Epidural anaesthesia for labour and Caesarean section in a parturient with a single ventricle and transposition of the great arteries

Abstract

We describe a case of a 29-year-oM Pregnancy is rare in patients with a single ventricle and transposition of the great arteries (TGA). Single ventricle anomalies occur in only 1.5 per cent of patients with congenital heart disease, and 80 per cent of these patients have TGA with an equal incidence of dextro-and laevo-malpositions. 1 Previously, pregnancy has been reported in only eight patients with a single ventricle with or without an associated TGA. 2-9 According to Mangano, ~~ in parturients with cyanotic congenital heart disease avoidance of regional anaesthetic techniques may be wise because a decreased systemic vascular resistance and/or venous return may worsen the right-to-left-shunt. This case presents the management of a parturient with a single ventricle and laevo-TGA. It is the first report of the use of lumbar epidural analgesia/anaesthesia with a local anaesthetic for labour, emergency Caesarean section, and postoperative pain. Case reportA 29-yr-old patient was admitted for induction of labour after an amniocentesis indicated fetal maturity. Her complex past medical history included cyanotic congenital heart disease. Five years before this admission, cardiac catheterization revealed a single ventricle, laevo-TGA, ventricular inversion, atrial septal defect, right atrioventricular valve atresia and mild subvalvular and valvular stenosis. Her single ventricle pressure was 120/10 mmHg with a mean pulmonary artery pressure of 15-20 mmHg and a normal pulmonary vascular resistance. Her haemoglobin oxygen saturations (SaOs) were: inferior vena cava and right atrium 75 per cent, left atrium and ventricle 87 per cent, aorta 88 per cent and pulmonary artery 86 per cent. The ventricular ejection fraction was 28 per cent, and the haematocrit (Hct) was 56 per cent. The patient never had hypercyanotic spells or congestive heart failure.Her obstetrical history included two spontaneous abortions six years before this admission and an uncomplicated successful pregnancy and vaginal delivery four years prior to admission. Throughout her previous pregnancy, the patient had a Hct of 55-60 per cent and an SaO2 of approximately 88 per cent. Labour was induced at 35 weeks gestation; the first stage lasted three hours with a fifteen-minute second stage. She delivered vaginally with CAN J ANAESTH 1990 / 37:6 /pp6S0-4

Successful pregnancy and delivery in patients with uncorrected single ventricle: Three new cases and literature review

“…These results encouraged us to further review the outcome for pregnancy in UVH patient without surgical correction in the literature, as summarized in Table 2. Surprisingly, all of the reported cases since 1963 show good outcomes [1,2,4,[10][11][12][13][14][15][16][17][18][19][20][21][22]. It was suggested that UVH is not an absolute contraindication to pregnancy.…”

“…While it is necessary to decrease it to reduce overload, it is also critical to maintain sufficient pulmonary blood flow to oxygenate the blood [3]. Furthermore, it was demonstrated that history of congestive heart failure and other cardiac event is also a risk factor to the mother and fetus [14,15,25,29].…”

Anaesthetic management of a rare case of single ventricle heterotaxy syndrome for emergency caesarean section

“…[ 7 ] Another case of a 29-year-old parturient with a single ventricle and TGA, who had lumbar epidural analgesia/anaesthesia for labour, emergency caesarean section and post-operative pain has been described. [ 8 ] A case of a pregnant woman with a functionally univentricular heart and double outlet right ventricle who underwent caesarean section was managed using an epidural technique. [ 9 ]…”

Segmental epidural anesthesia for cesarean section in a parturient with uncorrected Taussig–Bing anomaly with transposition of the great arteries physiology

“…Contrast enhanced cardiac computer tomography Figure 1b – d showed both great vessels arising from RV, sub-pulmonic VSD, large dilated pulmonary artery, suggestive of Taussig–Bing variant with TGA physiology. [ 4 5 ] She was prescribed tablet furosemide and tablet sildenafil[ 7 ] and subsequently followed-up by the cardiologist for further management. She was discharged from the hospital on the 8 th day postpartum.…”

“…Such patients have complex pathophysiology, which can lead to unstable haemodynamics, arrhythmias and cardiac arrest under anesthesia. This is a rare case of a parturient with Eisenmenger syndrome[ 1 2 3 ] due to Taussig–Bing anomaly[ 4 ] with transposition of the great arteries (TGA) physiology[ 4 5 ] (double-outlet right ventricle (DORV) with sub-pulmonic ventricular septal defect (VSD) presenting for elective cesarean section for oligohydramnios and intrauterine growth retardation (IUGR). We report the successful management of this patient under segmental epidural anesthesia.…”