Welcome to a new week of #Gasclass! This week you’re in the anesthesia pre-admission clinic.
The obstetrician has referred a patient for consideration of induction of labour because of worsening shortness of breath in the last few weeks of pregnancy. She is a 34 yo. G5P4 with 3 previous C-sections (first one was for fetal distress). She is currently at 30 weeks gestational age.
How would you assess this patient?
She has had 3 previous C-sections under neuraxial with no significant issues. The last one was 10 years ago. She reports having worsening dyspnea on exertions, orthopnea and PND. She has trouble sleeping flat and has taken to using 2 pillows. She reports no other significant medical issues on review of systems except for a history of rheumatic fever as a child in her home country.
On examination, she is speaking in 4-5 word sentences, HR 115 irregularly irregular, BP 100/60, SpO2 92% on room air. Her JVP is 5cm above the sternal angle, and there is a loud opening snap with diastolic murmur. She has crackles bilaterally and pedal edema.
Blood work shows mild elevations in her LFTs, but otherwise within normal limits.
You decide to order an ECG and CXR for this patient.
ECG shows atrial fibrillation with right sided strain.
CXR shows mild-moderate pulmonary edema.
You want to order an urgent echocardiogram but the patient lives far away and wants to go home to look after her kids.
Is it okay to let her go home and come back for the echocardiogram?
You counsel her that it is not safe for her to go home right now because she is showing signs and symptoms of pulmonary edema. If this is due to mitral stenosis from rheumatic heart disease, then it can worsen very quickly. You’ve pulled some strings for the echo to be done today, and as she is leaving the clinic she turns around and says “Oh by the way, the last few c-sections the anesthesiologists made a big deal of potentially needing a blood transfusion, but I’ve recently converted to Jehovah’s Witness and I must refuse any blood products.”
How would you counsel her now? Does this complicate your other considerations for the 4th c-section?
You’re worried because she has a high risk for placenta accreta/increta and she is at risk for significant post-partum hemorrhage. You discuss various transfusion options and which ones she would accept. She says she will think about it and discuss it with her Elder before getting back to you.
An echo is completed today and it shows moderate mitral stenosis with preserved LV function, dilated LA, and RVSP of 50 mmHg. It could not conclusively say if there was any thrombus in the left atrial appendage.
Would you consult any other services at this point? How would you formulate your anesthetic plan for this patient?
This is a very high risk patient and you arrange for a complex case conference between anesthesia, obstetrics, cardiology, cardiac surgery, neonatology, hematology and transfusion medicine, interventional radiology and bioethics.
You agree to a plan for elective section. She will be admitted to the antenatal ward with telemetry. She will be started on diuretics and beta-blockers for her pulmonary edema and mitral stenosis. Anticoagulation will be started with treatment-doses of low molecular weight heparin. She will be given celestone injections for fetal lung maturation and be placed on bed rest with supplemental oxygen (which may help decrease pulmonary pressures).
The plan is to undergo elective c-section at 34-36 weeks as long as she tolerates it. Some of your anesthetic considerations are:
- pregnant patient: two patients, aortocaval compression, rapid desaturation, “full stomach”
- moderate mitral stenosis with atrial fibrillation, likely some pulmonary hypertension and pulmonary edema
- sinus rhythm is ideal but need to anticoagulate for potential thrombus and will need TEE to verify before cardioversion anyway
- worry about autotransfusion and flash pulmonary edema
- hemodynamic goals for M.S. are to maintain low-normal HR, maintain afterload and preload, contractility and avoid sudden drops in preload or afterload
- would not tolerate spinal or inadvertent spinal from epidural test dose, would not tolerate oxytocin bolus
- high pulmonary pressures means no prostaglandins (e.g. Hemabate) either
- high risk of PPH and placenta accreta/increta/percreta
- optimize preop Hb levels
- meticulous surgical technique
- consider preoperative internal iliac balloons that can be inflated if massive hemorrhage occurs
- potential for gravid hysterectomy
- discuss all contingency plans for massive hemorrhage including aortic cross-clamp
- complication is she is a Jehovah’s WItness
- discuss which products she is willing to accept
- discuss if cell salvage is acceptable
- once again, meticulous surgical technique (not a “learning case”)
- consider tranexamic acid
- discuss plan if baby needs transfusion – have time to obtain court order ahead of emergency and bioethics counsel
- post-operative monitoring in high dependency unit
What do you think of the plan? Is there anything you would add or change?
You are waiting in line at the hospital coffee shop and see the patient waiting in line ahead of you. After getting her coffee she suddenly grabs her belly in pain and promptly collapses on the ground.
What do you do?
You rush to the patient’s side and see that they are breathing and have a pulse, albeit fast and thready. You call for a code blue, and with the help of the code team you put her on a stretcher and rush her to the L&D C-section suite.
The OB says there is some uterine bleeding and the FHR is slow – 80 bpm but present. She is worried about abruption and want to proceed with C/S emergently.
With some fluid resuscitation your patient actually becomes more alert and vitals are HR 100 afib, BP 95/50, SpO2 97% on 10L facemask.
Do you want to optimize her anymore for surgery? What is your anesthetic plan for this emergent C/S?
Thanks for all your responses this week! We move on to the final chapter…
You called for help and the code team arrives. She has a weak pulse but she regains consciousness with a fluid bolus and you are able to rush her up to the obstetric operating room for further resuscitation. The FHR is 80. The OB has noted some vaginal bleeding. She is currently 32 weeks gestational age.
After a short discussion with the team, it is decided to proceed with emergency c-section. You’ve placed an arterial line and two large bore IVs. You have a completed JW blood products form that states that she will accept albumin, recombinant factors and prothrombin complex concentrates, DDAVP, TXA, and cryoprecipitate. Blood bank was notified to prepare products for her.
A second anesthesiologist was called to help as well because of her hemodynamic issues as well being a very complex case. Neonatology was paged for potential resuscitation of the neonate.
Because her LMWH was not held, an epidural could not be performed. A general anesthetic was induced with very careful attention to hemodynamics and a TEE probe was inserted after intubation.
After deliver of the neonate, the obstetrician proceeds to do a hysterectomy and the patient is extubated and transferred to ICU with an estimated blood loss of 1.5 litres of blood.
After 2 hours you are called back to ICU because the patient’s heart rate is 140, and the ICU team wants you to start more analgesics for her.
What do you do?
Thank you to everyone for reading/tweeting about #gasclass this week! Hopefully there will be more “difficult” cases to come in the near future!
In the meantime, here is our Storify summary.
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