|Year : 2016 | Volume
| Issue : 2 | Page : 98-100
Anesthetic management of a parturient with primary pulmonary hypertension with Eisenmenger's syndrome
Kirti N Saxena, Bharti Taneja
Maulana Azad Medical College, New Delhi, India
|Date of Web Publication||7-Oct-2016|
Dr. Kirti N Saxena
B-302, Geetanjali Apartments, Vikas Marg Extension, New Delhi - 110 092
Source of Support: None, Conflict of Interest: None
Labor and delivery are associated with high mortality in parturients with primary pulmonary hypertension with Eisenmenger's syndrome. Epidural anesthesia during labor has been shown to be effective in reducing the morbidity and mortality. We administered epidural labor analgesia successfully to a parturient with primary pulmonary hypertension with Eisenmenger's syndrome. A team approach for such patients leads to successful outcome.
Keywords: Eisenmenger's syndrome, epidural analgesia, labor analgesia, primary pulmonary hypertension
|How to cite this article:|
Saxena KN, Taneja B. Anesthetic management of a parturient with primary pulmonary hypertension with Eisenmenger's syndrome. J Obstet Anaesth Crit Care 2016;6:98-100
|How to cite this URL:|
Saxena KN, Taneja B. Anesthetic management of a parturient with primary pulmonary hypertension with Eisenmenger's syndrome. J Obstet Anaesth Crit Care [serial online] 2016 [cited 2019 Dec 6];6:98-100. Available from: http://www.joacc.com/text.asp?2016/6/2/98/191604
| Introduction|| |
Increasing number of patients with congenital heart disease are now surviving into adulthood. Many such women present with pregnancy. Patients with right ventricular outflow tract lesions have higher complications in the form of right-sided heart failure and arrhythmias. Primary pulmonary hypertension is now recognized as a separate genetic entity and is usually associated with ventricular or atrial septal defect. Eisenmenger's syndrome is a cyanotic congenital heart disease that includes pulmonary hypertension with reversed or bidirectional shunt associated with septal defects or patent ductus arteriosus. Management of the patient should be by a multidisciplinary team consisting of a cardiologist, obstetrician, anesthesiologist, and pediatrician to look after the neonate who is also at risk.
| Case Report|| |
A 28-year-old primigravida was admitted in our hospital at 23-week pregnancy with breathlessness. She was a known case of primary pulmonary hypertension (PHT) with atrial septal defect (ASD) with left-to-right shunt diagnosed 1 year ago by echocardiography. She had been diagnosed as belonging to NYHA class I by the cardiologist. Treatment was started with digoxin and furosemide, after which she steadily improved and became asymptomatic. During pregnancy, her condition worsened. She deteriorated from NYHA class I to NYHA class II and came to the hospital. The cardiologist diagnosed her as having Eisenmenger's syndrome with severe PHT by echocardiography. She was started on tablet warfarin and sildenafil and the doses of digoxin and furosemide were increased.
At 34 weeks of pregnancy, warfarin was substituted with subcutaneous heparin 5000 intravenous twice daily, and dexamethasone 6 mg twice a day was started; the patient was kept in the hospital then on. Preanesthetic checkup revealed a prolonged end diastolic murmur heard in the pulmonary area, however, the patient had no signs of failure. All blood investigations were normal except International Normalization Ratio (INR), which was 1.6. Her electrocardiogram (ECG) showed right bundle branch block, intraventricular conduction defect, and inferior wall ischemia. Arterial blood gas (ABG) analysis showed PaO2 of 70 mmHg, pCO2 of 34 mmHg, and base excess of −4 mEq/L. Patient was kept under close monitoring in the obstetric ward. Regular ABG analysis was performed as advised by the cardiologist and her PaO2 reduced to 52 mmHg after a week; she was kept on oxygen by ventimask with FiO2 of 0.5.
