Interesting OB Case

[Noyac]

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25 yo female for elective C/S with Ebstein's anomoly with huge right atrium, apical displacement of the ant and septal leaflets with restricted motion. Relatively small RV with nl fxn. Moderate tricuspid insufficiency. Septal flattening, patent foramen ovale with R to L shunt. She has no h/o CHF, cor pulmonale, palpitations or syncope. TTE shows nl LV size, nl LV systolic fxn in addition to the above.

How do we proceed? What if she goes into labor?

 

[Planktonmd]

25 yo female for elective C/S with Ebstein's anomoly with huge right atrium, apical displacement of the ant and septal leaflets with restricted motion. Relatively small RV with nl fxn. Moderate tricuspid insufficiency. Septal flattening, patent foramen ovale with R to L shunt. She has no h/o CHF, cor pulmonale, palpitations or syncope. TTE shows nl LV size, nl LV systolic fxn in addition to the above.

How do we proceed? What if she goes into labor?

For an elective C section:
Start A line, Give some fluids then place epidural and titrate slowly to desired level.
Maintain BP with Phenylephrine infusion as needed.
For labor:
Labor will increase the pulmonary pressure and possibly worsens the R to L shunt. Since this patient does not have Right or left heart failure (yet) she will likely do well with Epidural analgesia.
On the other hand if her heart was in worse shape she should get an elective C section and avoid labor.

 

[VentdependenT]

How's she sating on RA noy? Just curious.

I'd make sure she was tanked up and place a labor epidural.

I like the Neo for BP to possibly decrease the R-->L shunt and boost up oxygenation.

Sounds like she is well compensated. Which is a good thing.

How'd it go?

 

[Noyac]

We haven't done this case yet.

RA sats are fine currently.

 

[Planktonmd]

We haven't done this case yet.

RA sats are fine currently.

I think you should be good to go with an epidural as I mentioned above.
Do you guys do High risk OB where you are?

 

[Noyac]

I think you should be good to go with an epidural as I mentioned above.
Do you guys do High risk OB where you are?

Your right about the epidural, it should be fine. Would you want any special monitors? An A-line?

I assume you wouldn't do a spinal, but how about a GETA?

What if she goes into labor?

As far as high risk OB, do you call this high risk? We also do VBAC/TOLAC's, pre-eclamptics and just about everything else. We just don't get that many high risk pts due to location. It has something to do with high altitude, healthy lifestyle, etc.

 

[pd4emergence]

I agree with the epidural plan. OB's do elective C sections for alot less. If it was my wife I would not want her to labor. Schedule the c section and if she goes into labor, section her. I think I would have time to get an epidural dosed up. I would also put in an aline. It sounds like her pump function is fine but I would rather have it and not need it.

 

[militarymd]

RV function is superfluous if you have normal pulmonary vasculature....

treat her like anyone else. ...other than meticulous debubbling of your iv tubing.

 

[Planktonmd]

Your right about the epidural, it should be fine. Would you want any special monitors? An A-line?

I assume you wouldn't do a spinal, but how about a GETA?

What if she goes into labor?

As far as high risk OB, do you call this high risk? We also do VBAC/TOLAC's, pre-eclamptics and just about everything else. We just don't get that many high risk pts due to location. It has something to do with high altitude, healthy lifestyle, etc.

Read my post # 2.
for the C section I would have an A line for better BP monitoring.
As for GA, if she needs it you can do it just make it smooth and avoid bucking and coughing at extubation.
If you are going to allow her to go into labor I would definitely consider her high risk and let the smart guys at the big university hospital take care of her.

 

[militarymd]

For an elective C section:
Start A line, Give some fluids then place epidural and titrate slowly to desired level.
Maintain BP with Phenylephrine infusion as needed.
For labor:
Labor will increase the pulmonary pressure and possibly worsens the R to L shunt. Since this patient does not have Right or left heart failure (yet) she will likely do well with Epidural analgesia.
On the other hand if her heart was in worse shape she should get an elective C section and avoid labor.

Read my post # 2.
for the C section I would have an A line for better BP monitoring.
As for GA, if she needs it you can do it just make it smooth and avoid bucking and coughing at extubation.
If you are going to allow her to go into labor I would definitely consider her high risk and let the smart guys at the big university hospital take care of her.

That's a WHOLE lot of

for a nothing burger case.

I'm just trying to fathom WHAT can possibly go wrong here....other air going to the brain.

Normal LV FXN and SIZE....NO clinical evidence of CHF....

