|Year : 2012 | Volume
| Issue : 1 | Page : 50-52
Anesthetic management of caesarean section in a patient with double outlet right ventricle
Rohith Krishna, Umesh Goneppanavar
Department of Anaesthesiology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
|Date of Web Publication||4-Aug-2012|
Department of Anaesthesiology, Kasturba Medical College, Manipal University, Manipal, Karnataka-576104
Source of Support: None, Conflict of Interest: None
Double outlet right ventricle (DORV) is a rare congenital heart defect involving the great arteries. In DORV, both aorta and pulmonary artery arise from the right ventricle resulting in admixture of blood. We report a 22-year-old parturient with DORV and severe pulmonary stenosis who underwent caesarean delivery at 36 weeks gestation with low dose combined spinal-epidural anesthesia. This lady was assessed by echocardiogram to have situs inversus, dextrocardia, severe pulmonary artery stenosis (gradient = 146 mm Hg), DORV with subarterial VSD (1 cm). She had 95% room air saturation and her blood investigations were within normal limits. We established a peripheral venous access and radial arterial line for continuous blood pressure monitoring. Combined spinal epidural anesthesia was considered a better option. Epidural catheter was secured at L 2 -L 3 space and fixed after giving test dose 3 mL 2% lignocaine. Subarachnoid block administered at L 3 -L 4 level using 1.2 mL of 0.5% heavy bupivacaine. A sensory block of T 10 was obtained which was supplemented with 4 mL 0.75% ropivacaine to obtain a level of T 6 . Patient tolerated the procedure well. She was shifted to post-operative ICU. Post-operative pain was managed with epidural 0.2% ropivacaine at 4 mL/h. Patient remained hemodynamically stable throughout the procedure and in the postoperative period while she was being followed up for subsequent 48 h.
Keywords: Caesarean section, combined spinal epidural anesthesia, double outlet right ventricle
|How to cite this article:|
Krishna R, Goneppanavar U. Anesthetic management of caesarean section in a patient with double outlet right ventricle. J Obstet Anaesth Crit Care 2012;2:50-2
|How to cite this URL:|
Krishna R, Goneppanavar U. Anesthetic management of caesarean section in a patient with double outlet right ventricle. J Obstet Anaesth Crit Care [serial online] 2012 [cited 2021 May 10];2:50-2. Available from: https://www.joacc.com/text.asp?2012/2/1/50/99328
| Introduction|| |
Appropriate management of the parturient with cardiac disease has to take into account the potential inability of the maternal cardiovascular system to compensate for normal pregnancy induced physiologic changes since this may result in deleterious effects on both mother and fetus. Double outlet right ventricle (DORV) is a rare congenital heart defect involving the great arteries. In DORV, the aorta and the pulmonary artery both arise from the right ventricle resulting in mixing of oxygenated blood with deoxygenated blood. Because of the great diversity in anatomical and pathophysiological implications in these patients, definite recommendations for peripartum management are not available. In this article, we report anesthetic management of a lady with DORV for Caesarean section and discuss the problems that may be encountered during management.
