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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 1  |  Page : 54-57

Anaesthetic management of caesearean section in a patient with severe uncorrected coarctation of aorta: A case report and literature review


Department of Anaesthesia, PGIMER, Chandigarh, India

Date of Web Publication13-Apr-2018

Correspondence Address:
Dr. Nitika Goel
Department of Anaesthesia, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_37_17

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  Abstract 


Perioperative management of parturients with congenital heart disease is a challenge for the anaesthesiologist. The choice of anaesthetic technique plays an important role in determining the postoperative outcome of such patients. We report a 35 weeks primigravida diagnosed with coarctation of aorta in early pregnancy. She had normal antenatal course but at 35 weeks she presented with uncontrolled upper limb hypertension. She was planned for early elective caesarean section in view of presence of imment HELLP syndrome. Here, we discuss the anaesthetic challenges and their perioperative management leading to favourable outcome of the patient.

Keywords: Anaesthesia, caesarean, coarctation of aorta


How to cite this article:
Goel N, Sen I, Mandal B, Prassana V. Anaesthetic management of caesearean section in a patient with severe uncorrected coarctation of aorta: A case report and literature review. J Obstet Anaesth Crit Care 2018;8:54-7

How to cite this URL:
Goel N, Sen I, Mandal B, Prassana V. Anaesthetic management of caesearean section in a patient with severe uncorrected coarctation of aorta: A case report and literature review. J Obstet Anaesth Crit Care [serial online] 2018 [cited 2019 Dec 10];8:54-7. Available from: http://www.joacc.com/text.asp?2018/8/1/54/230060




  Introduction Top


The incidence of congenital heart disease has been reported to be 0.4–0.9% of live births.[1],[2],[3] Due to advanced medical and/or surgical management, >85% of children with congenital heart disease survive to adulthood. Congenital defects diagnosed for the first time in adult life include atrial septal defects, pulmonary stenosis, bicuspid aortic valve and coarctation of the aorta (CoA).[4] Perioperative management of caesarean section in a patient with CoA is challenging. Physiological alterations in pregnant females with CoA can cause severe hypertension, cerebrovascular accident or aortic rupture.[5] We present the successful management of a patient scheduled for caesarean section having severe uncorrected CoA.

Case Report

A 26-year-old primigravida was referred to our institute with history of increased blood pressure readings in right upper limb compared to left upper limb and left lower limb for the last 6 months of period of gestation. During her antenatal check-up at private hospital, she was diagnosed with coarctation of aorta and referred to our institute for further management. She was average built weighing 60 kg. Her pulse rate was 60/min, regular and normal volume with blood pressure of 150/80 mmHg in right upper limb and 110/70 mmHg in left upper limb. Patient denied history of chest pain, palpitations, syncope, tachycardia or headache. She belonged to New York Heart Association (NYHA) functional Class II. 2 D Echo examination showed diameter of aortic arch before brachiocephalic artery 23 mm, after left carotid artery 14 mm, just before left subclavian artery 7 mm, gradient across the narrowing was 94 mmHg. There was no patent ductus arteriosus, ventricular septal defect or bicuspid aortic valve. On auscultation, a pansystolic murmur was present in aortic area and radiofemoral delay was present. Her initial treatment consisted of tablet Amlodipine 2.5 mg twice a day. At 32s weeks' period of gestation, she had persistently high blood pressure records not being controlled with amlodipine alone. She was hospitalized and prescribed tablet Labetalol 200 mg thrice a day. Her blood pressure, urine albumin, haemogram, liver function tests were serially monitored. Her blood pressure was variable as shown in [Figure 1]. Her haemogram showed decreasing platelet count and deranged liver function tests. In view of imminent HELLP syndrome, a decision for early caesarean section was made. Her preoperative investigations showed hemoglobin 12 g/dl, platelet count of 90,000/mm 3, SGOT 65U/L, SGPT 70U/L. On airway examination, she had mallampatti grade of II with normal mouth opening and neck movements.
Figure 1: The variation in blood pressure between right and left upper limbs during the hospital stay in the preceding days before surgery.