I thought we all learned to TREAT the patient NOT some IMAGES from an ultrasound.

Wait....I guess if one didn't even start training until after the millenium...one gets taught that the pictures that we get of patients are more important than the patients themselves.

 

[Planktonmd]

That's a WHOLE lot of

for a nothing burger case.

I'm just trying to fathom WHAT can possibly go wrong here....other air going to the brain.

Normal LV FXN and SIZE....NO clinical evidence of CHF....

I thought we all learned to TREAT the patient NOT some IMAGES from an ultrasound.

Wait....I guess if one didn't even start training until after the millenium...one gets taught that the pictures that we get of patients are more important than the patients themselves.

I have been in practice since 1989 and I was a fully trained internist before I started my anesthesia residency in 1995 so you might want to correct your assumptions.
The patient in question has a significant R to L shunt and if you allow significant decrease in systemic BP she will get cyanotic and the same thing would happen if the pulmonary pressure increases during contractions and pushing.
A cyanotic hypoxic pregnant woman is not what you want to achieve is it?

 

[militarymd]

We haven't done this case yet.

RA sats are fine currently.

I have been in practice since 1989 and I was a fully trained internist before I started my anesthesia residency in 1995 so you might want to correct your assumptions.
The patient in question has a significant R to L shunt and if you allow significant decrease in systemic BP she will get cyanotic and the same thing would happen if the pulmonary pressure increases during contractions and pushing.
A cyanotic hypoxic pregnant woman is not what you want to achieve is it?

Whatever the shunt is....it is insignificant...

Intermittent cyanosis is well tolerated...

trained anesthesiologists can treat r to l shunts...whether they are wanking it in the ivory tower or sharing call with a CRNA in the boonies.

Tell me what bad thing that can happen that a trained anestheiologist can't handle that the wankers in a ivory tower can....short of CPB before delivery to close the pfo.

 

[Planktonmd]

Whatever the shunt is....it is insignificant...



Tell me what bad thing that can happen that a trained anestheiologist can't handle that the wankers in a ivory tower can....short of CPB before delivery to close the pfo.

Sure you can handle it but the question is: Do you really want to?
I don't know about you but I like uneventful calls where I get to go home and sleep all night.
The "Wankers" in the ivory tower don't go home and they have residents that like to do interesting cases, so by sending cases to them I am contributing to the progress of this field.

 

[militarymd]

Sure you can handle it but the question is: Do you really want to?
I don't know about you but I like uneventful calls where I get to go home and sleep all night.
The "Wankers" in the ivory tower don't go home and they have residents that like to do interesting cases, so by sending cases to them I am contributing to the progress of this field.

I see.....you just want to do the cases that CRNAs can easily handle.

I guess that's why CRNAs always say that they can do what MD's do....because MD's want to do what CRNA's do....

 

[Planktonmd]

I see.....you just want to do the cases that CRNAs can easily handle.

I guess that's why CRNAs always say that they can do what MD's do....because MD's want to do what CRNA's do....

Exactly!
I am going to leave all the complicated cases to geniuses like you and to "Ivory tower wankers".

 

[VentdependenT]

I see.....you just want to do the cases that CRNAs can easily handle.

I guess that's why CRNAs always say that they can do what MD's do....because MD's want to do what CRNA's do....

You son-ofa-beaytch

 

[militarymd]

Exactly!
I am going to leave all the complicated cases to geniuses like you and to "Ivory tower wankers".

And this is why the CRNAs will eventually replace us in private practice.

 

[VentdependenT]

And this is why the CRNAs will eventually replace us in private practice.

Pushen propofol

 

[Gator05]

Folks, I'm with military on this one. How are you going to eval her RV function? It's gonna be hypoplastic, may appear dry or distended, won't contract in a normal pattern due to its asymmetry, tons of TR. The ASD is a bit scary in the face of impending AFE, but is probably serving as a pop-off.

Hard to predict effects during Stage 2; she's already alkalotic, volume replete,

Pregnany is a great CHD stress test. She's volume up, way-up, until she lays flat, and then she's missing some preload from aortocaval compression. Baby's done the stress test for you. Could she exercise before pregnancy? Sounds like yes. Then not to worry. If she's made it this far, then she'll make it the rest of the way. GA, epidural or spinal, if you're careful you'll be fine.

Nobody's mentioned EKG; if she has a well functioning BP cuff and is conversant, I'm not sure an A-line is necessary. However, these folks are at higher risk from SVT and the like.

