general anesthesia has been previously described.[5],[6],[7],[8] To the best of our knowledge, this is the first case report of spinal anesthesia in a parturient with POTS.

POTS is an autonomic disorder characterized by orthostatic intolerance. Based on pathophysiology, there are two subtypes: The first type, partial dysautonomia form (90% of cases), manifests as tachycardia in the upright position with symptoms of orthostatic intolerance such as lightheadedness, nausea, chronic fatigue, dependent edema, and acrocyanosis; the second type, hyperadrenergic form (<10%), manifests as increased serum norepinephrine levels (more than 600 pg/ml), tremulousness, anxiety, and an exaggerated response to β-adrenergic stimulation.[1] The specific anesthetic implications of POTS have not been described, but a lot of reports have discussed the anesthetic implications of dysautonomia.[9]

The relationship between pregnancy and POTS is uncertain. Blitshteyn et al. have described the clinical details of 10 parturients with a history of POTS, who had a total of 17 deliveries. They conducted a questionnaire-based study over 1 year in these women.

The authors concluded that POTS has a variable clinical course during pregnancy with 60% women reporting either improved or stable symptoms during pregnancy and 50% of women reporting either improved or stable symptoms 6 months after delivery. They also inferred that these women have a higher incidence of severe vomiting during the first trimester of pregnancy as compared to general population.[10]

In our case, the parturient did not report exacerbation of symptoms during pregnancy. Fludrocortisone was stopped in early pregnancy because of the increased blood volume and water retention due to estrogen and an increase in aldosterone secretion; β-blocker was stopped because of the hypotension.

Labor has some implications in patients with POTS, especially during the second stage: Pain and stress may worsen tachycardia. In these patients, there is a larger decrease in blood pressure during early phases of a valsalva maneuver, with a subsequently larger overshoot of blood pressure and heart rate in the late phases, showing an overall greater hemodynamic instability as compared to parturients without POTS.[11] In addition, peripheral vasodilatation and hypotension, which may result from epidural or spinal anesthesia, may worsen this hemodynamic instability.[8] Earlier authors have preferred epidural to spinal anesthesia to prevent hemodynamic instability in such patients. In a systemic review, Ng et al.[12] have concluded that both spinal and epidural anesthesia provide adequate anesthesia for cesarean sections but spinal anesthesia has quicker onset and requires more interventions to treat hypotension as compared to epidural anesthesia.

In this case, spinal anesthesia was administered because of the need to carry out a quick cesarean section in view of severe fetal distress requiring fetal extraction in <30 min.[13]


  Conclusion Top


Subarachnoid block is a suitable option in parturients with POTS requiring urgent cesarean section.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kanjwal Y, Kosinski D, Grubb BP. The postural orthostatic tachycardia syndrome: Definitions, diagnosis, and management. Pacing Clin Electrophysiol 2003;26:1747-57.  Back to cited text no. 1
[PUBMED]    
2.
Thieben MJ, Sandroni P, Sletten DM, Benrud-Larson LM, Fealey RD, Vernino S, et al. Postural orthostatic tachycardia syndrome: The Mayo clinic experience. Mayo Clin Proc 2007;82:308-13.  Back to cited text no. 2
[PUBMED]    
3.
Jacob G, Biaggioni I. Idiopathic orthostatic intolerance and postural tachycardia syndromes. Am J Med Sci 1999;317:88-101.  Back to cited text no. 3
[PUBMED]    
4.
Benrud-Larson LM, Dewar MS, Sandroni P, Rummans TA, Haythornthwaite JA, Low PA. Quality of life in patients with postural tachycardia syndrome. Mayo Clin Proc 2002;77:531-7.  Back to cited text no. 4
[PUBMED]    
5.
Powless CA, Harms RW, Watson WJ. Postural tachycardia syndrome complicating pregnancy. J Matern Fetal Neonatal Med 2010;23:850-3.  Back to cited text no. 5
[PUBMED]    
6.
Jones TL, Ng C. Anaesthesia for caesarean section in a patient with Ehlers-Danlos syndrome associated with postural orthostatic tachycardia syndrome. Int J Obstet Anesth 2008;17:365-9.  Back to cited text no. 6
[PUBMED]    
7.
Corbett WL, Reiter CM, Schultz JR, Kanter RJ, Habib AS. Anaesthetic management of a parturient with the postural orthostatic tachycardia syndrome: A case report. Br J Anaesth 2006;97:196-9.  Back to cited text no. 7
[PUBMED]    
8.
McEvoy MD, Low PA, Hebbar L. Postural orthostatic tachycardia syndrome: Anesthetic implications in the obstetric patient. Anesth Analg 2007;104:166-7.  Back to cited text no. 8
[PUBMED]    
9.
McGrane S, Atria NP, Barwise JA. Perioperative implications of the patient with autonomic dysfunction. Curr Opin Anaesthesiol 2014;27:365-70.  Back to cited text no. 9
    
10.
Blitshteyn S, Poya H, Bett GC. Pregnancy in postural tachycardia syndrome: Clinical course and maternal and fetal outcomes. J Matern Fetal Neonatal Med 2012;25:1631-4.  Back to cited text no. 10
[PUBMED]    
11.
Stewart JM, Medow MS, Montgomery LD, Glover JL, Millonas MM. Splanchnic hyperemia and hypervolemia during Valsalva maneuver in postural tachycardia syndrome. Am J Physiol Heart Circ Physiol 2005;289:H1951-9.  Back to cited text no. 11
[PUBMED]    
12.
Ng K, Parsons J, Cyna AM, Middleton P. Spinal versus epidural anaesthesia for caesarean section. Cochrane Database Syst Rev 2004;(2):CD003765.  Back to cited text no. 12
[PUBMED]    
13.
Figueireido S, Tsatsaris V, Mignon A. Anaesthetic management for acute fetal distress. Ann Fr Anesth Reanim 2007;26:699-704.  Back to cited text no. 13
[PUBMED]    



This article has been cited by
1 Hypermobile Ehlers-Danlos Syndrome during pregnancy, birth and beyond
Sally Pezaro,Gemma Pearce,Emma Reinhold
British Journal of Midwifery. 2018; 26(4): 217
[Pubmed] | [DOI]



 

Top
 
 
Search
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References

 Article Access Statistics
    Viewed4727    
    Printed50    
    Emailed0    
    PDF Downloaded341    
    Comments [Add]    
    Cited by others 1    

Recommend this journal