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Cardiopulmonary bypass support for emergency cesarean delivery in a patient with severe pulmonary hypertension
CASE REPORTS
Cardiopulmonary bypass support for emergency cesarean delivery in a patient with severe pulmonary hypertension Stephanie Penning, DO, Nancy Thomas, MD, Dawn Atwal, MD, Michael Nageotte, MD, and Douglas McConnell, MD Long Beach, California Cesarean delivery in a patient with pulmonary hypertension poses significant risks, particularly if the maternal status is decompensating. We present the first report of emergency use of cardiopulmonary bypass for cesarean delivery in a patient whose status was deteriorating. (Am J Obstet Gynecol 2001;184:225-6.)
Key words: Pulmonary hypertension, cardiopulmonary bypass
Medical advances over the last 50 years have dramatically improved maternal and fetal outcomes in women with cardiopulmonary disease. However, pulmonary hypertension remains one of the most lethal conditions complicating pregnancy. We present the first case of a patient with severe pulmonary hypertension who was placed on cardiopulmonary bypass support for a cesarean delivery with rapidly deteriorating maternal and fetal status. Case report A 23-year-old woman, gravida 2, para 0, abortions 1, with complete situs inversus underwent correction of a congenital atrial septal defect and pulmonary stenosis at the age of 6 years. Pulmonary and tricuspid regurgitation with worsening pulmonary hypertension subsequently developed. Approximately 5 months after conception, an echocardiogram estimated pulmonary artery pressures of 50 mm Hg. At 26 weeks’ gestation she was electively admitted to the hospital for bed rest and observation. On hospital day 2 she had acute shortness of breath with nausea and vomiting. An echocardiogram estimated the pulmonary artery pressure as 62 mm Hg with severe tricuspid and moderate pulmonary regurgitation. Pulmonary embolus was ruled out. Over the ensuing 12 hours, the patient had worsening dyspnea, orthopnea, and hypoxia. SimultaneFrom the Division of Maternal-Fetal Medicine, Departments of Cardiology and Cardiothoracic Surgery, Long Beach Memorial Medical Center. Received for publication January 6, 2000; accepted February 10, 2000. Reprint requests: Stephanie Penning, DO, Department of Obstetrics and Gynecology, UC Irvine Medical Center, 101 The City Drive, Bldg 25, Rt 81, Orange, CA 92868. Copyright © 2001 by Mosby, Inc. 0002-9378/2001 $35.00 + 0 6/1/106449 doi:10.1067/mob.2001.106449
ously, she began labor with moderate to severe variable fetal heart rate decelerations. In accordance with the patient’s requests, the decision was made to proceed with a cesarean delivery. The decision was made by the obstetric and cardiothoracic surgery teams to use cardiopulmonary bypass circulatory support during surgery to improve the patient’s chances for survival. The abdomen and groin were prepped and draped with the patient sitting at a 45° angle. While the patient was under local anesthesia, the left femoral artery and vein were isolated and cannulated, and partial cardiopulmonary bypass was initiated with flows of 4 to 6 L/min. The PO2 increased to >400 mm Hg with a dramatic improvement in symptoms. She was then able to be placed in a supine position for induction of general anesthesia. A classic cesarean delivery was rapidly performed with delivery of a 733-g female infant with normal blood gas values and Apgar scores. A Swan-Ganz catheter measured pulmonary artery pressure as high as 120 mm Hg, ultimately stabilizing at 70 to 80 mm Hg. The blood volume was reduced to normal by use of ultrafiltration, and she was removed from bypass after a total of 31 minutes. She was extubated in the immediate postoperative period and steadily improved. By postoperative day 7 she no longer required supplemental oxygen and had returned to her prepregnancy level of functioning (New York Heart Association class III). Unfortunately, she died of cardiorespiratory decompensation 14 months later. The child is currently doing well without any sequelae of prematurity noted. Comment This is the first report of an emergency cesarean delivery while a patient was on cardiopulmonary bypass support with worsening pulmonary hypertension.1 Car225
226 Penning et al
January 2001 Am J Obstet Gynecol
diopulmonary bypass accomplishes the following physiologic goals in a patient with acute decompensation and pulmonary hypertension: (l) It immediately unloads the pulmonary circulation and right ventricle; (2) it provides immediate oxygenation for both mother and fetus; (3) it allows control of the maternal circulating blood volume during and after delivery. Cardiopulmonary bypass has been used successfully for many years to conduct cardiac surgery that is necessary during pregnancy.2 In this case bypass allowed a cesarean
O
delivery to be performed safely with dramatic improvement in the patient’s oxygenation even after bypass was discontinued. REFERENCES
1. Sugioka J, Nakajima T, Ohsumi H, Kuro M, Sasako Y. [Anesthetic management using percutaneous cardiopulmonary support for cesarean section in a patient with severe pulmonary hypertension.] Masui 1995;44:574-8. 2. Strickland RA, Oliver WC Jr, Chantigian RC, Ney JA, Danielson GK. Anesthesia, cardiopulmonary bypass, and the pregnant patient. Mayo Clin Proc 1991;66:411-29.
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Cardiopulmonary bypass support for emergency cesarean delivery in a patient with severe pulmonary hypertension Stephanie Penning, DO, Nancy Thomas, MD, Dawn Atwal, MD, Michael Nageotte, MD, and Douglas McConnell, MD Long Beach, California Cesarean delivery in a patient with pulmonary hypertension poses significant risks, particularly if the maternal status is decompensating. We present the first report of emergency use of cardiopulmonary bypass for cesarean delivery in a patient whose status was deteriorating. (Am J Obstet Gynecol 2001;184:225-6.)
