Pregnancy complicated by aortic dissection: caesarean delivery during extradural anaesthesia

Jayaram, A.; Carp, H.; Davis, Lowell E.; Jacobson, Sig Linda

doi:10.1093/bja/75.3.358

Cited by 45 publications

(33 citation statements)

References 15 publications

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“…The first treatment option in acute dissection is providing adequate hemodynamic control (7). Additionally, it is recommended that surgical repair of the aorta should be accomplished before the foetus is delivered if gestation is <28 weeks, however if gestation is >32 weeks caesarean section should be performed together with aortic repair (3,6).…”

Section: Discussionmentioning

confidence: 99%

Anaesthesia for Caesarean Delivery in a Pregnant with Acute Type B Aortic Dissection

Kayhan¹,

Gülhaş²,

Şahin³

et al. 2013

Turk J Anesth Reanim

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Case Report 178About 50% of aortic dissections in women younger than 40 years occur during pregnancy; mostly in the 3rd trimesters and postpartum period. Aortic dissection in pregnancy creates a serious mortality risk for both mother and the foetus. The ultimate goal is to ensure the safety of both the mother and the foetus. In such cases, the best method of anaesthesia for caesarean delivery is still controversial. The first aim of anaesthetic management is to reduce the effect of cardiovascular instability on the dissected aorta. Here, we report the anaesthetic management of a 36 year-old pregnant woman who developed acute type B aortic dissection in the 30 th gestational weeks and scheduled for caesarean section. Since hemodynamic stability could not be achieved despite nitro-glycerine and esmolol infusions, together with invasive arterial monitoring, the decision for caesarean delivery was taken. A team of Cardiovascular Surgeons and an operating room were prepared because of the risks of aortic rupture and hemodynamic collapse during operation. Combined-spinal epidural anaesthesia was administered using 5 mg hyperbaric bupivacaine and 20 μg fentanyl given at the L3-4 spinal level in the side lying position. After achieving T4 sensory block level, the operation proceeded and a baby weighing 1432 grams was delivered in 4 min with a median subumbilical incision. Epidural patient controlled analgesia was applied to the patient during follow-up with medical treatment at postoperative period. In pregnant women with acute Type B aortic dissection, if adequate sensory block level cannot be achieved despite using a combination of low dose local anaesthetic (spinal use) and opioids, we are in the opinion that combined spinal-epidural anaesthesia, which allows the use of additional doses can be a decent choice.

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Section: Discussionmentioning

confidence: 99%

Anaesthesia for Caesarean Delivery in a Pregnant with Acute Type B Aortic Dissection

Kayhan¹,

Gülhaş²,

Şahin³

et al. 2013

Turk J Anesth Reanim

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“…19,20 The presence of DE may explain variability in the volume of cerebrospinal fluid, and as a result, different response to spinal anesthesia. Greater than normal volume of cerebrospinal fluid in the lumbar theca is postulated to restrict the spread of intrathecally injected local anesthetics and cause a ''failed'' spinal.…”

Section: Discussionmentioning

confidence: 99%

“…Further observations, however, are necessary to confirm this hypothesis. Although DE is not an absolute contraindication for epidural anesthesia, caution has been advised in its use for patients with Marfan syndrome and associated DE because of the theoretical risk of accidental dural puncture 20 and CSF leak; however, when performed carefully by an experienced anesthesiologist, many benefits of epidural anesthesia, including minimal hemodynamic fluctuations and excellent postoperative pain control, can outweigh the potential risk. There has been some suggestion in the literature to perform an epidural in the lateral decubitus position to minimize the chance of accidental dural puncture.…”

Section: Discussionmentioning

confidence: 99%

“…In this position, the ectatic dural sac is thought to be less extended in the region of needle insertion. 20 We postulated that the lateral position may hinder the performance of the neuraxial technique and elected to perform the procedure with both patients in the sitting position. Although we did not acknowledge abnormal ''loss of resistance'' due to structural changes in the ligamentum flavum in either patient, this phenomenon has been suggested as a likely cause of accidental dural puncture.…”

Section: Discussionmentioning

confidence: 99%

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Regional anesthesia in Marfan syndrome, not all dural ectasias are the same: a report of two cases

