Eisenmenger's syndrome in pregnancy: epidural anesthesia for elective cesarean section

Unilateral Absent Pulmonary Artery in Pregnancy: A Case Report and Systematic Literature Review

OBJECTIVE

 Unilateral absence of a pulmonary artery (UAPA) is a rare congenital malformation associated with hemoptysis, pulmonary hypertension, and infection. Little is known about the impact on pregnancy outcomes. We sought to synthesize the existing literature on pregnancy outcomes in patients with maternal UAPA.

STUDY DESIGN

 We report a case of maternal UAPA and performed a systematic review of the existing literature. Articles in English reporting pregnancy outcomes among women with unilateral absence or hypoplasia of the pulmonary artery were included. Articles were reviewed at the abstract level and, if eligible, at the full-text level by two independent reviewers with disagreements adjudicated by a third reviewer. Data were abstracted by two independent reviewers. Outcomes of interest were mode of delivery, gestational age at delivery, intensive care admission, maternal death, and length of stay. Summary statistics for each outcome are presented.

RESULTS

 We identified 14 studies, including the presented case, reporting outcomes in 22 pregnancies impacted by maternal UAPA. Median age at diagnosis was 21 years. Concurrent cardiac comorbidities were reported in 6/13 (46.2%) with pulmonary hypertension in 5/20 (25%) of cases where this information was reported. We observed high rates of preterm birth (4/12, 33.3%), cesarean delivery (10/15, 66.7%), and operative vaginal delivery (2/5, 40.0%). There was one maternal death occurring in the immediate postpartum period for a mortality rate of 4.5%.

CONCLUSION

 Our study provides a comprehensive review of existing literature on maternal UAPA. Our findings suggest increased rates of adverse outcomes and underscore the importance of early diagnosis, identification of pulmonary hypertension, and multidisciplinary care.

KEY POINTS

· There may be increased adverse outcomes in maternal UAPA.. · Concurrent cardiac abnormalities are common in maternal UAPA.. · Early diagnosis, identification of pulmonary hypertension, and multidisciplinary care are important..

Anesthesia in pregnancy with heart disease

Management of pregnant women with heart disease remains challenging due to the advancement of innovations in cardiac surgery and correction of complex cardiac anomalies, and more recently, with the successful performance of heart transplants, cardiac diseases are not only likely to coexist with pregnancy, but will also increase in frequency over the years to come. In developing countries with a higher prevalence of rheumatic fever, cardiac disease may complicate as many as 5.9% of pregnancies with a high incidence of maternal death. Since many of these deaths occur during or immediately following parturition, heart disease is of special importance to the anesthesiologist. This importance arises from the fact that drugs used for preventing or relieving pain during labor and delivery exert a major influence - for better or for worse - on the prognosis of the mother and newborn. Properly administered anesthesia and analgesia can contribute to the reduction of maternal and neonatal mortality and morbidity.

Perioperative Care of Children with Eisenmenger Syndrome Undergoing Non-cardiac Surgery

The Eisenmenger syndrome (ES) is a severe form of pulmonary arterial hypertension and arises in congenital heart disease with a systemic-to-pulmonary shunt. Patients with ES have multisystem involvement as a result of chronic hypoxemia with hematologic, skeletal, renal, and neurologic systems, causing significant morbidity and mortality. In contrast to pulmonary arterial hypertension, survival prospects are far superior in patients with ES and a growing number of ES patients are surviving into adulthood. As a result, many face the prospect of incidental surgery. To date, there is no guideline for the perioperative care of ES patients in children and limited data available for adult patients. This review provides an overview of appropriate measures for the safe perioperative care of patients, based on an understanding of the pathophysiological changes that occur in ES.

Transversus abdominis plane block for bilateral orchiopexy in an 8-year-old patient with Eisenmenger's syndrome

Non-cardiac surgery should only be performed in patients with Eisenmenger’s syndrome if absolutely mandatory because these patients are at high risk of perioperative mortality. Proper anesthetic and perioperative pain management in these patients remains a controversial topic. Transversus abdominis plane (TAP) block provides safe and beneficial perioperative analgesia in adults and children; however, no report has described the performance of TAP block in a child with Eisenmenger’s syndrome.

Herein, we describe the performance of bilateral orchiopexy for cryptorchidism in an 8-year-old boy with Eisenmenger’s syndrome due to an uncorrected muscular ventricular septal defect (mVSD). Anesthesia induction and maintenance were uneventful. Subsequently, the patient received ultrasound-guided bilateral TAP block by using 10 mL of 0.25 % levobupivacaine shortly before recovery from anesthesia. The TAP block provided pain relief and maintenance of stable hemodynamics during the postoperative period.

