Hemodynamic Stability Under Graded Epidural Anesthesia for Emergency Cesarean Delivery in a Parturient with Large Atrial Septal Defect and Pulmonary Hypertension: An Observational Analytic Study

Abstract

Background. Pregnancy with a large uncorrected secundum atrial septal defect (ASD) and pulmonary hypertension carries the highest maternal risk (modified WHO class IV). A sudden fall in systemic vascular resistance can reverse the shunt and precipitate right ventricular failure, which makes the anesthetic technique for cesarean delivery critical.

Objective. To describe the hemodynamic course of a graded lumbar epidural with invasive monitoring in such a patient.

Methods. A 28-year-old primigravida at 37+2 weeks with a 4.8 cm secundum ASD, severe right-heart dilatation, and an echocardiographic systolic pulmonary artery pressure of 50.2 mmHg needed emergency cesarean delivery for premature rupture of membranes and intrauterine fetal demise. After radial arterial and central venous cannulation, 0.5% levobupivacaine (85 mg in four aliquots) was given epidurally to a T6 level. Mean arterial pressure (MAP), heart rate, and central venous pressure (CVP) were recorded at five time points. The report follows the CARE guideline.

Results. The T6 level was reached at 25 minutes. MAP was 83 mmHg at baseline, 72 mmHg after induction (−13.3%), and 71 mmHg at closure (−14.5%). Heart rate stayed at 72–82 beats/min and CVP at 8–10 mmHg. No vasopressor, inotrope, or pulmonary vasodilator was needed. She was discharged on day 4 without complications.

Conclusion. In this patient, slow epidural titration of levobupivacaine was followed by stable MAP, heart rate, and CVP without vasoactive support. One case cannot prove a benefit, and systemic vascular resistance and shunt direction were not measured.