Early this morning at 3:15 AM, I have been called by the assistant lecturer of last night shift Dr. Rady Obeid, who was called for an emergency Caesarian delivery for a female parturient presenting with severe orthopnea and having a history of a tight rheumatic mitral valve pathology and having premature rupture of membranes
On my arrival (10 minutes later): the patient was severely distressed, acquiring an upright position and cannot stand lowering her back for a 60 degrees angle for 5 minutes. Crackles were mounting beyond basal levels and were heared clearly at an excuisite level of the 3rd-4th intercostal space on the back. Her rhythm showed frequent extrasysoles and HR: 130-135/min, BP: 135/80 mmHg, SPO2: 94%
This is her 2nd baby and she had a previous CS. MV area 0.9 cm(sq), HB 10.2 g%, ECG shows a prominent R in V1 indicating a pulmonary hypertension mounting to 80 mmHg. The patient was not on constant diuretic management
Conclusion: High-risk parturient indicated for emergency Caesarian delivery withing 1- hour to minimize feto-maternal complications. The underlying pathology is a tight rheumatic mitral valve stenosis with severe afterload augmentation, hypervolemia, and impending pulmonary edema.
Preoperative Intervention and/or Risk modification: We aimed in the short pre-surgical stage to lower her augmented afterload, pre-load and maniplulate the pulmonary vascular resistance in a to improve Rt vent. strain, and consequently improve the Lt vent performane. Following patient assurane, graded diuretic administration was done as far as 40 mg furesemide / 5-10 minutes up to 240 mg in 45-60 minutes. Urinary output response was marvellous in the form of 1200 ml. The patient experienced an improvement in hemodynamic profile HR: 120/min and BP: 115/70 mmHg. A cutaneous NGT patch (5 microgm)was adjunctively applied and replaced after anesthesia with a NGT nebulized administration
Anesthetic choice: Regardless of the common obestetrical concept of the "absolute" contraindication of a "Spinal Anesthesia" in a "tight mitral stenosis". We had believed of the preferrance of this maneuvor for a number of reasons. Most importantly is the benificial effect of afterload reduction and obviating the negative effects of positive pressure ventilation on the severely deranged pulmonary overloaded hemodynamics. The patient was remarkably brave and supported our decisions well. We explained to the obstericians that we might require to change the patient position markedly during the operation
Technique of Spinal Anesthesia: intrathecal injection of 2.5 ml hyperbaric marcaine 0.5% plus 25 microgm fentanyl followed by very slow positioning to a 30 degrees level for only 3 minutes then resuming a 60 degrees level. To facilitate fetal delivery her back was lowered to a 30 degrees then again once more to 60 degrees as soon as the fetaus was delivered
Intraoperative problems: Following fetal delivery, HR dropped to 90/min and BP lowered significantly to 60/30 mmHg which and this was promptly managed with lowering the back again to 30 degress to aid VR, VCs (unfortunately the best is phenylephrine but due to the known availability reasons in Egypt we gave graded ephedrine boluses up to 30 mgs) and small IV fluid pushes (50 ml each) till BP stabilized at 115/60 mmHg with a HR of 115/min and a total fluid amount given of 300 ml
Summary: careful spinal anesthetic management is always possible for the management of tight mitral stenotic parturients presenting for CS provided that prompt intervention with VC and graded fluid administration is looked for and anticipated esp. following fetal delivery and releasing the AV compression. High-dose frusemide and Nitroglycerin nebulization was tried effectively in this patient and was associated with marked reduction of symptoms of PHT
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