Baghirzada

Krings

Carvalho

2012

Can J Anesth/J Can Anesth

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Background The anesthetic management of women with Marfan syndrome and dural ectasia undergoing Cesarean delivery remains controversial. We present two cases of patients with Marfan syndrome and dural ectasia where neuraxial anesthesia was used successfully. Case 1 A 31-yr-old G1P0 female with Marfan syndrome presented for elective Cesarean delivery at 35 3/7 weeks' gestation. The magnetic resonance imaging of her spine revealed significant dural ectasia in the lumbosacral area with a mean lumbar dural sac area of 4.71 cm 2 . Intrathecal administration of 0.75% hyperbaric bupivacaine 9 mg produced only limited perineal analgesia. The epidural catheter was titrated, and 0.5% bupivacaine 150 mg were required to achieve a T4 sensory level. Case 2 A 34-yr-old G1P0 female with Marfan syndrome presented for elective Cesarean delivery at 37 weeks' gestation. The intrathecal administration of 0.75% hyperbaric bupivacaine 13.5 mg produced a T5 sensory level. Magnetic resonance imaging of her spine prior to discharge confirmed the diagnosis of moderate dural ectasia with a mean lumbar dural sac area of 3.61 cm 2 . Discussion The two patients described in this report responded differently to spinal anesthesia, most likely based on the severity of their dural ectasia. Although preoperative magnetic resonance imaging may help to identify patients at risk for a failed spinal, we suggest considering a combined spinal-epidural technique in cases of dural ectasia. RésuméContexte La prise en charge anesthe´sique de femmes ayant un syndrome de Marfan et une ectasie de la dure-me`re au cours d'un accouchement par ce´sarienne reste un sujet controverse´. Nous pre´sentons le cas de deux patientes ayant un syndrome de Marfan et une ectasie de la dure-me`re chez qui une anesthe´sie neuraxiale a e´te´re´alise´e avec succe`s. Cas n8 1 Une femme de 31 ans, G1P0, ayant un syndrome de Marfan a e´te´admise pour accouchement par ce´sarienne programme´a`35 semaines et 3 jours de grossesse. L'imagerie par re´sonance magne´tique de la colonne verte´brale a re´ve´le´une ectasie significative de la dure-me`re dans la re´gion lombosacre´e avec une surface moyenne du sac dural lombaire de 4,71 cm 2 . L'administration intrathe´cale de 9 mg de bupivacaı¨ne hyperbare a`0,75 % n'a procure´qu'une analge´sie pe´rine´ale limite´e. La dose du cathe´ter pe´ridural a e´te´titre´e et 150 mg de bupivacaı¨ne 0,5 % ont e´te´ne´cessaires pour atteindre le niveau sensitif D4. Cas n8 2 Une femme de 34 ans, G1P0, ayant un syndrome de Marfan a e´te´admise pour accouchement par ce´sarienne programme´a`37 semaines de grossesse. L'administration intrathe´cale de 13,5 mg de bupivacaı¨ne Author contributions Leyla Baghirzada and Jose C.A. Carvalho cared for patients, reviewed the literature, and wrote the manuscript. Jose C.A. Carvalho and Timo Krings revised the manuscript, and Leyla Baghirzada submitted the final version of the manuscript. Timo Krings interpreted the magnetic resonance imagings for both patients.

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“…[34][35][36][37][38] The risk of aortic separation or other serious complications such as endocarditis or development of heart failure has been estimated at approximately 1% in case the aortic root diameter being (ACTS) ≤40 mm. 36,37,39 This risk increases significantly for ACTS>40 mm and/or rapid increase in diameter of the aortic.…”

Section: Pregnancy and Childbirthmentioning

confidence: 99%

Pregnancy and Childbirth in Patients With Syndrome-Marfan

Zacharias¹,

Nikolaos²,

Emmanuel³

2017

Gynecol Obstet Res Open J

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Marfan syndrome (MFS) is an autosomal dominant condition with a reported incidence rate of 1 in 3000 to 5000 individuals. The majority of cases of MFS are caused by a mutation in the fibrillin-1 gene (FBN1). Transforming growth factor β (TGF-β) plays an important role in Marfan syndrome. The identification of the FBN-1 mutation will help identify potentially affected family members and promote prenatal diagnostic testing. β blockers decrease myocardial contractility and pulse pressure and may also improve the elastic properties of the aorta. Angiotensin II-receptor blockers attenuate the clinical manifestations of MFS.

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Pregnancy complicated by aortic dissection: caesarean delivery during extradural anaesthesia

Cited by 45 publications

References 15 publications

Anaesthesia for Caesarean Delivery in a Pregnant with Acute Type B Aortic Dissection

Anaesthesia for Caesarean Delivery in a Pregnant with Acute Type B Aortic Dissection

Regional anesthesia in Marfan syndrome, not all dural ectasias are the same: a report of two cases

Pregnancy and Childbirth in Patients With Syndrome-Marfan

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