Vol 10 | Issue 1 | January-April 2024 | Page: 19-21 | Prabhu Gnapika Putta, M. Reshma Habeeb, Shaik Sumiya Begum, J. Hemalatha
DOI: https://doi.org/10.13107/jaccr.2024.v10.i01.233
Submitted: 05/11/2022; Reviewed: 03/12/2023; Accepted: 21/12/2023; Published: 10/01/2024
Author: Prabhu Gnapika Putta [1], M. Reshma Habeeb [1], Shaik Sumiya Begum [1], J. Hemalatha [1]
[1] Department of Anaesthesiology, S.V. Medical College. Tirupati, Andhra Pradesh, India.
Address of Correspondence
Dr. M. Reshma Habeeb,
Department of Anaesthesiology, S.V. Medical College. Tirupati, Andhra Pradesh, India.
E-mail: reshma.28.7.1994@gmail.com
Abstract
We report the successful management of a 25-year-old primi with post PBPV with right hemiparesis and epilepsy on treatment with moderate restenosis posted for emergency LSCS and done under graded epidural anaesthesia. The perioperative course was uneventful, with satisfactory maternal and foetal outcomes.
Keywords: Pulmonary restenosis, Emergency caesarean section, Graded epidural anaesthesia.
Introduction
Pulmonary stenosis (PS) is a common form of congenital heart disease that refers to a dynamic or fixed obstruction of flow from the right ventricle to the pulmonary vasculature that is occasionally diagnosed for the first time in adulthood. Isolated valvular pulmonary stenosis comprises approximately 10% of congenital heart disease. [1] Anaesthetic management of a parturient with pulmonary stenosis requires an understanding of its physiological adaptations and also the drugs that alter the right ventricular outflow.
Case Description:
A 25-year-old primi, with 37 weeks of gestational age, was admitted with complaints of abdominal pain and leaking per vaginum and posted for emergency LSCS in view of meconium-stained liquor. She was diagnosed with right hemiparesis and epilepsy at her 15 years of age and evaluated and diagnosed to have isolated severe pulmonary stenosis, for which she underwent percutaneous balloon valvuloplasty, which was uneventful and lost to follow-up. Since then, she had been on treatment with tab phenytoin 100mg BD and tab. aspirin 75 mg OD. She had a history of mild breathlessness on exertion (NYHA grade I) at present; otherwise, there were no other complaints or comorbidities. On pre-anaesthetic examination, she was restless due to labor pains and on examination, her vital signs were: HR:120/min, BP:130/80 mmHg, and spo2:96% with room air. On auscultation, her chest was clear with normal S1 and split S2, and her motor power was 4/5 for both upper and lower limbs on the right side with 5/5 on the left side (the rest of the examination was insignificant). Her investigations revealed Hb 12.6 g/mL, platelet count 2.4 lakh/cumm, S. creatinine of 0.8 mg/dl, and a normal coagulation profile.
The ECG showed sinus rhythm with T wave inversions in V2-V4 leads with RAD. Echocardiogram showed S/P PBPV with moderate restenosis and a gradient of 38 mmHg with LVEF of 56% with mild TR.
On arrival at the OR, IV access was secured with an 18-G IV cannula. She received prophylactic antibiotics, IV pantoprazole 40mg and IV metoclopramide 10 mg, and monitoring: 5 lead ECG with ST analysis NIBP and SPO2 were connected. A wedge was placed under the right hip. Preloading was done with 200 ml of Ringer lactate. Baseline vitals were PR = 115/min, Bp = 140/80 mmHg, and SPO2 = 96%.
Under aseptic precautions, a 20G epidural catheter was placed in L2-L3 interspace using 18G Touhy’s needle (loss of resistance to air technique) and fixed at 12 cm. An epidural test dose of 2 ml of 2% lignocaine without adrenaline was given. This was followed by 15 ml of 0.5% bupivacaine in small increments of 3 ml and 50 mcg of fentanyl in aliquots until the sensory level was achieved up to T6. Oxygen was supplemented with a simple facemask at 6 l/min. Hemodynamic parameters were stable throughout the intraoperative period. (Fig. 1)
A healthy infant weighing 3.2 kg was delivered with APGAR scores of 8 and 9 at 1 and 5 min, respectively. Intravenous infusions of 5–10 IU/hr of oxytocin started. Intraoperatively, a total of 1 litre of Ringer’s lactate was infused. Urine output at the end of surgery was 350 ml, and estimated blood loss was 600 ml. The rest of the course was uneventful and shifted to HDU. Postoperative analgesia was maintained for the following 36 hours with intermittent bolus doses of 10 ml of 0.1% bupivacaine and 25 mcg of fentanyl every 8 hours and monitored thereafter. Motor power was assessed throughout the course and was the same as baseline and antiepileptics continued throughout the perioperative period. The patient was shifted to the ward the next day and discharged on the 4th postoperative day without any complications.
