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Home , Tetralogy of Fallot

International Journal of Current Medical And Applied Sciences, 2020, January, 25(2), 35-37.

CASE REPORT Anaesthetic Management in A Case of A Parturient with Uncorrected Tetralogy of Fallot For Cesarean Section. Shilpa Loya1 & Mitalee Pareek2 1Consultant Anaesthesiologist, 2Resident, Department of Anaesthesia, MGM Medical College & Hospital, Aurangabad [MS], India. ------Abstract: - Tetralogy of Fallot is the most common cyanotic congenital disease. Uncorrected TOF is hardly seen in adulthood. We report the anaesthetic management of a patient with uncorrected Fallot's tetralogy for Cesarean section. A 25 years old G3P2D2 patient came to the outpatient department at 33 weeks gestational age for routine antenatal checkup. Patient was a known case of Tetralogy of Fallot, diagnosed at 7 months of amenorrhoea. She came with no complaints of breathlessness, chest pain, palpitations, dyspnea on exertion or bluish discoloration of limbs. History of previous two intrauterine deaths were given suggestive of bad obstetric history. Keywords- Tetralogy of Fallot, , Adult ToF, Cesarean section.

Introduction: Tetralogy of fallot (ToF) is the most common form of exertion or bluish discoloration of limbs. History of cyanotic congenital heart disease after 1 year of age, previous two intrauterine deaths were given with overall incidence approaching 10% of all suggestive of bad obstetric history. Her pulse rate was congenital heart disease [1]. Prevalence of adult ToF is 92 beats/min and her blood pressure was 142/90 approximately 1 in 3500 to 1 in 4300 [2], whereas mmHg. There was no variation of pulse and blood prevalence of pregnancy with ToF is 0.08% [3]. pressure in the extremities. When sitting, her SPO2 on Uncorrected cyanotic heart disease carries a high risk room air was 93%. USG was suggestive of a single live in pregnancy for both mother and [4]. intrauterine pregnancy of average maturity of 33 Discussed below is a case of a 25 years old, 36 weeks weeks and 6 days with IUGR. gestational age and IUGR, with bad obstetric history in Patient was vitally stable with cardiovascular system a known case of uncorrected Tetralogy of Fallot, examination suggestive of clearly audible S1S2, loud diagnosed at 7 months of amenorrhoea. P2 and pan systolic murmur of grade 3 in the Case Report: pulmonary as well as aortic areas on auscultation. A 25 years old G3P2D2 patient came to the Out Patient Patients lab reports were as follows- Hb: 11.8, TLC: department at 33 weeks gestational age for routine 10480, Platelets: 284000, Creat: 0.7, Na: 130, K- 3.4, antenatal checkup. Patient was a known case of TSH: 2.6. Tetralogy of Fallot, diagnosed at 7 months of ECG- Sinus Tachycardia with P pulmonale and Right amenorrhoea. She came with no complaints of axis deviation was seen along with Q waves in V1, V2, breathlessness, chest pain, palpitations, dyspnea on V3. ------Address for correspondence: Dr. Shilpa Loya, Access this Article Online Consultant Anaesthesiologist, Department of Anaesthesiology, MGM Medical College & Hospital, Website: Aurangabad [MS], India. www.ijcmaas.com Email ID- [email protected] How to cite this article: Shilpa Loya & Mitalee Pareek : Anaesthetic Management In A Case Subject: of A Parturient With Uncorrected Tetralogy of Fallot For Medical Sciences Cesarean Section.: International Journal of Current Medical and Quick Response Code Applied sciences; 2020 25(2), 35-37.

