P020: ANESTHETIC MANAGEMENT OF A PATIENT WITH SEVERE PULMONARY VALVE REGURGITATION UNDERGOING ELECTIVE CESAREAN SECTION: A CASE REPORT
D McDougal, DO; E Chung, DO; K King, DO; R Esmail, MD; G Papacuri, MD
HCA Florida Kendall Hospital
Introduction/Background: The maternal physiologic changes that occur during pregnancy and a patient’s desire to participate in the birthing experience lead to unique considerations when providing anesthetic care for cesarean section (C-section). Often neuraxial anesthesia is employed to facilitate maternal participation and adequate analgesia for the surgical procedure. Additional maternal comorbidities, especially cardiac, often require additional considerations.
Methods: A 26-year-old female G2P0A1 presented for elective cesarean section at 38 weeks gestation. Her past medical history included congenital pulmonic valve stenosis that was repaired at 3 days old.
The patient was admitted before the scheduled c-section for cardiac evaluation. Patient was in normal sinus rhythm and transthoracic echocardiogram was significant for severe pulmonic valve regurgitation (PR).
After discussion with the obstetrician and patient, the decision was made to use an epidural to provide surgical anesthesia and to do the c-section in the main OR where additional providers were available to help should the patient decompensate. A radial arterial line was placed followed by a lumbar epidural in the preoperative area.
Results: Intraoperatively, 2% lidocaine was used to build an adequate level of anesthesia for the procedure. The patient’s hemodynamics and fetal heart rate were carefully monitored throughout preparation. Low-dose phenylephrine and epinephrine drips were used to maintain blood pressure close to preoperative values. The baby was successfully delivered and the patient remained hemodynamically stable throughout. Morphine was given via the epidural for postoperative pain before its removal. The patient was then transferred to the ICU for close monitoring. On POD2, patient was transferred to the postpartum floor and on POD3 was discharged.
Discussion/Conclusion: Although complications from heart disease during pregnancies are <1%, the presence of heart disease can significantly increase maternal and fetal risks of adverse events. With valvular disease, women with semilunar valve regurgitation have lower rates of cardiac complications compared to those with atrioventricular regurgitation. PR is generally tolerated well in pregnancy, especially as SVR and PVR decrease during pregnancy. They are generally considered at increased risk for arrhythmias when compared to other valvulopathies. The increased plasma volume and cardiac output associated with pregnancy can lead to right-sided heart failure symptoms in women with severe PR. During pregnancy, patients with valvulopathies should be carefully monitored and treated to control symptoms. This can be difficult as many pharmacologic agents used to manage valvular conditions are teratogenic. Once symptoms have been optimized, depending on the severity of the disease, a decision between a short vaginal delivery vs c-section needs to be made. In a vaginal delivery, the use of epidural anesthesia is generally recommended and IV fluids should be used to maintain euvolemia. If highly symptomatic, c-section is recommended with consultation of a cardiac anesthesiologist. These patients are at higher risk for acute right ventricular failure which may require immediate valve repair or ECMO cannulation. In addition, the delivery of the placenta increases afterload and rapidly increases preload with venous return of blood to maternal circulation. These sudden increase in demand on cardiac function may require aggressive management in the peripartum period.