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She was premedicated with injection ranitidine 50 mg, injection metoclopramide 10 mg intravenous half hour before shifting to operation theatre. Amoxycillin 1 g and gentamicin 120 mg were given IV before shifting to operation theatre for endocarditis prophylaxis. Electrocardiagraphy, pulse oximetry and both right radial artery and left dorsalis pedis were cannulated for invasive blood pressure monitoring. Central line was also inserted in right internal jugular vein after giving local anaesthetic. Her baseline blood pressure was 250/130 mmHg in right upper limb and 150/110 mmHg in left lower limb with heart rate of 110/minute. Nitroglycerin infusion was started at 0.5 μg/kg/min to lower the right limb blood pressure before induction. Titrated doses of labetalol were also given preoperatively; total 40 mg of labetalol was given before induction. Blood pressure decreased to 220/140 mmHg in right upper limb and 140/90 mmHg in left lower limb. Anaesthesia was induced with injection fentanyl 50 ug, injection thiopentone 150 mg and succinylcholine 100 mg IV. Injection xylocard 60 mg was given 60 seconds before endotracheal intubation to blunt the intubation response. Trachea was intubated using 7.5 mm ETT. Intermediate acting muscle relaxant atracurium was administered. Balanced general anaesthesia was given with oxygen and nitrous oxide (1:1 ratio) with isoflurane using 8 ml/kg tidal volume at rate of 12 breaths/min on volume controlled ventilation. Just before skin incision, a local infiltrate of 2% lignocaine 8 ml was given along the incision site. Heart rate ranged between 80–90/min during intubation. The mean arterial pressure in right upper limb was maintained between 90–100 mmHg and left lower limb between 60–70 mmHg [Figure 2]. No episode of hypotension occurred intraoperatively. Maximum nitroglycerin infusion rate was 3 mcg/kg/min. Left uterine displacement was ensured throughout surgery and a live male baby weighing 2180 grams was delivered. Apgar scores were 9 and 10 at 1 and 5 min, respectively. After the delivery, she was administered a slow injection of dilute oxytocin 5 units, followed by an oxytocin infusion at 10 units/hour for 4 hours. After delivery of baby, injection Morphine 4.5 mg IV was given. Perioperatively, patient received 900 mL of balanced salt solution and estimated blood loss during surgery was 500 mL.
Figure 2: The following figure shows the intraoperative hemodynamic variations in right upper limb and left lower limb. SBP-systolic blood pressure. DBP-diastolic blood pressure

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At the end of the surgery, residual neuromuscular blockade was reversed with IV glycopyrrolate 0.4 mg and neostigmine 2.5 mg and trachea was extubated. A local infiltrate with 8 ml of 0.25% bupivacaine was also given along the incision. Patient was shifted to the intensive care unit (ICU) for monitoring. Post operatively, nitroglycerin was tapered off and she was started on tablet amlodipine 10 mg once a day. In ICU, she had complete pain relief with injection Tramadol 100 mg thrice daily and paracetamol 1 g thrice daily. Further, ICU stay was uneventful and the patient was shifted to the ward on the second day and discharged home on the fifth day.


  Discussion Top


Pregnancy in women with CoA is associated with maternal mortality of 3–9% and foetal mortality of up to 20%.[6] Pregnant women with aortic coarctation may present in several ways. Most commonly they have a history of previous surgical repair. The majority of preductal coarctation are diagnosed in the neonatal period and are corrected surgically in infancy. Preductal coarctation is associated with patent ductus arteriosus, ventricular septal defect, bicuspid aortic valve and transposition of great vessels. Occasionally, when coarctation is postductal, it may be diagnosed initially during pregnancy when a cause for hypertension is sought [7] or when aortic dissection occurs.[8] They may be associated with berry aneurysm (in 10% cases) and bicuspid aortic valve (in 50% cases).[7]