IJCMAAS, E-ISSN: 2321-9335,P-ISSN:2321-9327 Page | 35 Shilpa Loya & Mitalee Pareek 2DECHO- , LVEF-55 to 65%, CCHD- ventricular septal defect so that does not Tetralogy of fallot, large outlet VSD with bidirectional occur [5]. shunt, severe pulmonary valvular stenosis of gradient The four components of TOF are malaligned 68mm, prolapse, mild mitral ventricular septal defect (VSD), obstruction to right regurgitation, good biventricular function. ventricular (RV) outflow, aortic overriding of VSD After obtaining cardiologist s opinion, she was posted and right (RVH) due to the for an elective cesarean section. High risk consent RV seeing aortic pressure via large VSD[4]. The was taken. Patient was accepted’ under ASA grade 3 relationship between resistance of blood flow from high risk for LSCS by 37 weeks of GA, along with ventricles into and into the pulmonary vessels avoidance of fluid overload and tachycardia and plays a major role in determining the hemodynamic compulsory Infective endocarditis prophylaxis. The and clinical picture. Severe pulmonary vessel patient was started on Tb. MetXl (metoprolol) obstruction causes marked reduction in pulmonary 12.5mg OD and Tb. Dytor (torsemide) 10mg OD after blood flow and a large volume of desaturated diagnosis. systemic venous blood is shunted from right to left An USG-guided 18G Central Venous catheter was across VSD [6]. inserted into the Right Internal Jugular Vein. The cvp In pregnant patients with TOF, the decrease in was measured from the sternum as the reference peripheral resistance that accompanies pregnancy point using a manometer and the reading was 6-8 cm augments right to left shunt and may exaggerate H20 throughout the surgery. maternal cyanosis, which poses risks for both mother All emergency drugs and defibrillator were kept and fetus [7]. Diseases complicated by severe ready. Peripheral IV line 20G was secured in right maternal hypoxemia are likely to lead to miscarriage, hand. Patient was preloaded with 500ml of lactated preterm delivery or fetal death. Patients with TOF ringer s solution before the start of surgery. Patient have an increased risk of fetal loss or their offsprings was induced under General Anaesthesia with Inj. are more likely to have congenital anomalies. Adverse Thiopentone’ 250mg and Inj. Succinyl Choline 100mg maternal events can be associated with left as induction agents. Scopy was done using McCoy ventricular dysfunction, severe pulmonary blade no.3 and Cuffed endotracheal tube no.7 was hypertension and severe pulmonic regurgitation with inserted under vision. The cuff was inflated and air RV dysfunction. Anaesthetic goals of a patient with entry checked bilaterally. Intermediate acting muscle Tetralogy of Fallot remains to prevent 1) acidosis, 2) relaxant Inj. Atracurium 20mg and Inhalational agent hypoxia, 3) hypercarbia, 4) hypovolaemia, 5) Isoflurane with Oxygen and Air at 50:50 ratio were maintaining SVR and minimizing PVR. The tet spell given to maintain adequate depth of anaesthesia. A or hypercyanotic attacks are generally triggered by a single top up of Inj. Atracurium 5mg was given decrease in SVR or a spasm of cardiac muscle“ in the” intraoperatively. Inj. 100mcg was given region of the RVOT, resulting in an increase in the after the delivery of the baby. [8]. Factors responsible Inj. Lasix 10mg and Inj. Esmolol 10mg was given to to increase right to left intracardiac shunt are- 1]. the patient before extubation to control the magnitudeDecreased systemicof the R→L vascular shunt resistance, 2]. Increased tachycardia and hypertension during extubation. pulmonary vascular resistance, 3]. Increased The surgery lasted for 1 hour and the patient was myocardial contractility [9]. reversed with Inj. Glycopyrrolate 0.5mg + Inj. However, a major objective of intraoperative Neostigmine 2.5mg and smoothly extubated after eye management is to promote tissue oxygen delivery by opening, adequate neck holding, obeying oral preventing arterial desaturation, maintaining a commands and maintenance of 100% SPO2 by balance between pulmonary and systemic flows, and patient. IV paracetamol 1g was then administered for by optimizing hematocrit [10]. postoperative analgesia. General anesthesia is commonly used in these BP was maintained throughout between 144/90 and patients. Many of the agents used for induction and 136/90 mmHg and pulse rate which was 96 maintainance of general anesthesia depress beats/min before the induction of anaesthesia came myocardial function and reduce SVR. Also, it is down to 86 beats/min at the end of the procedure. associated with adverse hemodynamic response to Patient was shifted to the Cardiac Care Unit for laryngoscopy. It can cause rise in PVR due to hypoxia, observation post surgery. The postoperative period hypercarbia, acidosis, hypothermia and positive was uneventful and she was discharged on the 7th pressure ventilation. Still, general anesthesia is postoperative day with the advice to undergo surgical considered a technique of choice as it offers a benefit intervention. of better oxygenation [8]. There were no adverse intraoperative event or any Discussion: fall in blood pressure or decrease in oxygen While it is highly unusual for ToF to go undiagnosed saturation below 90% in the intraoperative period. until adulthood, it does happen typically in cases such Adrenergic agonist phenylephrine was kept ready in as this when there is a perfect balance in childhood case of emergency. between the narrowing of the pulmonic valve and the

