Anesthesia management for cesarean section in a twin pregnant with severe mitral stenosis, pulmonary hypertension and placenta accrete

Karacaer F. , Büyükkurt S. , Ünlügenç H.


  • Publication Type: Conference Paper / Summary Text
  • Page Numbers: pp.17


ABSTRACT In this case report, we present our anesthesia management in a twin pregnant patient with mitra MS, pulmonary hypertension (PH) and placenta accrete (PA) for caesarean section. A 36-years-old multigravida parturient with a dichorionic diamniotic pregnancy at 24 weeks gestation was presented to the anesthetic department for caesarean section with a diagnosis of severe MS, PH and PA. The transthoracic echocardiography revealed MS with a mitral valve area of 1 cm2 , ¼ mitral regurgitation, ¾ tricuspid regurgitation, and PH with a systolic pulmonary artery pressure of 88 mmHg. The left atrium was dilated, the left ventricular ejection fraction was 65%. General anesthesia was planned for the cesarean section. An invasive arterial line and central venous catheterization were applied. Anesthesia was induced by 250 mg pentothal and 100 mcg fentanyl, and maintained with 1-1,5 % sevoflurane. The placenta was found to invade the bladder. During the hysterectomy, the patient experienced transient hypotensive episodes. Dopamine was administered to prevent low mean artery pressure (MAP) by titrating at 5-10 µg/kg/min dopamine doses. A total of 4500 ml crystalloid and a 1000 ml colloid were given and 7 units of packed red cells, 4 units of fresh frozen plasma (FFP), 1 unit platelet concentrate, and 8 units of cryoprecipitate were transfused intraoperatively. The surgery lasted at 4 hours and the estimated blood loss was around 5000 ml. As hemostasis was achieved and the patient was hemodynamically stable, she was extubated and transferred to the intensive care unit (ICU) in the stable condition. Postoperative care was unremarkable. Pregnancy places a high physiologic demand on the cardiovascular system. Maternal mortality rate rises up to 16-30 % in women with PH1,2. Our patient had a PA, which significantly complicated the management of anesthesia. Anesthesia management for cesarean section in a twin pregnancy with severe MS, PH and PA should begin with preoperative assessment that needs to continue through the surgery and the postpartum period. Choosing intraoperative suitable hemodynamic monitoring, tailoring the anesthetic technique, and optimizing cardiovascular and respiratory functions using appropriate drugs and fluids are the crucial factors for the management of anesthesia in this patient population3 . Keywords: Twin pregnancy, placenta accrete, mitral stenosis, pulmonary hypertension, sectio.