Key words: Pulmonary hypertension, cardiopulmonary bypass
Medical advances over the last 50 years have dramatically improved maternal and fetal outcomes in women with cardiopulmonary disease. However, pulmonary hypertension remains one of the most lethal conditions complicating pregnancy. We present the first case of a patient with severe pulmonary hypertension who was placed on cardiopulmonary bypass support for a cesarean delivery with rapidly deteriorating maternal and fetal status. Case report A 23-year-old woman, gravida 2, para 0, abortions 1, with complete situs inversus underwent correction of a congenital atrial septal defect and pulmonary stenosis at the age of 6 years. Pulmonary and tricuspid regurgitation with worsening pulmonary hypertension subsequently developed. Approximately 5 months after conception, an echocardiogram estimated pulmonary artery pressures of 50 mm Hg. At 26 weeks’ gestation she was electively admitted to the hospital for bed rest and observation. On hospital day 2 she had acute shortness of breath with nausea and vomiting. An echocardiogram estimated the pulmonary artery pressure as 62 mm Hg with severe tricuspid and moderate pulmonary regurgitation. Pulmonary embolus was ruled out. Over the ensuing 12 hours, the patient had worsening dyspnea, orthopnea, and hypoxia. SimultaneFrom the Division of Maternal-Fetal Medicine, Departments of Cardiology and Cardiothoracic Surgery, Long Beach Memorial Medical Center. Received for publication January 6, 2000; accepted February 10, 2000. Reprint requests: Stephanie Penning, DO, Department of Obstetrics and Gynecology, UC Irvine Medical Center, 101 The City Drive, Bldg 25, Rt 81, Orange, CA 92868. Copyright © 2001 by Mosby, Inc. 0002-9378/2001 $35.00 + 0 6/1/106449 doi:10.1067/mob.2001.106449
ously, she began labor with moderate to severe variable fetal heart rate decelerations. In accordance with the patient’s requests, the decision was made to proceed with a cesarean delivery. The decision was made by the obstetric and cardiothoracic surgery teams to use cardiopulmonary bypass circulatory support during surgery to improve the patient’s chances for survival. The abdomen and groin were prepped and draped with the patient sitting at a 45° angle. While the patient was under local anesthesia, the left femoral artery and vein were isolated and cannulated, and partial cardiopulmonary bypass was initiated with flows of 4 to 6 L/min. The PO2 increased to >400 mm Hg with a dramatic improvement in symptoms. She was then able to be placed in a supine position for induction of general anesthesia. A classic cesarean delivery was rapidly performed with delivery of a 733-g female infant with normal blood gas values and Apgar scores. A Swan-Ganz catheter measured pulmonary artery pressure as high as 120 mm Hg, ultimately stabilizing at 70 to 80 mm Hg. The blood volume was reduced to normal by use of ultrafiltration, and she was removed from bypass after a total of 31 minutes. She was extubated in the immediate postoperative period and steadily improved. By postoperative day 7 she no longer required supplemental oxygen and had returned to her prepregnancy level of functioning (New York Heart Association class III). Unfortunately, she died of cardiorespiratory decompensation 14 months later. The child is currently doing well without any sequelae of prematurity noted. Comment This is the first report of an emergency cesarean delivery while a patient was on cardiopulmonary bypass support with worsening pulmonary hypertension.1 Car225
226 Penning et al
January 2001 Am J Obstet Gynecol
diopulmonary bypass accomplishes the following physiologic goals in a patient with acute decompensation and pulmonary hypertension: (l) It immediately unloads the pulmonary circulation and right ventricle; (2) it provides immediate oxygenation for both mother and fetus; (3) it allows control of the maternal circulating blood volume during and after delivery. Cardiopulmonary bypass has been used successfully for many years to conduct cardiac surgery that is necessary during pregnancy.2 In this case bypass allowed a cesarean
O
delivery to be performed safely with dramatic improvement in the patient’s oxygenation even after bypass was discontinued. REFERENCES
1. Sugioka J, Nakajima T, Ohsumi H, Kuro M, Sasako Y. [Anesthetic management using percutaneous cardiopulmonary support for cesarean section in a patient with severe pulmonary hypertension.] Masui 1995;44:574-8. 2. Strickland RA, Oliver WC Jr, Chantigian RC, Ney JA, Danielson GK. Anesthesia, cardiopulmonary bypass, and the pregnant patient. Mayo Clin Proc 1991;66:411-29.
N THE MOVE? Send us your new address at least six weeks ahead
Don’t miss a single issue of the journal! To ensure prompt service when you change your address, please photocopy and complete the form below. Please send your change of address notification at least six weeks before your move to ensure continued service. We regret we cannot guarantee replacement of issues missed due to late notification. JOURNAL TITLE: Fill in the title of the journal here.
OLD ADDRESS: Affix the address label from a recent issue of the journal here.
NEW ADDRESS:
Clearly print your new address here. Name Address City/State/ZIP
COPY AND MAIL THIS FORM TO: Mosby Subscription Customer Service 6277 Sea Harbor Dr Orlando, FL 32887
OR FAX TO: 407-363-9661
OR PHONE: 1-(800)654-2452 Outside the U.S., call (407)345-4000