Our patient had isolated preductal coarctation diagnosed during pregnancy due to hypertension. The prime concern for anesthetic management in our patient was to keep mean arterial pressure (MAP) distal to coarctation above 60 mmHg in order to maintain placental perfusion while avoiding maternal hypertension. Poorly controlled maternal hypertension and aortic wall intimal changes can lead to increased risk of aortic rupture or dissection especially in third trimester.[9],[10],[11] The choice of anaesthetic technique plays an important role in determining the perioperative outcome of CoA patients posted for non cardiac surgery. There are case reports describing successful outcomes for parturients with a history of aortic coarctation, delivered both vaginally and by caesarean section.[12] Though regional anaesthesia have been known to decrease systemic vascular resistance in patients with fixed ventricular outflow obstruction, there are reports of successful outcome of pregnancy following regional anaesthesia. Benny et al. reported uneventful vaginal delivery in a parturient with a congenital uncorrected aortic coarctation, gradient not reported, facilitated with lumbar epidural analgesia.[13] Yavuz et al. have described successful administration of spinal anaesthesia for caesarean section in a patient with surgically corrected coarctation of aorta.[5] In another case report by Bourgeade et al., they have described the administration of spinal epidural for caesarean section in an uncorrected CoA patient. However, patient had intraoperative hypotension which was managed with vassopressors.[14] Ruys et al. have described successful use of epidural anaesthesia for caesarean section in a patient with native coarctation of aorta.[15] They avoided general anaesthesia due to occurrence of haemodynamic changes with intubation and incision. Amongst the case reports so far, none of them reported systolic pressure gradient ranging more than 100 mmHg. Since the administration of regional anaesthesia can lead to preload and afterload reduction in a patient with fixed left ventricular outflow obstruction,[16] thus compromising the placental perfusion, we preferred to give general anaesthesia in our patient. We decided to first establish the invasive haemodynamic monitoring with two invasive arterial lines and central venous pressure line. Thereafter, we tried to reduce the upper limb hypertension with nitroglycerin infusion and intermittent bolus of injection labetalol 10 mg. Once the systolic gradient between upper and lower limb reached 80 mmHg, slow and titrated doses of anaesthetic agents were administered taking care not to cause haemodynamic changes with intubation or incision while also maintaining the placental perfusion. Vasodilator infusion initiation before administration of anaesthesia decreased the blood pressure hike following intubation. Other measures like administration of injection Xylocard, Labetalol and infiltration of local anaesthetic across the incision site were also beneficial in reducing the sympathetic responses following intubation and incision. The effectiveness of nitroglycerin, xylocard and labetolol in reducing the intubation response has been previously documented in both pregnant and non-pregnant states.[17],[18],[19] There is one reported case by Theodore et al.[16] where successful remifentanil-based general anaesthetic technique for caesarean section in a parturient with recurrent aortic coarctation has been described. Remifentanyl infusion was started before induction which maintained stable hemodynamics during intubation and incision. Our approach was to administer general anaesthesia under aggressive hemodynamic monitoring, while preserving the mean arterial pressure in lower limb between 60–70 mmHg using titrated doses of nitroglycerin and inhalation agent. Meticulous attention was given to maintaining an adequate intravascular volume and preserving sinus rhythm, while avoiding tachyarrhythmias and systemic hypotension. To avoid hypotension and tachycardia in response to oxytocin, dilute oxytocin 5 units over 5 minutes followed by slow intravenous infusion of 10 units per hour under haemodynamic monitoring was done.


  Conclusion Top


Women in child bearing age with congenital heart disease should undergo proper preconceptional counselling and the maternal, fetal and neonatal risks should be thoroughly discussed with the patient.[20] Those with significant CoA contemplating pregnancy should undergo repair before pregnancy. For women who become pregnant, serial follow-up by a specialized multidisciplinary team throughout pregnancy and postpartum period is required.[20] The delivery should be properly planned and be conducted in the presence of obstetrician, anaesthetist and cardiologists. Should a caesarean section is planned, appropriate invasive hemodynamic monitoring is established and aggressive management of hemodynamic disturbances should be done.[21],[22] Moreover, the role of maintaining adequate depth of anaesthesia and providing good analgesia cannot be undermined.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Bourgeade F, Malinovsky JM. Anaesthetic management for caesarean section in a parturient with uncorrected coarctation of the aorta. Ann Fr Anesth Reanim 2010;29:642-4.  Back to cited text no. 14
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Ruys TPE, Bekkers JA, Duvekot JJ, Roos-Hesselink JW. A Pregnant Patient with Native Aortic Coarctation and Aneurysm. Aorta 2014;2:110-2.  Back to cited text no. 15
    
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Theodore R, Manullang TR, Chun K, Egan TD. The use of remifentanil for cesarean section in a parturient with recurrent aortic coarctation. Can J Anaesth 2000;47:454-9.  Back to cited text no. 16
    
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Van den Berg AA, Savva D, Honjol NM. Attenuation of the haemodynamic responses to noxious stimuli in patients undergoing cataract surgery. A comparison of magnesium sulphate, esmolol, lignocaine, nitroglycerine and placebo given i. v. with induction of anaesthesia. Eur J Anaesthesiol 1997;14:134-47.  Back to cited text no. 18
    
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