|Year : 2017 | Volume
| Issue : 2 | Page : 100-102
Minimally invasive cardiovascular monitoring in patient with severe pulmonary hypertension for caesarean delivery
Rakesh Singla, Deep Arora, Hari H Dash
Department of Anaesthesiology and Pain Medicine, Fortis Memorial Research Institute, Gurgaon, Haryana, India
|Date of Web Publication||7-Nov-2017|
Department of Anaesthesiology and Pain Medicine, Fortis Memorial Research Institute, Gurgaon, Haryana
Source of Support: None, Conflict of Interest: None
Management of severe pulmonary hypertension in pregnancy poses a multitude of problems. This report presents a case of severe primary pulmonary hypertension for elective caesarean section managed successfully under combined spinal epidural anaesthesia with newer minimally invasive cardiac output monitoring.
Keywords: Caesarean section, pregnancy, pulmonary hypertension
|How to cite this article:|
Singla R, Arora D, Dash HH. Minimally invasive cardiovascular monitoring in patient with severe pulmonary hypertension for caesarean delivery. J Obstet Anaesth Crit Care 2017;7:100-2
|How to cite this URL:|
Singla R, Arora D, Dash HH. Minimally invasive cardiovascular monitoring in patient with severe pulmonary hypertension for caesarean delivery. J Obstet Anaesth Crit Care [serial online] 2017 [cited 2020 Nov 24];7:100-2. Available from: https://www.joacc.com/text.asp?2017/7/2/100/217768
| Introduction|| |
Primary (idiopathic) pulmonary hypertension (PH) in pregnancy is a rare but life threatening condition with a high mortality rate. Increased pulmonary vascular resistance (PVR) concomitant with haemodynamic changes of pregnancy is a nightmare for anaesthesiologists. Literature search revealed umpteen reports of such cases where caesarean delivery were managed with pulmonary artery catheter (PAC) monitoring.,, This case report highlights successful anaesthetic management of an elderly primigravida with severe primary pulmonary hypertension who underwent elective caesarean section under combined spinal epidural anaesthesia with newer minimally invasive cardiac output (CO) monitoring with good maternal and neonatal outcome.
| Case Report|| |
A 38-year-old elderly primigravida (conceived after in-vitro fertilization) weighing 72 kg presented in the obstetric outpatient department at 19 weeks of gestation with progressive dyspnea [New York Heart Association (NYHA) class III], palpitation, cough and pedal oedema. On two-dimensional echocardiogram, right atrium and right ventricle were dilated with right ventricle systolic dysfunction and severe tricuspid regurgitation. Right ventricular systolic pressure (RVSP) was 72 mmHg and left ventricular ejection fraction was 50%. Lower limb venous Doppler and D-dimer were normal. Diagnosis of primary (idiopathic) PH was made. The patient was counseled for medical termination of pregnancy to which she declined. She was started on frusemide 20 mg once daily, enoxaparin 60 mg subcutaneous once daily, aspirin 75 mg once daily and sildenafil 25 mg twice daily on outpatient basis. After treatment, her dyspnea and lower limbs oedema improved.
Patient was managed with a multidisciplinary approach including cardiologist, obstetrician and anaesthesiologist. She was planned for elective caesarean section at 35 weeks. There were no other symptoms except dyspnoea before surgery. Enoxaparin was stopped 24 hours prior to the surgery, and all other medications were continued as per schedule. Echocardiogram study on the day of surgery showed RVSP 90 mmHg. On examination, pulse rate was 118 per min, blood pressure was 130/82 mmHg, room air saturation was 92%, chest was clear and jugular venous pressure was raised. Haematological and biochemical investigations were within normal limits. Anaesthetic procedure was explained to the patient in detail and high-risk consent was obtained. In the operating room, the patient was oxygenated with a face mask; apart from the standard ASA monitoring, central venous pressure catheter in right internal jugular vein and left radial artery cannulation were done under local anaesthesia. An arterial pulse contour Lithium dilution cardiac output (LiDCO) monitor (Cambridge, United Kingdom) was attached through arterial line. Combined spinal epidural (CSE) at L3–L4 level in sitting position was placed, 25 μg fentanyl was given intrathecally and graded epidural keeping a close watch on CO monitor was given with 0.5% bupivacaine. A total of 13 ml (4 + 4 + 3 + 2) bupivacaine 0.5% over 18 min was administered which achieved spinal level of T6. Intraoperative haemodynamic recordings are shown in [Figure 1].
