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In this case report, the management of a pregnant patient with this cardiac disease with epidural anesthesia is described following the current basic principles of the anesthetic management of pregnant women with cardiac disease. Pregnancy, Ebstein anomaly, anesthesia, cesarean section. This anomaly was described in by Wilhelm Ebstein after the autopsy of a young Polish worker 1.
Its incidence is of 1: The sex distribution is 1: Its cause is unknown 1. On the other hand, the right ventricular degree of dysfunction and the size of the septal defect determines its severity 4. These symptoms can be associated with WPWS in 0. Atrial fibrillation and flutter are commonly seen in adult patients 7. During pregnancy, the main hemodynamic changes which increase the risks of complications for the mother and fetus include: The electrocardiogram shows low-voltage, steep P waves in leads V1 and DII, which reflect right atrial enlargement and commonly, various types of right bundle blocks.
This was a year-old female patient with a 37 week 2nd pregnancy. She had a previous medical history for a cardiac murmur without any follow-up, and a surgical history of a prior cesarean section 13 years earlier under regional anesthesia without any complications, and 2 dilation and curettages with a complication of a uterus perforation which required a laparotomy under general anesthesia.
Epidural Anesthesia for Cesarean Section in a Patient with Ebstein’s Anomaly
The transthoracic echocardiogram showed a low implantation of the tricuspid valve with severe regurgitation, Carpentier B, right ventricular hypoplasia, an enlarged right atrium and moderate pulmonary hypertension. She had follow-up by high-risk obstetrics and cardiology. When the fetus was 32 weeks old, lung maturation was done.
She had an episode of significant vaginal bleed with clotsfro which she was hospitalized and scheduled for emergent Anomalla. A ml bolus of crystalloid was administered and a left radial arterial line with a 20gauge catheter was inserted for continuous invasive blood pressure monitoring. In the left lateral position an epidural anesthesia was administered with prior local anesthetic infiltration.
The catheter was inserted through an 18 gauge Touhy needle between L 3 and L4. After the umbilical cord clamping, 10 units of intravenous oxytocin were administered over 10 min.
ce Intraoperatively, although the patient was in prone embsrazo with a wedge under her right lumbar area, she developed a transient hypotensive episode 10 min after the administration of the anesthetic mean blood pressure of 52 mm Hg / which responded to a ml bolus of crystalloid and a 2 mg bolus of ethylephrine to maintain hemodynamic stability and a MAP above 60 mmHg throughout the procedure. The catheter was removed at the end of the surgery. The sensitive block reached the T8 dermatome.
The pain assessed with the visual analogue scale VAS was 0. In the post anesthesia care unit she had close monitoring. She had a favorable evolution without any complications, and at 48 hours, both the patient and the child were discharged with written indications for any alarming signs with obstetric and cardiologic follow-up.
In the C-section she could have had an increase in the right to left shunt, and increasing pulmonary vascular resistance with increased risk of mortality The risk of paradoxical embolism increases specifically with the increases of intrathoracic pressure during labor The position during surgery is very important: In this case even though the patient was in prone position a wedge was inserted under the right posterior lumbar area to shift the uterus emgarazo the left.
This patient was given 10 units of intravenous wnomalia oxytocin during 10 min using an infusion pump without relevant hemodynamic effects, although Jonnson 13 showed in a double- blind randomized clinical study with a total embwrazo patients for elective C-section, that administering 10 units of oxytocin in bolus had a higher risk of ST segment depression compared to 5 units with a statistically significant difference 13, Both epidural as well as general anesthesia have been used for C-section with good results 12, These patients can have prolonged induction times with intravenous anesthesia which increases the risk emmbarazo pulmonary aspiration.
Anommalia epidural anesthesia is recommended to administer a ml bolus of crystalloid with graduated compression stockings to avoid hypotension 2.
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ebsteib In this case, the fluid bolus was administered without graduated compression stockings. Ephedrine does not produce uterine artery vasoconstriction but can stimulate beta receptors and thus exacerbate tachycardia 2. Rathna et al considered that epidural anesthesia is a good choice in pregnant women who have little clinical changes 4. Most of the patients with cardiac diseases tolerate vaginal delivery. The indications for C-section are the same as for the general population, although some entities benefit more with vaginal delivery than with a C-section, as is the case of hemodynamic instability during labor.
The factors that could indicate poor prognosis are early age of diagnosis, NYHA embarzao class III or IV, severe cyanosis, severe tricuspid regurgitation, a cardiothoracic index above 0. Ephedrine, commonly used in obstetrics, can produce beta adrenergic stimulation and could induce supraventricular tachycardia It is important to consider, on the other hand, that excess fluid administration can worsen the right to left shunt and thus produce hypoxemia and congestive heart failure Likewise, oxytocin should be carefully administered.
Beta adrenergic medications are commonly used in obstetrics but should be carefully used as they produce beta 1 receptor stimulation which could produce tachyarrhythmias. Archives des maladies du coeur et des vaisseaux. Can Anaesth Soc J. Anesthesia and coexisting disease. Adult congenital heart disease: Pregnancy complicated by maternal heart disease at the National Maternity Hospital, Dublin, Ireland, to Am J Obstet Gynecol.
Linter SP, Clarke K.
Int J Obstet Anesth. ST depression at caesarean section and the relation to oxytocin dose: Cardiopatias en el embarazo.
anomalia de ebstein y embarazo pdf
J Obstet Gynaecol Res. Prevention of infective endocarditis: J Am Coll Cardiol. Anaesthesia for caesarean section in a pre-eclamptic patient with Ebstein’s anomaly. Pathologic anatomy of Ebstein’s anomaly of the heart revisited.
Anaestheisa for incidental surgery in a patient with Ebstein’s anomaly. Ebstein’s anomaly presenting as Wolff-Parkinson white syndrome in a postpartum patient. Caesarean section anomlia extradural analgesia in a patient with Ebstein’s anomaly.
Caesarean section using total intravenous anaesthesia in a patient with Ebstein’s anomaly complicated by supraventricular tachycardia. Ebstein’s anomaly in pregnancy: Prolonged induction with exaggerated chamber enlargement in Ebstein’s anomaly.
Outcome in cyanotic neonates with Ebstein’s anomaly. Services on Demand Article. The tricuspid valves is usually regurgitant but sometimes it can become stenotic 4,5. The symptoms in adult patients are often related to the age 4. Case report This was a year-old female patient with a 37 week 2nd pregnancy. Prognosis The factors that could indicate poor prognosis are early age of diagnosis, NYHA functional class III or IV, severe cyanosis, severe tricuspid regurgitation, a cardiothoracic index above 0.
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