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Anesthetic Implications for Cesarean Section in a Parturient with Complex Congenital Cyanotic Heart Disease

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Anesthetic Implications for Cesarean Section in a Parturient with Complex Congenital Cyanotic Heart Disease Hindawi Case Reports in Anesthesiology Volume 2018, Article ID 2616390, 5 pages https://doi.org/10.1155/2018/2616390 Case Report Anesthetic Implications for Cesarean Section in a Parturient with Complex Congenital Cyanotic Heart Disease Huili Lim, Chuen Jye Yeoh, Jerry Tan, Harikrishnan Kothandan ,andMayU.S.Mok Department of Anesthesia and Intensive Care, Singapore General Hospital, Singapore Correspondence should be addressed to Harikrishnan Kothandan; [email protected] Received 18 October 2017; Accepted 28 February 2018; Published 29 March 2018 Academic Editor: Latha Hebbar Copyright © 2018 Huili Lim et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Te discordance between increased physiological demand during pregnancy and congenital cardiac pathology of a parturient is a perilous threat to the maternal-fetal well-being. Early involvement of a multidisciplinary team is essential in improving peripartum morbidity and mortality. Designing the most appropriate anesthetic care will require a concerted efort, with inputs from the obstetricians, obstetric and cardiac anesthesiologists, cardiologists, neonatologists, and cardiothoracic surgeons. We report the multidisciplinary peripartum care and anesthetic management for cesarean section (CS) of a 28-year-old primigravida who has partially corrected transposition of the great arteries, atrial and ventricular septal defect, dextrocardia, right ventricle hypoplasia, and tricuspid atresia. 1. Introduction septal defect (ASD), dextrocardia with atrial and abdominal situs solitus, hypoplastic right ventricle, tricuspid atresia, and In Asia, congenital heart disease occurs in approximately 9.3 multiple aortopulmonary collaterals to the right lung. She had per 1000 live births [1]. Modern medicine has substantially pulmonary artery banding at 6 weeks of age and bidirectional improved the survival of patients with major congenital heart cavopulmonary connections (also known as Glenn’s shunt) disease and extended their life expectancy beyond reproduc- were performed at the age of 18 (see Figure 1.) Completion tive age. Te complex nature of the cardiac anomaly coupled of Fontan’s procedure was held of indefnitely because of withthewidearrayofsophisticatedtemporizingorcorrective an incidental fnding of cerebral arteriovenous malformation procedures performed on these patients translates into a (AVM). Te AVM was deemed unsuitable for embolization daunting task for the anesthesiologists. Te physiological duetoitsconnectionwithalargevenouspouch.Shehad changes associated with pregnancy and delivery compound been counselled against pregnancy by her cardiologist before the problem further. conception. Te patient’s other comorbidities include mild Writtenconsentwasobtainedfromthepatientforpub- scoliosis, prolapsed intervertebral disc between the fourth lication with approval from local ethics committee. Tis and ffh lumbar vertebrae, previous infective endocarditis manuscript adheres to the applicable EQUATOR guidelines. complicated by a cerebrovascular accident (full neurological recovery from lef-sided numbness), and compensatory poly- 2. Case Description cythemia (hemoglobin concentration: 20–22 g/dL). At 17 weeks’ gestation, the patient was admitted by her Our patient is a 28-year-old primigravida who presented with cardiologist because of increasing cyanosis and dyspnea. New York Heart Association (NYHA) class III symptoms Her oxygen saturation (SpO2)onairdecreasedfrom90% at 17 weeks’ gestation. She was diagnosed with complex before pregnancy to 80% on admission. Obstetrical work- congenital cyanotic heart disease at birth and her cardiac up revealed a healthy viable fetus. Serial transthoracic echo- malformations included transposition of great arteries, large cardiography showed an ejection fraction of 55% with bidi- nonrestrictive ventricular septal defect (VSD) and atrial rectional shunt across the VSD. Due to pulmonary artery 2 Case Reports in Anesthesiology Figure 1: Patient’s abnormal cardiac anatomy (picture courtesy of cardiologist Dr. Tan Ju Le). (1) Transposition of great arteries: the morphologic lef ventricle is connected to the pulmonary artery (PA) and pulmonary circulation; the hypoplastic right ventricle is connected to the aorta and systemic circulation. (2) Te tight pulmonary artery band limits blood fow from the lef ventricle into the pulmonary circulation to prevent development of pulmonary hypertension and to direct oxygenated blood from lef ventricle to right ventricle through the large nonrestrictive ventricular septal defect (VSD) and then from right ventricle to systemic circulation. (3) Systemic venous blood from the superior vena cava enters the pulmonary circulation for oxygenation via the bidirectional cavopulmonary connection. (4) Systemic venous blood from the inferior vena cava returns to the right atrium and enters lef atrium via the large nonrestrictive atrial septal defect (ASD), from lef atrium to the morphologic lef ventricle. Due to the congenital tricuspid atresia, there is no blood fow form right atrium to right ventricle. (5) Oxygenated blood from the lungs enters the pulmonary veins, fows to lef atrium and lef ventricle and then through the ventricular septal defect to right ventricle. Both the hypoplastic right ventricle and the lef ventricle (via the ventricular septal defect) eject blood into the aorta. Bidirectional shunting occurs across the ventricular septal defect with mixing of oxygenated and deoxygenated blood. banding, transpulmonary gradient was 41 mmHg. Te obstet- bytheobstetricianandtheanesthesiologists.Teteammet ric anesthesiologist and obstetrician were alerted from the regularly with the following agenda: (1) update on patient’s time of admission. Te patient was again counselled exten- condition, (2) update on fetal condition (afer 24 weeks), (3) sively regarding the risks of further maternal decompensation plans for an early elective delivery, and (4) formulation of and fetal anomaly. However, she remained keen to continue an emergency plan in the event of acute maternal decom- withthepregnancy.Tepatientstayedinthecardiology pensation. Te multidisciplinary team had consensus that high dependency ward for bed rest, oxygen therapy, and maternal condition would deteriorate in the 3rd trimester, monitoring by a cardiologist who was specialized in adult and cesarean section (CS) should happen before 28 weeks congenital heart disease from 17 weeks’ gestation until the of gestation to avoid maternal decompensation. Nearing the point of delivery. end of 2nd trimester, the patient was demonstrating NYHA A multidisciplinary team comprising cardiologists, obste- class IV symptoms and would desaturate during minimal tricians, obstetric and cardiothoracic anesthesiologists, car- eforts such as eating and speaking. Her highest SpO2 value diothoracic surgeons, and neonatologists was established prior to delivery was 85% on a nonrebreathing mask with from the time of admission. Te discussions were led jointly 15 L/min of oxygen. A decision was made for an elective Case Reports in Anesthesiology 3 CStobeperformedat27weeksofgestationinviewofher view of the presence of VSD. Cardiac function was contin- worsening functional capacity. Tis was to allow the conduct uously monitored by TEE performed by the cardiologist in of anesthesia and surgery under controlled conditions. direct contact with the anesthesiologist. A general anesthetic technique was jointly agreed upon Following the delivery of the baby, three intravenous by the cardiac and obstetric anesthesiologists because of the boluses of oxytocin 1 U were administered, which achieved potential for less hemodynamic instability. Members of the satisfactory uterine contraction. Tere were no noticeable multidisciplinary team were present in the operating theatre changes in the vital signs during autotransfusion. on the day of surgery. Te perfusionists were also on standby At the end of surgery and before tracheal extubation, in preparation for the possible need for extracorporeal mem- bilateral transversus abdominis plane blocks were performed. brane oxygenation (ECMO). Te muscle relaxant was reversed with sugammadex 2 mg/kg. Equipment necessary for both maternal and neonatal care Te hemodynamic stimulation during tracheal extubation and monitoring were available, including transesophageal was blunted by titrated boluses of esmolol. echocardiography (TEE), nitric oxide for inhalation, and Afer tracheal extubation, she was monitored in the neonatal resuscitator (medical device). Intravenous cardio- intensivecareunitfor1day.Shewassubsequentlytransferred vascular drugs (nitroglycerine, norepinephrine, epinephrine, to a high dependency ward under the care of the cardiologist and milrinone) were prepared. Before the induction of and had no episodes of acute desaturation during her stay. She anesthesia, the vascular access sites for emergency ECMO was discharged home on postoperative day 10. support were identifed and marked. Standard monitors were Te baby was delivered weighing 870 g and was sent to attached, and the lef radial artery and lef internal jugular neonatalintensivecareunit.Hewassubsequentlydischarged vein were cannulated for intra-arterial and central venous well. pressure lines. Te lef internal jugular vein was cannulated as the right internal jugular vein was noted to be small on 3. Discussion ultrasound
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