Not a problem really until after delivery, when the placenta auto-transfuses that blood back. Then you'll see how well the RV is working. Aside from considering neo, I'd consider some ntg for Stage 3/4 if she crumps and looks congested by exam.

So yeah, lots to think about, good to have some backup plans, but if you're familiar with the pathophysiology I think it's business as usual for this gal. Congrats to her!

 

[Planktonmd]

And this is why the CRNAs will eventually replace us in private practice.

Ok, so you want to turn a discussion about the management of a pregnant woman with Ebstein's anomaly into a debate about how CRNA's are taking over anesthesia?
I am going to stick with the original subject and say:
Pregnancy in these women including vaginal delivery and C sections are in general well tolerated and any anesthetic or analgesic technique is acceptable as long as you are careful.
There is increased incidence of prematurity, low birth weight, fetal loss and congenital heart disease in the newborn if the woman is cyanotic originally.
The specifics of how you manage the anesthetic or the timing of transfer to a center with better resources are subject to personal preferences and available resources.
There are many things that you feel you are qualified to do as a well trained anesthesiologist but many times there are factors beyond your medical knowledge that dictate what you can and what you can not do in a certain institution and under certain circumstances.

 

[militarymd]

Ok, so you want to turn a discussion about the management of a pregnant woman with Ebstein's anomaly into a debate about how CRNA's are taking over anesthesia?
I am going to stick with the original subject and say:
Pregnancy in these women including vaginal delivery and C sections are in general well tolerated and any anesthetic or analgesic technique is acceptable as long as you are careful.
There is increased incidence of prematurity, low birth weight, fetal loss and congenital heart disease in the newborn if the woman is cyanotic originally.
The specifics of how you manage the anesthetic or the timing of transfer to a center with better resources are subject to personal preferences and available resources.
There are many things that you feel you are qualified to do as a well trained anesthesiologist but many times there are factors beyond your medical knowledge that dictate what you can and what you can not do in a certain institution and under certain circumstances.

changing your story now....are we???

I've already outlined the care....no need to repeat what I said..

and for the 2nd time...patient is not cyanotic....just so you don't say it again...for the 4th time...patient is not cyanotic.

and once again...what else can a transfer offer this patient.....other than cpb for pfo closure before delivery....

stick with your story...you said YOU didn't want to deal with cases like this....NOT that your institution cannot deal with it.

 

[Planktonmd]

changing your story now....are we???

I've already outlined the care....no need to repeat what I said..

and for the 2nd time...patient is not cyanotic....just so you don't say it again...for the 4th time...patient is not cyanotic.

and once again...what else can a transfer offer this patient.....other than cpb for pfo closure before delivery....

stick with your story...you said YOU didn't want to deal with cases like this....NOT that your institution cannot deal with it.

I said the management is subject to personal preferences and available resources, my personal preference is to leave these cases to cowboys like you.
I initially said that I wouldn't mind doing the C section on her but if they choose to let her go into labor and vaginal delivery she does not belong on our OB floor, she belongs with people who like to sleep at the hospital like yourself.

 

[Noyac]

This lady will not labor. If she goes into labor we will section her, either GETA or epidural. If she makes it to term she will have an elective c/s under epidural. You can mange her other ways if you wish but this is my approach. I'm not sold on the a-line but what will it hurt?

 

[Planktonmd]

This lady will not labor. If she goes into labor we will section her, either GETA or epidural. If she makes it to term she will have an elective c/s under epidural. You can mange her other ways if you wish but this is my approach. I'm not sold on the a-line but what will it hurt?

Good plan.

 

[urge]

I like the Neo for BP to possibly decrease the R-->L shunt and boost up oxygenation.

Are you sure about that?

 

[Noyac]

Are you sure about that?

What are you going to use?

 

[Noyac]

How are you guys going to place the epidural? Loss of resistance to saline or air and why? Would you do a CSE and give IT narc's without local?

What if she became cyanotic during the c/s under epidural?

 

[Planktonmd]

How are you guys going to place the epidural? Loss of resistance to saline or air and why? Would you do a CSE and give IT narc's without local?

What if she became cyanotic during the c/s under epidural?

I understand your concern about injecting air with the PFO but I wouldn't change my technique just for that concern.
I always use air and I would use air for this one too.
Giving intrathecal narcotics sounds like a good idea, it will likely improve the quality of your epidural block.
If she becomes cyanotic during the surgery: Give more oxygen, correct BP using Phenylephrine and/or Ephedrine, tell them to stop pushing on her diaphragm, make sure there is no aortocaval compression....