| Case Report|| |
A 22-year-old lady with DORV and severe pulmonary stenosis was scheduled for elective Caesarean section at 36 weeks. Her echocardiogram revealed situs inversus, dextrocardia, severe pulmonary stenosis (gradient = 146 mm Hg), and DORV with sub-arterial VSD (1 cm). She was scheduled for elective LSCS in view of previous LSCS which was also done under central neuraxial block. On examination, room air saturation was 95%, pulse rate 108/min, BP 116/65 mm Hg. Hematological investigation and bleeding profile were normal with a hematocrit value of 50% (Hb 16.5 g/dL). The patient was counseled preoperatively about her existing cardiac conditions and the possible intraoperative and postoperative complications. Phenylephrine (50 μg/mL) was specially loaded and kept for BP control during surgery. Preoperatively, after establishing ECG, SpO 2 , and NIBP, we secured a peripheral venous access and radial arterial line for continuous blood pressure monitoring. Combined spinal epidural anesthesia was considered a better option rather than general anesthesia. Epidural catheter was secured at L 2 -L 3 space while the spinal anesthetic was administered at a lower space L 3 -L 4 level with 1.2 mL 0.5% heavy bupivacaine. Epidural catheter was tested to be correctly in place with a test dose of 3 mL 2% lignocaine followed by another 2 mL 2% lignocaine. The spinal anesthetic achieved a sensory block of T 10 which was supplemented by epidural 0.75% ropivacaine (4 mL) to obtain a sensory level up to T 6 . Beat to beat monitoring of the blood pressure, heart rate, and SpO 2 was done throughout the procedure. There were no episodes of hypotension or bradycardia. The patient tolerated the procedure well. Oxytocin 15 unit in 500 mL normal saline was given after the delivery of the baby over 1 h. Intense monitoring of the hemodynamics was continued into the postoperative period in the high dependence unit while the patient received epidural infusion of 0.2% ropivacaine at 4 mL/h for postoperative analgesia. The patient remained hemodynamically stable throughout the postoperative stay of 48 h in the high dependency unit following which she was discharged to the ward.
| Discussion|| |
The incidence of cardiac disease in pregnant patients in developed countries ranges from 0.2% to 3% and the incidence in developing countries may be still higher. Early studies have reported that 44% women with cardiac disease develop pulmonary edema in the third trimester of pregnancy. ,
Risk factors for adverse neonatal and maternal cardiac outcomes among cardiac parturients have been identified. Poor maternal NYHA functional class or cyanosis, myocardial dysfunction, left heart obstruction, prior arrhythmia, and prior cardiac events have been shown to be independent predictors of maternal cardiac complications. Pulmonary edema, arrhythmia, and stroke complicate 13% of pregnancies in women with cardiac disease. In addition, maternal cyanosis has been shown to be a risk factor for fetal and neonatal complications such as spontaneous abortion, preterm delivery, and severe IUGR due to low maternal oxygen saturation and high blood viscosity. ,,,
DORV is a rare congenital cyanotic heart disease with an incidence of 0.5-0.8 per 10000 births.  Anesthetic management of these challenging parturients has been described with only few reports in the contemporary anesthesia literature. Major intraoperative hemodynamic concerns in patients with single ventricle (complex cyanotic heart diseases) usually include the following: myocardial performance is likely to be negatively impacted by long-standing alterations in cardiac chamber pressures and/or volumes, as well as chronic hypoxaemia. This places these individuals at increased risk for hemodynamic compromise or cardiovascular collapse during anesthesia if there is further reduction in myocardial contractility, systemic vascular resistance, or myocardial blood flow. Other concerns are the presence of chronic cyanosis, polycythaemia that might precipitate cyanotic spell in the perioperative period.
Caesarean delivery in such patients may either be done under general anesthesia or central neuraxial block depending upon the patient's presentation and her responses to physiological changes of pregnancy with cardiovascular stability being the goal. We chose to perform combined spinal epidural anesthetic technique. Low dose spinal anesthetic will result in minimal hemodynamic consequences while ensuring rapid onset of block and absence of sacral sparing. Further enhancement of the level of the block can easily be done by repeated small boluses of epidural local anesthetic thus minimizing the chances of significant hemodynamic instability. We choose to use epidural ropivacaine (0.75%) as it is found to be a more cardio stable drug.  Post-operative pain management is also very crucial as pain free patient can be mobilized early with lesser post-operative complications like thromboembolism. ,,
Although the echocardiogram showed a complex cardiac anatomy, our patient was well preserved and her room air saturation was 95% with a hematocrit of 50%. Furthermore, she had tolerated the physiological changes of all stages of pregnancy without any complications during antenatal period. We had the option of doing this procedure under either general anesthesia or combined spinal anesthesia or epidural anesthesia. We choose central neuraxial blockade as a choice for anesthesia with low dose spinal anesthesia followed by gradual extension of the block level to T 6 dermatome by epidural supplements. This was done to ensure that sacral sparing which is observed during epidural anesthesia when it is used as sole anesthetic would be prevented by the administration of low dose spinal anesthetic. While at the same time, low dose spinal anesthetic would ensure rapid onset of a low thoracic or upper lumbar level sensory motor blockade with minimal sympathetic blockade thus preventing hemodynamic disturbances. Further enhancement of blockade can easily be achieved with gradual, small, and incremental boluses of epidural local anesthetic thus allowing body enough time to adjust for sympathetic blockade. On the other hand, general anesthesia (with or without supplemental epidural anesthesia) could have resulted in sudden precipitous fall in blood pressure as rapid sequence induction with precalculated dose of intravenous induction agent would have had to be administered.