We successfully used a TAP block in a child with Eisenmenger’s syndrome to provide postoperative analgesia. No side effects were apparent during the perioperative period. TAP block can be considered a beneficial pain management technique for analgesia in children with Eisenmenger’s syndrome.

Eisenmenger's syndrome in pregnancy: Use of epidural anesthesia and analgesia for elective cesarean section

We describe a case of a pregnant patient with a large ventricular septal defect (VSD) and pulmonary artery hypertension, presented to the hospital and underwent elective cesarean section under epidural anesthesia and postoperative analgesia. The procedure was uneventful till the patient was discharged on 10^th day.

The pregnant patient with congenital heart disease

Advances in the surgical palliation and correction of congenital heart lesions have improved survival and increased the number of patients living into adulthood. Although pregnancy outcomes will be favorable for most patients with congenital heart disease, the cardiovascular challenges associated with pregnancy and delivery are best managed with a multidisciplinary approach during the puerperium. This review addresses the prevalence, physiology, risk assessment, peripartum complications, and anesthetic management of the pregnant patient with underlying congenital heart disease.

Low-dose bupivacaine-fentanyl spinal anesthesia for lower extremity surgery in a nonparturient with Eisenmenger's syndrome

Perioperative mortality in patients with Eisenmenger's syndrome is very high, particularly following cesarean section. This case report describes the successful use of low-dose bupivacaine-fentanyl spinal anesthesia for lower extremity surgery in a nonparturient with Eisenmenger's syndrome. A 21-year-old woman with Eisenmenger's syndrome was scheduled to have a fibular head tumor excision. After placement of routine monitor and an arterial line, we inserted an epidural catheter at the L3-L4 interspace to cover a potential inadequate block and then we administered 6 mg of hyperbaric bupivacaine 0.5% with 20 microg of fentanyl intrathecally via a 27-gauge needle at the L4-L5 interspace. There were no hypotension, respiratory depression, hypoxemia, and other severe hemodynamic alterations. No drug was administered via the epidural catheter in the 2-hour operative period and the postoperative course was uneventful. Therefore, we propose that intrathecal opioids combined with local anesthetics may be an alternative anesthetic method in patients with Eisenmenger's syndrome.

HEART DISEASE IN PREGNANCY 2: Congenital Heart Disease in Pregnancy

Congenital heart disease has become more prevalent in women of childbearing age and represents about 75% of the heart disease seen in pregnancy. Close monitoring by both obstetricians and cardiologists is advisable for women with complex heart disease, and pregnancy should still be considered contraindicated in several types of congenital heart disease. Women should also be advised of the risk that their offspring may be affected. Women at increased risk for a cardiac event in pregnancy include those with a prior cardiac event or arrhythmia, NYHA functional class > II or cyanosis, left heart obstruction, and systemic ventricular dysfunction. In the absence of adverse predictors, however, women with congenital heart disease can be assured that pregnancy does not pose a significant risk to their health.

Labor analgesia for the parturient with cardiac disease: what does an obstetrician need to know?

Maternal heart disease complicates 0.2-3% of pregnancies. The optimal management of the pregnant patient with cardiac disease depends on the cooperative efforts of the obstetrician, the cardiologist and the anesthesiologist involved in peripartum care. A comprehensive understanding of physiology of pregnancy and pathophysiology of underlying cardiac disease is of primary importance in provision of obstetric analgesia or anesthesia for this high-risk group of patients. This article will review the current guidelines and standards pertinent to management of obstetric analgesia and anesthesia in parturients with cardiac disease.

Pulmonary hypertension complicating twin pregnancy: continuous spinal anaesthesia for caesarean section

A case of secondary pulmonary hypertension complicating twin pregnancy and necessitating caesarean section is presented. A planned team approach involving senior consultants in obstetrics, cardiology, neonatology and cardiac and obstetric anaesthesia resulted in successful perioperative management. Continuous spinal anaesthesia was the chosen technique to give adequate operating conditions with least haemodynamic disturbance. This is the first report of continuous spinal anaesthesia in such a condition.

Epidural anesthesia for cesarean section in a patient with Eisenmenger's syndrome

Eisenmenger's syndrome is a complex combination of cardiovascular abnormalities and is defined as pulmonary hypertension at systemic pressure level with reversed or bi-directional shunt through an intracardiac or aortopulmonary communication. Patients with Eisenmenger's syndrome are at high risk for peripartum morbidity and mortality. Multigravid patients with this disease are therefore uncommon. We report the anesthetic management for cesarean section of a 27-year-old multigravid female at 35 weeks' gestation with Eisenmenger's syndrome. Titrated epidural anesthesia was administered with incremental doses of 2% lidocaine. Intraoperative course was uneventful except for an episode of hypotension immediately after delivery of the baby, which was managed successfully. We conclude that carefully titrated epidural anesthesia may be safe, appropriate, and effective for patients with Eisenmenger's syndrome for cesarean section.

Incremental spinal anaesthesia for elective Caesarean section in a patient with Eisenmenger's syndrome

We describe a new approach to anaesthesia for elective Caesarean section in a woman with Eisenmenger's syndrome. Incremental regional anaesthesia was performed using a microspinal catheter and haemodynamic monitoring included transthoracic bioimpedance cardiography. This approach allowed the disadvantages of general anaesthesia and invasive cardiac output monitoring to be avoided.

Eisenmenger Syndrome

The incidence of congenital cardiovascular malformation is unknown but is estimated to be approximately 0.8% of live births. This figure does not include preterm infants (all of whom have a patent ductus arteriosus [PDA]) or stillborn infants (who have a high incidence of cardiovascular abnor malities). Approximately 9% of patients with congenital car diac disease and 11% of those with uncorrected left-to-right intracardiac shunts will develop the Eisenmenger syndrome (ES). ES develops at different rates, depending on the size and location of the cardiac lesion and the amount of in creased pulmonary blood flow and pressure. Onset in in fancy is common in patients with PDA or a large ventricular septal defect (VSD). ES is seen in up to 50% of patients with VSD larger than 1.5 cm in diameter, whereas there is only a 3% incidence in those with defects that are less than 1.5 cm in diameter. Children with Down syndrome and a VSD or atrioventricular canal defect are prone to early development of ES. They have abnormal upper airways that predispose them to chronic upper airway obstruction and sleep apnea, both of which promote hypoxemia, hypercarbia, and early development of pulmonary hypertension. ES develops early in nearly all patients with uncorrected transposition of the great arteries and truncus arteriosus, whereas most patients with uncorrected ASD who develop the syndrome do so in the second decade of life. The prognosis for survival through childhood with ES is relatively good. Patients usually lead remarkably active lives until shortly before they die. The goal of this article is to provide a detailed overview of the pathophysiology, clinical presentation, and medical and sur gical management of these patients. Particular focus on the anesthetic management of patients undergoing cardiac and noncardiac surgery is provided.

Management of labor in Eisenmenger syndrome with inhaled nitric oxide

Administration of nitric oxide by means of inhalation during the labor of a woman with Eisenmenger's syndrome caused by an atrial septal defect resulted in improved oxygenation and initial pulmonary arterial pressure. She gave birth to a live infant at 34 weeks' gestation but died of worsening pulmonary hypertension and heart failure 21 days post partum.

Outcome of pregnancy in women with congenital shunt lesions

OBJECTIVE

To evaluate the outcome of pregnancy in women with congenital shunt lesions.

SETTING

Retrospective study in a tertiary care centre.

METHODS

Pregnancy history was obtained by a standardised questionnaire and medical records were reviewed.

PATIENTS

175 women were identified, at a mean (SD) age of 42 (14) years. Pregnancies occurred in 126 women: 50 with an atrial septal defect, 22 with a ventricular septal defect, 22 with an atrioventricular septal defect, 19 with tetralogy of Fallot, and 13 with other complex shunt lesions.

RESULTS

309 pregnancies were reported by 126 woman (2.5 (1.6) pregnancies per woman). The shortening fraction of the systemic ventricle was 40 (8)%, and 98% were in New York Heart Association class I-II at last follow up. Spontaneous abortions occurred in 17% of pregnancies (abortion rate, 0.4 (0.9) per woman). Gestational age of the 241 newborn infants was 8.8 (0.8) months. There were no maternal deaths related to pregnancy. Pre-eclampsia and embolic events were observed in 1.3% and 0.6%, respectively of all pregnancies. Women with complex shunt lesions more often underwent caesarean section (70% v 15-30%, p = 0.005) and gave birth to smaller babies for equivalent gestation (2577 (671) g v 3016 (572) to 3207 (610) g, p < 0.05). The recurrence risk of congenital heart disease was 2.5%.

CONCLUSIONS

The outcome of pregnancy is favourable in women with congenital shunt lesions if their functional class and their systolic ventricular function are good. Such patients can be reassured.

Outcome of pregnancy in women with congenital heart disease

Improvements in diagnosis and surgical technique for correction have led to an increasing number of women with congenital heart disease reaching the child-bearing age. Pregnancy places considerable strain on the heart and circulation and necessitates marked cardiorespiratory adaptation. Today, with the exception of the Eisenmenger syndrome, there is no increased mortality associated with pregnancy in congenital heart disease. In contrast, there is still considerable morbidity, due to congestive heart failure, thromboembolic complications and disturbances of rhythm. Fetal outcome is complicated by a high rate of spontaneous abortions (20-25%), retardation of fetal growth, and premature delivery (almost 100% in cyanotic mothers). Based on an extensive review of the literature, we discuss the specific risks in pregnancy depending on the hemodynamic situations produced by different heart defects. We also discuss the risks and advantages of different regimens for anticoagulation. Counselling concerning contraception is frequently inadequate. The most important problems are thromboembolic complications with the use of hormonal contraception, and hyper- and dysmenorrhea in those using intrauterine devices. Finally, the genetic risks must be considered, differentiating between single gene defects and the sex of the parents suffering from congenital heart diseases.

Noncardiac surgery in Eisenmenger syndrome

OBJECTIVES

The purpose of this study was to evaluate the morbidity and mortality associated with noncardiac surgery (NCS) in patients (pts) with Eisenmenger syndrome.

BACKGROUND

Noncardiac surgery in pts with Eisenmenger syndrome is associated with increased cardiovascular complications.

METHODS

Fifty-eight pts with Eisenmenger syndrome (17M, 41F aged 18 to 69 years (mean 41 years) who had been followed for up to 41.5 years (mean 9.3 years) were retrospectively evaluated for any NCS done at > or = 17 years of age.

RESULTS

Twenty-four pts had a total of 28 NCSs at an age of 17 to 55 years (mean 29 years) including 9 tubal ligations, 3 neurosurgeries, 3 cholecystectomies, 3 hysterectomies, 3 vasectomies, and 1 each spinal fusion, appendectomy, eye enucleation, hernia repair, hand surgery, tonsillectomy and therapeutic abortion. There were two deaths (7%), one following spinal fusion and the other following appendectomy at another institution. Fourteen of these NCSs were performed at our institution, including 11 under general anesthesia. The duration of anesthesia varied from 75 to 525 min (mean 165 min). All pts remained in sinus rhythm. The lowest systolic blood pressure (BP) ranged from 78 to 125 mm Hg. Of those 11 pts, 9 were extubated immediately after surgery and 2 needed dopamine. Ten patients were discharged without any complications, including 3 within 1 day of surgery. One death occurred 10 days following spinal fusion. This pt had the longest anesthesia (525 min) and an intraoperative systolic BP as low as 78 mm Hg. She also needed the largest fluid administration (6,475 cc) in addition to postoperative mechanical ventilation and dopamine.

CONCLUSIONS

Adult pts with Eisenmenger syndrome are at increased risk with NCS, but with current/modern techniques, the risk of death is less than previously thought. In the vast majority of cases, NCS can be undertaken without substantial morbidity, and early extubation is achievable. However, even with relatively minor surgery, significant complications, including death, can occur. Referral to major centers with expertise in the care of pts with Eisenmenger syndrome is advisable.

Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996

OBJECTIVES

Published reports were reviewed to evaluate the characteristics of peripartal management and the late pregnancy outcome in women with pulmonary vascular disease (PVD).

BACKGROUND

Pulmonary hypertension poses one of the highest risks for maternal mortality, but actual data on the maternal and neonatal prognosis in this group are lacking.

METHODS

Reports published from 1978 through 1996 of Eisenmenger's syndrome (n = 73), primary pulmonary hypertension (PPH) (n = 27) and secondary vascular pulmonary hypertension (SVPH) (n = 25) complicating late pregnancy were included and analyzed using logistic regression analysis.

RESULTS

Maternal mortality was 36% in Eisenmenger's syndrome, 30% in PPH and 56% (p < 0.08 vs. other two groups) in SVPH. Except for three prepartal deaths due to Eisenmenger's syndrome, all fatalities occurred within 35 days after delivery. Neonatal survival ranging from 87% to 89% was similar in the three groups. Previous pregnancies, timing of the diagnosis and hospital admission, operative delivery and diastolic pulmonary artery pressure were significant univariate (p < 0.05) maternal risk factors. Late diagnosis (p = 0.002, odds ratio 5.4) and late hospital admission (p = 0.01, odds ratio 1.1 per week of pregnancy) were independent predictive risk factors of maternal mortality.

CONCLUSIONS

In the last two decades maternal mortality was comparable in patients with Eisenmenger's syndrome and PPH; however, it was relevantly higher in SVPH. Maternal prognosis depends on the early diagnosis of PVD, early hospital admission, individually tailored treatment during pregnancy and medical therapy and care focused on the postpartal period.

Caesarean delivery of a patient with truncus arteriosus

Truncus arteriosus Type IV is a rare congenital cardiac malformation characterized by agenesis of the pulmonary arteries. Pulmonary perfusion is ensured by bronchial arteries. One common arterial trunk arises from both ventricles and systemic pulmonary and coronary arteries originate from this common vessel. Survival is rare without surgical correction. We report a case of uncorrected truncus arteriosus Type IV in a 28-year-old primigravid woman who underwent caesarean section.

Anesthetic management and outcome following noncardiac surgery in nonparturients with Eisenmenger's physiology

STUDY OBJECTIVE

To evaluate the perioperative risk to nonparturients with Eisenmenger's physiology for noncardiac surgical procedures.

DESIGN

Retrospective chart review.

SETTING

University-affiliated hospital.

PATIENTS

12 nonparturients with Eisenmenger's physiology who underwent 25 noncardiac surgical procedures requiring care by an anesthesiologist.

MEASUREMENTS AND MAIN RESULTS

Preoperative, intraoperative, and postoperative records were retrospectively analyzed. Data examined included patient age, gender, symptoms, laboratory values, monitors used, surgical procedure, and outcome. Twenty-five procedures were performed on 12 patients; 13 procedures were performed with general anesthesia, 6 with peripheral nerve blocks, 5 with sedation by an anesthesiologist with or without local anesthetic infiltration, and one with epidural anesthesia. One patient died perioperatively. Review of the literature revealed two deaths in 32 procedures for nonparturients with Eisenmenger's physiology undergoing noncardiac surgery.

CONCLUSIONS

A variety of anesthetic techniques and drugs may be used successfully in nonparturients with Eisenmenger's physiology undergoing noncardiac surgery. Although the study group is small, the perioperative mortality risk is lower than that for parturients undergoing either labor and delivery or cesarean section and is probably in the range of approximately 10%.

The anaesthetic management of the child with Eisenmenger's syndrome

There is little clinical data in the literature on the anaesthetic management of paediatric patients with Eisenmenger's syndrome undergoing non-cardiac surgery. This paper reviews our experiences with either such patients who underwent a total of 11 surgical procedures. Of the eight children, six had Down's syndrome and an atrio-ventricular septal defect, one had a ventricular septal defect and one an atrial septal defect. Nine of the eleven operations consisted of minor dental, plastic or ENT procedures, while one patient underwent two laparotomies. Premedication (trimeprazine/ meperidine combination or midazolam) was administered on three occasions. Induction of anaesthesia was achieved by either inhalation of halothane (2), or intravenously with thiopentone (6), ketamine (2) or propofol (1). Muscle relaxation and mechanical ventilation were employed only for both intra-abdominal procedures, otherwise patients were allowed to breathe spontaneously with, or without, manual assistance. Halothane (8), isoflurane (2) and enflurane (1) were all used for maintenance of anaesthesia. Non-invasive monitoring was applied intraoperatively for minor procedures, and arterial and central venous catheters inserted for the laparotomies. Postoperative analgesia for both these cases was provided by an epidural infusion of bupivacaine 0.125% and fentanyl 5 micrograms x ml(-1). A single im bolus of morphine was required following a dental clearance, otherwise pain relief for the rest of the cases was achieved by local anaesthetic infiltration and NSAIDS. With the exception of a single episode of bradycardia, induction, maintenance and recovery from anaesthesia were well tolerated in all cases. In conclusion, our experience suggests that despite theoretical risks, children with Eisenmenger's syndrome appear to tolerate a variety of anaesthetic techniques.

Pulmonary hypertension and pregnancy: a series of eight cases

This is the report of a series of eight patients with pulmonary hypertension (primary and secondary) who delivered at the McMaster University Medical Centre between 1978 and 1987. Seven of the eight patients delivered vaginally and had a successful outcome. The eighth patient was admitted as an emergency and died shortly after Caesarean section under general anaesthesia, performed to save the infant. The other seven patients were all managed by a team, including anaesthetists, cardiologists and obstetricians, from about 25 wk. The patients were hospitalized pre-partum and received oxygen therapy and anticoagulation with heparin. Analgesia in labour was managed, once anticoagulation was reversed, by low concentrations of epidural bupivacaine (0.125%-0.375%) and fentanyl. The patients were monitored during labour and delivery with oximetry and arterial and central venous pressure lines. Pulmonary arterial lines were not used because of increased risk and questionable usefulness. Vaginal delivery was managed with vacuum extraction or forceps lift-out to minimize the stress of pushing. After delivery, all patients were monitored in an intensive care unit for several days, anticoagulation was restarted, and all patients were discharged home taking oral anticoagulant therapy. The successful management of pulmonary hypertension in pregnancy should include team management started early in pregnancy and controlled vaginal delivery utilizing epidural analgesia.

Cyanotic congenital heart disease and pregnancy: natural selection, pulmonary hypertension, and anesthesia

Pregnancy carries substantial maternal and fetal risks in patients with uncorrected or palliatively corrected cyanotic congenital heart disease (CHD). In tricuspid valve Ebstein's anomaly, pregnancy is well tolerated. Maternal mortality in tetralogy of Fallot seems to be less than 10%, but it exceeds 50% in Eisenmenger's syndrome and primary pulmonary hypertension (PPH). Maternal hematocrit greater than 60%, arterial oxygen saturation lower than 80%, right ventricular hypertension, and syncopal episodes are poor prognostic signs. Maternal risk could be reduced by vaginal delivery. Continuous monitoring of arterial and central venous pressure, electrocardiography, and pulse oximetry are recommended for every anesthetic procedure. The use of a pulmonary artery catheter is controversial and probably should be avoided in parturients with cyanotic CHD or PPH. The choice of anesthetic technique and drugs per se is of secondary importance and should be governed by individual preferences. Titration of anesthetic drugs, general anesthesia with controlled ventilation, or, preferably, regional anesthesia with spontaneous breathing should be used cautiously to avoid worsening of the preexisting condition. Prevention of excessive erythrocytosis, volume and blood loss substitution, cardiocirculatory pharmacologic support, prophylaxis of infective endocarditis, and judicious use of anticoagulant drugs should be applied as indicated by the type and presentation of CHD. Poor outcome of pregnancy in PPH requires an early consideration of heart-lung or lung transplantation. Multidisciplinary team effort and prolonged monitoring in the intensive care unit are mandatory to ensure a favorable outcome for cyanotic CHD and PPH parturients.

General anesthesia for cesarean section in a parturient with a single ventricle and pulmonary atresia

The successful management of a cesarean section in a parturient with a single ventricle and pulmonary atresia using general anesthesia is discussed. After cyanosis at birth, the patient underwent cardiac catheterization, which showed an apparent severe tetralogy of Fallot, atresia of the main pulmonary artery (PA), and a large patent ductus arteriosus. When she was 7 months of age, a Blalock-Taussig shunt (right subclavian artery to right PA) was done. She remained stable until age 11, when cyanosis increased and exercise tolerance decreased. Recatheterization more clearly defined the lesion: closed shunt, pulmonary valvular atresia, severe ductal stenosis, reduced pulmonary flow, double-outlet right ventricle, and severe hypoplasia of the left atrium, mitral valve, and left ventricle. A Potts shunt (left descending aorta to left PA) was done. Compliance with therapy was poor and follow-up difficult. Exercise tolerance was poor, but the patient remained otherwise stable. At 28 weeks' gestation, this 23-year-old parturient presented with severe congestive heart failure (CHF). After initial therapy with oxygen, bed rest, digoxin, and diuretics, she improved and remained stable for a month. At that time (32 weeks' gestation), CHF worsened. Because the cervix was unfavorable for a vaginal delivery, a cesarean section was planned. The patient was then taken to the operating room electively, and an opioid-based general anesthetic was administered. Both mother and infant did well. This case is presented because the physiology of the patient's lesion and her unusual social history presented challenges for her anesthetic management.

Does the addition of tris(hydroxymethyl) aminomethane to 0.5% bupivacaine delay epidural onset in parturients?

A rapid onset of epidural anesthesia may predispose a pregnant patient to hypotension during the first stage of labor. