Anaesthesia for urgent caesarean delivery with severe pulmonary hypertension and spina bifida

Abstract

Background: Pulmonary hypertension (PH) in pregnancy is associated with a high maternal mortality and morbidity. The mortality rate is 30-56%. Case Report: A 19 year old primipara at 37 weeks of gestation were transfered from regional to university hospital with regular uterus contractions. The patient had congenital ventricular septal defect (VSD) which cause the PH (risk for pregnancy IV class), right heart failure (NYHA III), paroxismal supraventricular tachicardia. Medication for PH treatment: Sildenafil, Carvedilol, Amiodarone. The partial correction of VSD was done when she was 4 year old. She also had congenital spina bifida meningocele at lumbosacralic part. It was corrected by surgery at childhood and lower limb function remained normal. Cardioechoscopy: Left ventricule CO 40%, max systolic pressure (SP) of pulmonary artery (PA) 141-146 mmHg, median PA SP 43 mmHg, III֯ tricuspid valve regurgitation. Laboratory tests: Hgb 90 g/l, Plt 155*10/9/l, SPA 69%, INR 1.17, NT-proBNP 780 ng/l. Multidisciplinary team (neurosurgeon, cardiologist, anaesthesiologist, obsterician) decided to do urgent caesarian delivery. Anaesthesia: ASA class IVE. Epidural space was catheterizated at L2-L3 segment and sol. Bupivacaine 0,5% - 17 ml (85 mg) was infused. Fluid balance: crystalloids 1000 ml, blood loss 500 ml. Anaesthesia was adequate, hemodynamics was stable. Patient was transfered to ICU after operation and remained here for 7 hours. Heart function was compensated for all perioperative period. Patient was discharged after 4 days. Discussion: Pregnant women with PH have high risk of mortality. Pregnancy is contraindication for these patients (1). Elective ceasarean delivery with epidural anaesthesia is the safest choice. Spina bifida is not an absolute contraindication for epidural or spinal anaesthesia but it could be less effective and more difficult to perform (2). [...].