 

[militarymd]

This lady will not labor. If she goes into labor we will section her, either GETA or epidural. If she makes it to term she will have an elective c/s under epidural. You can mange her other ways if you wish but this is my approach. I'm not sold on the a-line but what will it hurt?

Why epidural?

 

[Noyac]

Why epidural?

This case can be done under epidural or GETA. I choose epidural. Unless you are thinking about putting a spinal in her which I won't do. I will do a CSE however, injecting 200 mcg Duramorph and 20 mcg fentanyl for post-op w/c is another reason that I choose epidural route. But I guess I you could do this and put her to sleep without the epidural but with the duramorph. Not me. I think having the father present and mom awake when possible is actually a good thing when feasible.

So does that answer your question? Or are you just trying to poke sticks in my eyes?

 

[militarymd]

This case can be done under epidural or GETA. I choose epidural. Unless you are thinking about putting a spinal in her which I won't do. I will do a CSE however, injecting 200 mcg Duramorph and 20 mcg fentanyl for post-op w/c is another reason that I choose epidural route. But I guess I you could do this and put her to sleep without the epidural but with the duramorph. Not me. I think having the father present and mom awake when possible is actually a good thing when feasible.

So does that answer your question? Or are you just trying to poke sticks in my eyes?

and not a spinal

 

[urge]

I like the Neo for BP to possibly decrease the R-->L shunt and boost up oxygenation.

What are you going to use?

Neo is fine. It won't improve the shunt, though.

 

[Planktonmd]

and not a spinal

An epidural is a more appropriate anesthetic for this patient because it offers gradual onset.
A spinal could cause a sudden drop of BP, acutely increase the shunt and cause cyanosis.
I know that doesn't bother you but many anesthesiologists don't like their patients to become cyanotic especially if they are pregnant.

 

[militarymd]

An epidural is a more appropriate anesthetic for this patient because it offers gradual onset.
A spinal could cause a sudden drop of BP, acutely increase the shunt and cause cyanosis.
I know that doesn't bother you but many anesthesiologists don't like their patients to become cyanotic especially if they are pregnant.

You know...this has been studied and published on severe pre-eclamptics already....a patient population at the highest risk of hypotension.....

epidural vs spinal.....no difference in hypotension...that's the fact, jack.

I would have thought that Steadman would have taught you that....or maybe she did, and you just forgot.

 

[Planktonmd]

You know...this has been studied and published on severe pre-eclamptics already....a patient population at the highest risk of hypotension.....

epidural vs spinal.....no difference in hypotension...that's the fact, jack.

I would have thought that Steadman would have taught you that....or maybe she did, and you just forgot.

What's the connection between pre eclampsia and the case we are discussing?
How many times in your career have you placed a spinal in a patient with Ebstein's anomaly?
I think you are comparing apples and oranges.

 

[militarymd]

An epidural is a more appropriate anesthetic for this patient because it offers gradual onset.
A spinal could cause a sudden drop of BP, acutely increase the shunt and cause cyanosis.
I know that doesn't bother you but many anesthesiologists don't like their patients to become cyanotic especially if they are pregnant.

What's the connection between pre eclampsia and the case we are discussing?
How many times in your career have you placed a spinal in a patient with Ebstein's anomaly?
I think you are comparing apples and oranges.

I thought we were talking about hypotension.....hypotension is hypotension...

you said that epidurals don't cause sudden drops in bp like spinals....

and I'm just raising the

 

[militarymd]

if joy were in a grave she would be rolling over.....but unfortunately for her, she 's alive, and i get to give her grief about you.

 

[Planktonmd]

Once again you fail to understand a simple concept!
You want to talk about pre eclampsia:
In pre eclampsia you start with a high BP and that's why you have less pronounced hypotension after a spinal contrary to the old belief that spinals were dangerous in pre eclampsia.
In a syndrome where there is no hypertension and there is a right to left shunt the situation is totally different, there will be hypotension and it will be sudden because that's how aspinals work: SUDDENLY!
and if this happens the shunt will increase and she will get cyanotic.
Is that too complicated?

 

[Noyac]

I don't know who this Steadman person is but if she says that it fine to do a spinal in someone with a R>L shunt then I don't have much faith in her. Especially, when there are better alternatives. Why would you do a spinal in someone like this? Just because you can or because you want to prove something? Sure, it may be fine but so what. Maybe it is academic but an epidural is so simple, just do it.