|Figure 1: Perioperative variation of systolic blood pressure, heart rate, systemic vascular resistance and cardiac output with time|
Click here to view
A female baby weighing 1770 g with an APGAR score of 7 at 1 min and 9 at 5 min was delivered. Oxytocin ten units i.v. slow infusion was continued. Dobutamine infusion (5 μg/kg/min) was started for hypotension following epidural boluses. Despite dobutamine, there was aggravation of hypotension along with decrease in systemic vascular resistance (SVR) and CO, which was detected early by CO monitor. Dobutamine infusion was discontinued and norepinephrine infusion (0.05 μg/kg/min) was started and vitals slowly restored to the baseline value. Rest of the surgery was uneventful and the patient was shifted to the intensive care unit (ICU). Norepinephrine infusion was tapered and stopped after 2 hours. Patient was kept in the ICU for 48 hours with CO monitoring. Lower dose of epidural morphine (1.5 mg/12 h) along with intravenous paracetamol was used for postoperative pain relief. Enoxaparin 40 mg subcutaneous once daily along with sildenafil 25 mg twice daily and frusemide 20 mg once daily was restarted 12-h postoperatively. Epidural catheter was removed after 48 h. Postoperative course of the patient was uneventful. The patient was discharged on the 6th postoperative day in stable condition.
| Discussion|| |
PH is defined as mean pulmonary artery pressure more than 25 mmHg at rest. Due to high maternal mortality rate in PH, patients are counseled to avoid pregnancy or opt for medical termination. Guidelines and standards are still lacking regarding anaesthesia technique in these patients. General anaesthesia with opioids and inhalational agents has been described by some authors because of better control of haemodynamic parameters with good maternal outcome. However, others have reported increased PVR during laryngoscopy and tracheal intubation, which may be detrimental for the patient. Recently graded epidural anaesthesia with appropriate monitoring has been recommended., Purpose of using combined spinal epidural in this case was because intrathecal fentanyl improves the quality of regional anaesthesia  and it is being practiced in our institution.
Systemic hypotension due to right ventricle failure from exacerbation of PH may result in dreaded complication. Prevention and management of hypotension using systemic vasoconstrictors and pulmonary vasodilators during the perioperative period is of paramount importance. Our patient developed hypotension (systolic blood pressure 100 mmHg from 130 mmHg) despite low-dose graded epidural boluses. Dobutamine infusion in low dose was started considering the beneficial effect on pulmonary vasculature and myocardial contractility. However, the hypotension got exacerbated probably due to decrease in SVR. To prevent further fall in blood pressure, dobutamine was stopped and noradrenaline infusion was started which maintained the blood pressure in normal range.
Our patient was receiving diuretic, anticoagulant and pulmonary vasodilator (sildenafil). Although sildenafil has been used in patients with PH during pregnancy, till date, there is no report of its ill effect on the foetus. One should be careful about interaction of sildenafil with nitrates, which may result in severe hypotension.
Invasive cardiovascular monitoring (PAC monitoring) has been recommended in patients with severe PH with pregnancy., Nevertheless, invasive monitoring have multiple limitations such as arrhythmia, pulmonary artery rupture, and systemic embolisation. Newer minimally invasive CO monitor provide real-time data on stroke volume, stroke volume variation, SVR and CO. It can also detect early haemodynamic changes and provides time to undertake appropriate intervention., Over the past several decades, mortality has declined from 30–56% to 17–33% because of better monitoring and better understanding of pathophysiology of PH.
| Conclusion|| |
A case of severe PH for elective caesarean section which was managed safely and effectively with slow-graded epidural with newer minimally invasive CO monitoring is described.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bédard E, Dimopoulos K, Gatzoulis MA. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension? Eur Heart J 2009;30:256-65.
Monagle J, Manikappa S, Ingram B, Malkoutzis V. Pulmonary hypertension and pregnancy: The experience of a tertiary institution over 15 years. Ann Card Anaesth 2015;18:153-60.
] [Full text]
Weeks SK, Smith JB. Obstetric anaesthesia in patients with primary pulmonary hypertension. Can J Anaesth 1991;38:814-6.
Kiely DG, Condliffe R, Webster V, Mills GH, Wrench I, Gandhi SV, et al
. Improved survival in pregnancy and pulmonary hypertension using a multiprofessional approach. BJOG 2010;117:565-74.
Duggan AB, Katz SG. Combined spinal and epidural anaesthesia for caesarean section in a parturient with severe primary pulmonary hypertension. Anaesth Intensive Care 2003;31:565-9.
Sangkum L, Liu GL, Yu L, Yan H, Kaye AD, Liu H. Minimally invasive or noninvasive cardiac output measurement: An update. J Anesth 2016;30:461-80.
Baron CM, Swedlo D, Funk DJ. Minimally invasive cardiac output monitoring for a parturient with pulmonary hypertension. Int J Obstet Anesth 2013;22:78-80.
Ma L, Liu W, Huang Y. Perioperative management for parturients with pulmonary hypertension: Experience with 30 consecutive cases. Front Med 2012;6:307-10.