Most commonly seen immediate complications with central neuraxial blockade are hypotension and bradycardia. These need to be treated when the fall is more than 20% of the baseline value. In patients with complex congenital anomalies, 50-100 μg phenylephrine boluses are used to treat hypotension as this would improve systemic vascular resistance without increasing the heart rate or decreasing the uterine blood flow.  In view of this, we opted to monitor invasive blood pressure to know beat to beat variability that would help us identify and treat hypotension aggressively. Oxytocic drugs such as oxytocin and ergometrine that improve uterine contraction may also contribute to hemodynamic instability. While oxytocin can induce vasodilatation and arterial hypotension, ergometrine can cause arterial hypertension. These adverse cardiovascular effects may be catastrophic in patients with complex congenital heart disease when administered rapidly or given in high dose. Hence, titrated dose of oxytocin should be used and ergometrine should be avoided. ,
In summary, we report the successful use o[f low dose combined spinal epidural anesthesia for cesarean section in a parturient with DORV, in which both maternal and neonatal outcomes were good.
| References|| |
|1.||Lovell AT. Anaesthetic implications of grown-up congenital heart disease. Br J Anaesth 2004;93:129-39. |
|2.||Szekely P, Turner R, Snaith L. Pregnancy and the changing pattern of rheumatic heart disease. Br Heart J 1973;35:1293-303. |
|3.||Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001;104:515-21. |
|4.||Siu SC, Sermer M, Harrison DA, Grigoriadis E, Liu G, Sorensen S, et al. Risk and predictors for pregnancy-related complications in women with heart disease. Circulation 1997;96:2789-94. |
|5.||Presbitero P, Somerville J, Stones S, Aruta E, Spiegelhalter D, Rabajoli F. Pregnancy in cyanotic congenital heart disease. Outcome of mother and fetus. Circulation 1994;89:2673-6. |
|6.||Whittemore R, Hobbins JC, Engle MA. Pregnancy and its outcome in women with or without surgical treatment of congenital heart disease. Am J Cardiol 1982;50:641-51. |
|7.||Pradat P, Francannet C, Harris JA, Robert E. The epidemiology of cardiovascular defects, part I. A study based on data from three large registries of congenital malformations. Pediatr Cardiol 2003;24:195-221. |
|8.||Bajwa SS, Bajwa SK, Kaur J. Comparison of epidural ropivacaine and ropivacaine clonidine combination for elective cesarean sections. Saudi J Anaesth 2010;4:47-54. |
|9.||Landau R, Giraud R, Morales M. Sequential combined spinal-epidural anesthesia for cesarean section in a woman with a double-outlet right ventricle. Acta Anaesthesiol Scand 2004;48:922-6. |
|10.||Ben-David B, Miller G, Gavriel R, Gurevitch A. Low dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery. Reg Anesth Pain Med 2000;25:235-9. |
|11.||Crowhurst JA, Birnbach DJ. Small-dose neuraxial block: Heading towards the new millennium. Anesth Analg 2000;90:241-2. |
|12.||Ngan Kee WD, Khaw KS, Tan PE, Ng FF, Karmakar MK. Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology 2009;111:506-12. |
|13.||Lupton M, Oteng-Ntim E, Ayida G, Steer PJ. Cardiac disease in pregnancy. Curr Opin Obstet Gynecol 2002;14:137-43. |
|14.||Uebing A, Steer PJ, Yentis SM, Gatzoulis MA. Pregnancy and congenital heart disease. BMJ 2006;332:401-6. |