Corrected Tetralogy of Fallot and emergency cesarean section under regional anesthesia

Abstract Type: Medically Challenging Case

REBECCA M CARROLL MD1 ; MADHUMANI N RUPASINGHE FRCA2; WILLIAM H DAILY MD3
UTHSC HOUSTON1 ; UTHSC2; UTHSC3

Corrected Tetralogy of Fallot and emergency cesarean section under regional anesthesia

Introduction:
Most patients with tetralogy of Fallot undergo surgical treatment during infancy or childhood. For patients entering pregnancy with a corrected lesion, the prognosis is favorable. However, complications such as arrhythmias and right ventricular failure do occur, particularly in the presence of residual shunts, right ventricular outflow obstruction and pulmonary hypertension.

Case:
A 20-year-old woman, gravida 1, para 0 at 36 weeks presented from CCU for labor induction after being found to have intra-uterine growth retardation (IUGR) and oligohydraminos with absent end-diastolic flow. Our patient had a history of congenital Tetrology of Fallot (TOF), repaired as an infant and consequent pulmonary valve replacement surgery and cardiac catheterization in 2005. A cardiac MRI in 2007 showed marked atresia of left main pulmonary artery, incompetence of replaced pulmonary valve, and aortic valve stenosis. A recent cardiac echocardiogram showed an ejection fraction of 65%, moderate-to-severe right ventricular dilatation, moderate-to-severe systolic dysfunction, mild pulmonary insufficiency, mild pulmonary stenosis, and paradoxical ventricular septal motion. She was admitted to CCU with short episodes of ventricular tachycardia that self resolved and was started on an esmolol infusion. She was then transferred to the labor and delivery suite for labor induction under the supervision of OB/GYN, Anesthesia, and a Cardiac Critical Care Nurse.

Once in the labor suite an epidural and a radial arterial line were placed by Anesthesia prior to induction of labor. As labor progressed, the epidural was bolused with 20mL of 0.1% Ropivacaine with 2mcg/mL Fentanyl and an infusion of this same mixture was started at a rate of 8mL/hour. With contractions, continuous decelerations of the fetal heart rate were noted; hence a decision for cesarean section was made. The Anesthesia team placed standard ASA monitors and bolused the patient's epidural with increments of 2% Lidocaine to achieve a surgical block to T4. The patient tolerated the surgical procedure well without hemodynamic compromise and was transferred back to CCU.

Summary:
A comprehensive understanding of the physiology of pregnancy and pathophysiology of maternal cardiac disease is of importance for anesthesiologists. Effective management is based upon prepregnancy counseling and risk assessment, close fetal and maternal monitoring during pregnancy, a detailed management plan for labor and delivery and close surveillance in the immediate postpartum period. Invasive monitoring and slowly titrated neuraxial analgesia or anesthesia may be prudent.



Reg Anesth Pain Med Spring 2011;