She went into spontaneous labor at 36 weeks and a request for labor analgesia was received by the anesthesiologist. She had been given the last dose of heparin 10 hours earlier. She was shifted to the operation theatre (OT) in the first stage of labor, in left lateral position on oxygen by ventimask. In the OT, her pulse rate was 102/min, blood pressure 100/60, and spO2 was 88% on FiO2 of 0.5. The patient was in early labor and was experiencing mild pain. After co-loading with 500 ml of Ringers lactate solution, a lumbar epidural catheter was inserted and test dose given with lignocaine. The catheter was charged with 8 ml 0.0625% bupivacaine +2 mcg/ml fentanyl. Analgesia was achieved and SpO2 improved to 90–92% immediately. The baby was delivered by Ventouse application to shorten the second stage of labor. Following the delivery, SpO2 improved further to 94%. The uterus was massaged by the obstetrician, methergin was avoided and oxytocin was used to help the uterus to contract. Patient withstood the procedure well and there was normal blood loss of approximately 500 ml. She was shifted to the intensive care unit for further monitoring and to watch for cardiac decompensation following labor. Epidural catheter was maintained in the postoperative period and was topped up with 8 ml 0.0625% bupivacaine (without fentanyl) twice at 4-hour intervals. The catheter was removed after 12 hours after assessing the coagulation profile of the patient. She was started on low molecular weight heparin 4 hours after the removal of the catheter. She continued to maintain saturation of 95–98% and was shifted to a high dependency unit after 24 hours. She was discharged from the hospital 10 days later on treatment with tablet Bosentan 62.5 mg and digoxin 0.25 mg once daily, sildenafil 12.5 mg and lasix 20 mg twice daily, and warfarin 3 mg on alternate days as advised by the cardiologist.
| Discussion|| |
Primary pulmonary hypertension is now recognized as a distinct congenital heart disease. Pregnancy is not known to be tolerated well by patients having primary pulmonary hypertension with Eisenmenger's syndrome. The drug treatment includes diuretics, digoxin, and pulmonary vasodilators such sildenafil (pulmonary vasodilator) and bosentan (oral, nonspecific endothelin-1 receptor antagonist and pulmonary vasodilator). Oral anticoagulants are given for thromboprophylaxis as large number of deaths have been reported due to pulmonary embolism.
The maternal mortality rate is estimated at 30–50%, accounting for approximately 50% of the maternal mortality in parturients with congenital heart disease. Death occurs most often at the time of delivery or in the early postpartum period. Cardiovascular changes that occur during labor are tolerated well by parturients with normal physiology. These physiological changes can cause decompensation and failure in patients with Eisenmenger's syndrome. Pain and bearing down during labor are particularly harmful for such patients. Epidural labor analgesia was used for reducing stress, reduction of preload, and reduction of afterload, which helps accommodate autotransfusion, thus preventing right heart failure. Phenylephrine was kept for use in case severe hypotension and increase of right to left shunt occurred. Obstetrical management included early use of Ventouse to reduce the maternal bearing down.
Neuraxial blockade has been used previously for cesarean section but rarely for delivery in such patients. Robinson et al. and Bansal et al. used continuous epidural analgesia administered with 0.25% bupivacaine with fentanyl for a parturient with Eisenmenger's syndrome for labor analgesia. They reasoned that with an epidural catheter in place it would be easy to administer incremental doses of local anesthetic, and it would be simple to tailor the anesthesia in case cesarean section was required. Cole et al. used a spinal catheter to administer incremental spinal anesthesia for this purpose. All these workers removed the epidural/spinal catheter following delivery. However, the risk of the patient going into failure is higher in the post-delivery period, and has been found to last up to 12 hours. With this in mind, the indwelling epidural catheter was for a further 12 hours and gave increments of only 0.0625% bupivacaine, the effect of which was expected to last a further 4 hours after the last dose given before removal of the catheter. No fentanyl was given as analgesia is not required following vaginal delivery but only sympathetic blockade was provided to accommodate the autotransfusion of blood. Local anesthetics themselves have some antithrombotic effect in addition to the antithrombotic effect of regional anesthesia, hence risk of thromboembolism was not present in this period. Fluid management in these patients is a two-edged sword and fluids need to be given cautiously, therefore, co-loading was done in our patient with only 500 ml of Ringer's lactate solution. The other drugs were continued as advised by the cardiologist.
| Conclusion|| |
To conclude, mortality at delivery can be reduced by multidisciplinary management of parturients with Eisenmenger's syndrome. Neuraxial blockade has provided a successful modality of management in this regard.
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Conflicts of interest
There are no conflicts of interest.
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