Discussion:
In planning an anaesthetic for delivery in a woman with congenital or acquired heart disease, the anaesthesia provider must take into consideration the patient’s cardiac lesion or disease state, the normal physiologic changes of pregnancy, labour, and delivery, and the hemodynamic changes of the anaesthetic itself. During pregnancy, labour, and delivery, regurgitant valvular lesions are generally tolerated better than stenotic valvular lesions [2]. Isolated valvular pulmonary stenosis comprises approximately 10% of congenital heart disease. [1] It is graded based on peak pressure gradient (PPG) across the pulmonary valve into mild (<36 mm Hg), moderate (36–64 mm Hg), and severe (> 64 mm Hg) [3]. Surgical or balloon pulmonary valvotomy is recommended with pulmonary stenosis when the Doppler gradient across the valve is more than 40 mmHg, and periodic follow-up is recommended every 5 years, even if the patient remains asymptomatic. [4] Our patient lost follow-up and presented to our hospital in active labour, and she was found to have moderate pulmonary restenosis on echocardiogram. Severe PS may be associated with increased risk during labour, delivery, and the puerperium due to an increase in intravascular volume with autotransfusion, which can precipitate right heart failure and cardiac arrest. Decreased venous return with aortocaval compression results in decreased preload, which can be further worsened by the neuraxial blockade. Anaesthetic management of a parturient with pulmonary stenosis requires an understanding of its physiological adaptations and also the drugs that alter the right ventricular outflow. The goals of anaesthetic management include maintaining adequate right ventricular preload, left ventricular afterload, and right ventricular contractility and avoiding a further increase in pulmonary vascular resistance. Anaesthetic management is mainly implicated in the reduction in PVR and SVR, maintaining normal sinus rhythm and effective ventricular filling pressures by optimum preloading, but excessive preloading can also precipitate RHF. [5]
Combined spinal and epidural anaesthesia were used by Makkar et al. [6] for a caesarean section in a parturient with severe PS and an uneventful perioperative course. General anaesthesia with epidural analgesia was administered in the case of a parturient with isolated severe PS and was uneventful, which was reported by Sanikop et al. [3] In a case done by Shah et al. [7] as a similar case to ours: a parturient S/P PBPV with severe pulmonary restenosis posted for elective LSCS was managed under graded epidural anaesthesia without any significant hemodynamic fluctuation.
We chose the graded epidural anaesthesia technique to avoid sudden hemodynamic fluctuations; A general anaesthesia-induced increase in pulmonary vascular resistance with positive pressure ventilation, N2O, and exaggerated stress responses during laryngoscopy and extubation and spinal anaesthesia-induced precipitous hypotension can be prevented by our technique. Low-dose aspirin (tab aspirin 75 mg), which the patient is on, is not a contraindication for the neuraxial blockade [8]. As the patient had right hemiparesis, we assessed motor power during the entire hospital stay, which was the same as the baseline.
Hence, graded epidural anaesthesia in our case led to satisfactory maternal and foetal outcomes.
Conclusion:
Pulmonary stenosis can worsen during labour and delivery, resulting in high maternal mortality. Our case report is evidence of the successful outcome of a patient with moderate pulmonary restenosis with hemiparesis under graded epidural anaesthesia, but recommendations cannot be taken from a single report. This technique may have the advantage of avoiding overt hemodynamic alterations associated with spinal and general anaesthesia.
References
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3. Sanikop CS, Umarani VS, Ashwini GS. Anaesthetic management of a patient with isolated pulmonary stenosis posted for cesarean section. Indian Journal of Anaesthesia. 2012;56(1): 66-8.
4. Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease. Circulation 2008;118:2395‑451.
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8. Horlocker, Terese T. MD; Wedel, Denise J. MD; Schroeder, Darrell R. MS; Rose, Steven H. MD; Elliott, Beth A. MD; McGregor, Diana G. MD; Wong, Gilbert Y. MD Preoperative Antiplatelet Therapy Does Not Increase the Risk of Spinal Hematoma Associated with Regional Anesthesia1995:vol 80; 303-309
| How to Cite this Article: Putta PG, Habeeb MR, Begum SS, Hemalatha J | Anaesthetic Management of Primi with Post Percutaneous Balloon Pulmonary Valvuloplasty (PBPV) with Moderate Restenosis with Right Hemiparesis and Epilepsy Posted for Emergency Lower Segment Caesarean Section (LSCS) Under Graded Epidural Anaesthesia: A Case Report | Journal of Anaesthesia and Critical Care Case Reports | January-April 2024; 10(1): 19-21. |
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