Logic Publications @ 2020, IJCMAAS, E-ISSN: 2321-9335,P-ISSN:2321-9327. Page | 36

Logic Publications @ 2020, IJCMAAS, E-ISSN: 2321-9335,P-ISSN:2321-9327.

Conclusion: section. Anesth Essays Res. 2012 Jul-Dec; 6(2): The Intraoperative and Postoperative management of 244–246. a patient with uncorrected TOF posted for LSCS 5. Gösta Pettersson and Richard Krasusk. Tetralogy proves to be a great challenge for an of Fallot in Adults: What to Do When the anaesthesiologist and should be treated in a tertiary Diagnosis Is — and Is Not — a Surprise. hospital. A team of experts including an https://consultqd.clevelandclinic.org/tetralogy- of-fallot-in-adults-what-to-do-when-the- anaesthesiologist, an obstetrician and a cardiologist diagnosis-is-and-is-not-a-surprise should be considered for core management of such a 6. Child JS, Friedman WF. Congenital heart disease patient. A thorough pre-operative evaluation and in the adult. In: Kasper DL, et al., meticulous preparation for management of such a editors. Harrison's Principles of Internal patient intra-operatively, will give excellent post- Medicine. 16th ed. New York: McGraw Hill operative results. Publishers; 2005. p. 1389. 7. Douglas Mann Douglas Zipes Peter Libby Robert References: Bonow . Braunwald’s Heart Disease A textbook 1. Sinto R., Nasution S.A., Pregnancy in a woman of cardiovascular medicine, 8th ed.;2007 p.1971. with uncorrected a Tetralogy of Fallot. Acta Med 8. Vasanti P. Kelkar, Ankita Nathani, Sanhita J. Indones. 2009 Apr;41(2):81-6. Kulkarni. Anaesthetic Management of A Patient 2. Bhimji S., Ali Y.S. Tetralogy of Fallot (TOF) in with Tetralogy of Fallot Undergoing Non Cardiac Adults. Medscape: Nov 13, 2018 Surgery. Indian Journal of applies research; https://emedicine.medscape.com/article/20359 2016; 6(11), 92-93. 49-overview 9. Hines RL, Maranets I, Marschall KE,editors. 3. J M Meijer, P G Pieper, W Drenthen, A A Voors, J Congenital Heart Disease In: Stoelting’s W Roos-Hesselink, A P J van Dijk, B J M Mulder, T Anaesthesia and Co-existing disease. 5th edition. Ebels, and D J van Veldhuisen. Pregnancy, P 50-3. fertility, and recurrence risk in corrected 10. Maxime Canneson, Michael G. Earing, Vincent tetralogy of Fallot . Heart. 2005 Jun; 91(6): 801– Collange, Judy R. kertse. Anesthesia for non 805. in adults with congenital heart 4. Chitra Juwarkar & Sidhesh S. Bharne. disease. Anesthesiology 2009; 111:432-40 . Anaesthesia management of a parturient with uncorrected tetralogy of fallot for caesarean ------

Conflict of interest: None declared Source of funding: None declared

International Journal of Current Medical And Applied Sciences [IJCMAAS], Volume: 25, Issue: 2 Page | 37