Anesthesia management in pregnant women with pulmonary hypertension underwent

cesarean section under epidural anesthesia

Muhamad Ibnu, Mohammad Andy Prihartono

RSUP Hasan Sadikin, Universitas Padjadjaran Bandung

Abstract

Background: Pulmonary hypertension is a rare condition, and will increase mortality when experienced
by pregnant women. Treatment of pregnant women with pulmonary hypertension is a challenge in
anesthesia. In the report of this case will be explained about the management of anesthesia in pregnant
women with pulmonary hypertension who underwent cesarean section operation in epidural regional
anesthesia.

Case report: 24-year-old woman diagnose with gravida 34-35 weeks with premature contractions in the
presence of pulmonary hypertension. Echocardiography obtained dilatation of the atrium and right
ventricle, severe pulmonary hypertension, moderate tricuspid regurgitation. We decided to perform
epidural regional anesthesia in these patients. Epidural block is done in a sitting position at L3-4 with the
insertion of catheters as high as T10. Awarded a total of 0.5% bupivacaine as 18 cc. Blocks as high as T6.
Babies born with Apgar score of 6-8. After the operation is complete the patient was transferred to ICU.

Conclusion: Pulmonary hypertension in pregnancy have a high mortality rate. Epidural anesthesia is a
technique that most have minimal effects on the cardiovascular compared to spinal or general anesthesia.
Therefore this technique is the safest technique for cesarean section operation.

Keyword : Pulmonary hypertension, epidural anesthesia, cesarean section

Case report

Pregnant woman lady admitted to our hospital, with shortness of breath and fatigue. The patient
was diagnosed as having primery pulmonary hypertension by echocardiography. On examination her BP
was 13 0/90 mmHg, pulse rate 118 times per minute and regular. The respiratory rate was 28 permin, her
oxygen saturation was 84 % on room air increase to 89 % with supplemental 5 L/min O2 therapy with
mask. Chest was clear on auscultation. She had sianosis and bilateral pedal udem. The ECG showed sinus
rhythm with right axis. The echo cardiogram with dopler ultrasonography demonstrated dilated right
atrium and ventrikel, tricuspid regurgitation and systolic pulmonary artery pressure 34 mmHg. The Hb
was 10,9 and platelet count 173.000. coagulation factor in normal value.

Patient was explained about the poor outcomes of delivery and inform consent was obtained.
Lumbar epidural anesthesia was administered without any difficulty in L3-4 inter space; with patien in
sitting position, a test dose was administered. Anesthesia was instituted slowly with incremental doses up
to 12 ml bupivacaine 0,5 %. The sensory block spread up to T6 level.

The approximate blood lost was about 600 ml. The patient received a total of 1000 ml of
crystalloids solution in OT. A male baby weighning 2,4 kg was delivered with APGAR score of 6 and 9 at
1 and 5 minute. Post operatively patient was continued on supplemental O2 5 L/min through mask.
Epidural postoperative analgesia was administered with bupivacaine 0,125% with fentanyl 2mcg/ml for
the next 48 hours. After surgery, the patient was transferred to the intensive care unit.

Discussion

Pulmonary hypertension represent an important risk factor for increased perioperative morbidity
and mortality. Stress, pain, ventilation, and surgery can further increase pressure and resistance within the
pulmonary arteries and cause right sided heart failure. (1)

Pulmonary hypertension regarded as a mean pulmonary artery pressure greater than 25 mmHg.
Primary pulmonary hypertension has been defined by the Worl Health Organization as pulmonary arterial
hypertension of unknown cause.(2)

Multiple molecular pathway have been implicated in the pathogenesis of pulmonary

hypertension, vaso affective molecules produced in the pulmonary vascular endothelium include nitrit
oxide and prostacyclin, which are vasodilators. Endothelin act as a vasoconstrictor and is involved in
vascular smooth ploriferation.(3) Elevation in pulmonary artery pressure is induced by disequilibrium
between vasidilating (NO, prostaglandin) and vasoconstricting (tromboxanne,endothelin). (1)

The hemodynamic goal of obstetric and anesthetic management are similar to those for the
patient with eisenmenger syndrome involved, 1. prevent pain, acidosis, and hypercarbia which can cause
increase in pulmonary vascular resistance, 2. Maintain intravascular volume and venous return, 3.
Maintain adequate SVR, as women with fixed pulmonary hypertension cannot increase their cardiac
output to compensate for a decrease in blood pressure that result from a decrease SVR, 4. Avoid
myocardial depression.(4)
 Epidural anesthesia may cause less cardiopulmonary compromise in patient with pulomanr
hypertension than general or spinal anesthesia. General anesthesia was avoid because of the parturient
heightened risk of aspiration and the risk of rapic change in systemic vascular resistance and increase
pulmonary vascular resistance. Spinal anesthesia was avoided because of the risk of a rapid
sympatectomy and sudden decrease in the vascular systemic resistance. (5)

Postoperative pain control was also an important aspect of care o avoid increase in pulmonary
hypertension. (6)

Conclusion

The primary pulmonary hypertension can worsenduring labor, delivery, and postoperative
resulting in high maternal mortality. Epidural anesthesia seems to be a safely alternative for cesarean
section in patient with primary pulmonary hypertension.

References

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patient with pulmonary hypertension:Anesth Research and practice, 2012;10.1155/2012/356982

2. Saya Raghavendra Prasad, Radhika Yadava, Chandrasekar Pulala. Anasthetic management of a

parturient with primary pulmonary hypertension for cesarean section:Journal of dr. NTR
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3. Adel M. Bassily marcus, Carol Yuan, John Oropello, et al. Pulmonary hypertension in
pregnancy:critical care menegement;Hindawi publishing corporation;doi:10.1155/2012/709407.

4. Miriam Harnett, M.B. Cardiovascular disease;Obstetric Anesthesia principles and practice 3 rd

ed;2004;Elsevier mosby, Philadelphia.

5. Elizabeth I, Stuart R, Hart, et al. Epidural Anesthesia for cesarean delivery in a patient with
severe pulmonary artery hypertension. The Ochsner journal;2011;11:78-80

6. McDonnell JG, Curley G, Carney J, et al. The analgesic efficacy of transverse abdominalis plane
block after cesarean delivery: a randomized controlled trial` Anesth Analg. 2006;106(1):186-191