P074: AORTIC ANEURYSM AND PREGNANCY: INTRAOPERATIVE CONSIDERATIONS
Divy Mehra, BS1; Rishi Hajirawala, BS1; Bansi Patel, DO2; Thais Franklin Dos Santos, MD2; Katherine Hoctor, MD2; 1Nova Southeastern University KP College of Osteopathic Medicine; 2University of Miami Miller School of Medicine - Jackson Memorial Hospital
Background: Despite its rarity, an ascending aortic aneurysm can be life-threatening and have major impacts on pregnancy outcomes. During pregnancy, a wide array of hormonal, receptor-related, and genetic changes occur in order to prepare a mother to carry her child, but these physiological events also predispose the mother and child to a variety of health conditions. For instance, evidence suggests that pregnancy-related upregulation of estrogen receptors expressed on the elastic fibers found in large vessels like the aorta may play a role in weakening the integrity of vascular tissue. Such interactions are believed to increase patient risk for vascular events, particularly aortic aneurysm, dissection, and rupture. Patients with pre-existing genetic conditions or uncontrolled chronic conditions (e.g. hypertension, hyperlipidemia, and diabetes) experience an even greater risk for such events throughout the intra-partum and post-partum periods. Thus, special considerations must be taken in relation to anesthetic and obstetric management in order to avoid precipitating life-threatening vascular events.
Case: A 28-year-old prima-gravid female presented at 38.2 weeks for a cesarean section. She had untreated chronic hypertension since age 21. Although initially asymptomatic, at age 27 she developed chest pain during a hypertensive crisis and workup revealed a 4 cm ascending aortic aneurysm. She was placed on metoprolol and six months prior to delivery, she was switched to labetalol 100mg twice a day, which was continued throughout pregnancy. Congenital testing did not reveal any identifiable genetic predispositions. Second and third-trimester echocardiograms revealed no change in the size of the aneurysm. The patient remained asymptomatic with controlled heart rate and blood pressure (BP).
An early multidisciplinary discussion for her delivery planning included high-risk maternal-fetal medicine, cardiology, cardiothoracic surgery, and obstetric anesthesiologists. The decision was made for scheduled cesarean section at 38 weeks to avoid the risks of valsalva with labor. She continued beta-blockers perioperatively. Cardiothoracic surgery and cardiac anesthesia were available as backup. After arterial line placement for tight hemodynamic monitoring, a modified combined spinal epidural (CSE) anesthesia was performed to minimize hemodynamic changes associated with neuraxial anesthesia. A T4 level was obtained and her delivery was uneventful. On post-operative day (POD) 3, the patient developed elevated BPs, headaches and a twofold increase in liver function tests. She was classified as superimposed pre-eclamptic with severe features, her labetalol dose was increased and a magnesium sulfate infusion was started for seizure prophylaxis. On POD 5 she was asymptomatic with controlled BP and HR, so she was discharged on the following day with a plan for outpatient surveillance of the aneurysm.
Discussion: This case highlights the importance of a multidisciplinary approach in order to achieve preoperative optimization, as well as the significance of intraoperative anesthetic considerations while delivering obstetric care to patients with ascending aortic aneurysm to improve health outcomes of both mother and child.