Anaesthesia for caesarean section in the presence of severe primary pulmonary hypertension

Abstract

We describe the case of a pregnant woman, 35 weeks' gestation, with primary pulmonary hypertension and coarctation of the aorta requiring emergency Caesarean section under general anaesthesia. The patient had a pulmonary artery catheter inserted before operation which revealed pulmonary artery pressures in excess of 80/40 mm Hg. These were lowered using an infusion of glyceryl trinitrate. After delivery of the baby and administration of oxytocin, pulmonary artery pressures were more difficult to control. An infusion of prostacyclin was substituted which stabilized pulmonary pressures. After operation, she was transferred to the intensive care unit where prostacyclin was administered by an "aerosolized" route. Her trachea was extubated after 48 h and she made an uneventful recovery.

Pulmonary hypertension and pregnancy—a review of 12 pregnancies in nine women

“…Their baseline characteristics, together with maternal and neonatal outcomes, are recorded in Table 1. Their mean age at the initial clinic visit was 27 years (median 25 years, range [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38]. There were seven primigravidas.…”

“…However, the majority of the women received general anaesthesia for their caesarean sections, because it facilitated the use of transoesophageal echocardiography (TOE) to monitor cardiac output, and diminished the work of breathing, while allowing the anaesthetist to manipulate metabolic parameters. [30][31][32] Further, direct pulmonary vasodilators, such as nebulised prostacyclins and nitric oxide, can be given more easily and in the event of major complications the woman can be put onto cardiac bypass quickly. In most cases in this series, induction of general anaesthesia was achieved with high-dose fentanyl, etomidate and suxamethonium with cricoid pressure.…”

“…In most cases in this series, induction of general anaesthesia was achieved with high-dose fentanyl, etomidate and suxamethonium with cricoid pressure. In the literature, use of suxamethonium and a large dose of opiate to blunt the intubation response has been reported; 33 etomidate has been used by others 30 as has propofol, 31,32 but the actual effect of propofol on the pulmonary circulation is controversial because it may increase or decrease pulmonary vascular resistance. 33 Maintenance of anaesthesia was generally with high fractional inspired oxygen concentration and a volatile agent, usually isoflurane, which has been reported to suppress the pulmonary vasoconstrictor response to hypotension.…”

“…33 Vecuronium and atracurium have been used for muscle relaxation, the former being more cardiostable and the latter being better metabolised by the pregnant woman. Nitrous oxide was used in the first case (its suitability has been recommended by others 30,31 ), but as it has since been shown to be cardiodepressant as well as potentially increasing pulmonary vascular resistance in women with PH, 34 we have subsequently avoided its use.…”

Epoprostenol treatment for idiopathic pulmonary arterial hypertension in pregnancy

“…Postoperative increases in peripheral vascular resistance occur and may contribute to post-partum mortality. 21 Although there may be less alteration to hemodynamic parameters with regional anesthesia, good outcomes have been reported with both regional and general anesthesia [1][2][3][4][22][23][24] Little has been written about the effects of epoprostenol on the intrauterine environment. In our case, intensive fetal surveillance during intravenous epoprostenol therapy failed to show fetal harm.…”