The BASIC principles of anesthetic management of a pt with cardiac disease is to maintain preload, afterload and sinus rhythm. Increased R>L shunting will occur if there is a decrease in PVR, an increase in Pulm Vascular Resistance, or an increase in intrathoacic pressure.

The maintenance of sinus rhythm is something to think about in this case as well. The increase in catecholamines during labor can exacerbate an episode of dysrhythmia. Therefore, if she goes into labor and you are not going to section her then an epidural is a good idea as well.

 

[Noyac]

You know...this has been studied and published on severe pre-eclamptics already....a patient population at the highest risk of hypotension.....

epidural vs spinal.....no difference in hypotension...that's the fact, jack.

I would have thought that Steadman would have taught you that....or maybe she did, and you just forgot.

Pre-eclamptics are not what we are talking about. You are comparing apples and oranges here. And I understand that you are just talking about hypotension b/w spinals and epidurals. But these pts are different. Thats like saying that its ok to place a spinal in someone with severe AS b/c they don't cause hypotension. Apples and Oranges again.

 

[urge]

Increased R>L shunting will occur if there is a decrease in PVR(Typo??---SVR?), an increase in Pulm Vascular Resistance...

A spinal could cause a sudden drop of BP, acutely increase the shunt and cause cyanosis.

No. Not in this case. A increase or decrease in svr will not change any shunting in this case. Anyone cares to comment about this?

 

[Noyac]

No. Not in this case. A increase or decrease in svr will not change any shunting in this case. Anyone cares to comment about this?

Sure, the atrialized portion of the right ventricle, although anatomically part of the right atrium, contracts and relaxes with the right ventricle. This discordant contraction leads to stagnation of blood in the right atrium. During ventricular systole, the atrialized part of the right ventricle contracts with the rest of the right ventricle, which causes a backward flow of blood into the right atrium, accentuating the effects of tricuspid regurgitation. Add some cyanosis to this scenario and it gets worse as Pulm vasc resistance increases.

 

[militarymd]

Pre-eclamptics are not what we are talking about. You are comparing apples and oranges here. And I understand that you are just talking about hypotension b/w spinals and epidurals. But these pts are different. Thats like saying that its ok to place a spinal in someone with severe AS b/c they don't cause hypotension. Apples and Oranges again.

What I'm saying is that the degree of hypotension between a spinal and an epidural is the same....it's published.

Steadman was director of obstetric anesthesia at University of Miami and chair of the education committee there...

She also trained plank.....and she is now one of my partners.

 

[Noyac]

What I'm saying is that the degree of hypotension between a spinal and an epidural is the same....it's published.

Steadman was director of obstetric anesthesia at University of Miami and chair of the education committee there...

She also trained plank.....and she is now one of my partners.

Yes, I know of everything you speak here.

And I agree that the degree of hypotension is the same for the two. But it is the onset that is different in my experience. The spinal being more rapid and therefore, the epidural is easier to control.

About Steadman. I know her history as you have posted it here before. But I don't know her personally therefore, I will stick with my original point of view.

 

[militarymd]

Yes, I know of everything you speak here.

And I agree that the degree of hypotension is the same for the two. But it is the onset that is different in my experience. The spinal being more rapid and therefore, the epidural is easier to control.

About Steadman. I know her history as you have posted it here before. But I don't know her personally therefore, I will stick with my original point of view.

ok...if you say so.

 

[Noyac]

ok...if you say so.

That was easy.😉

 

[jetproppilot]

What I'm saying is that the degree of hypotension between a spinal and an epidural is the same....it's published.

Steadman was director of obstetric anesthesia at University of Miami and chair of the education committee there...

She also trained plank.....and she is now one of my partners.

Plank, you trained at DA U???

Was Michael Baron still there? Jim Cerullo?

 

[Planktonmd]

What I'm saying is that the degree of hypotension between a spinal and an epidural is the same....it's published.

.

Not true!
First the comaprison was done on pre eclamptic women and they are different because they are HYPERTENSIVE!
Second: the key word is GRADUAL!

 

[Planktonmd]

Plank, you trained at DA U???

Was Michael Baron still there? Jim Cerullo?

Yes 🙂
and yes!
Baron is still there right now I think.

 

[Planktonmd]

This is the study MMD is trying to somehow incorporate in this discussion:
http://www.anesthesia-analgesia.org/cgi/content/abstract/97/3/867

and maybe this one:
http://www.obgynsurvey.com/pt/re/ob...YmYyVhRTvwQBdV1!-1786064718!181195629!8091!-1

All in pre eclamptic women.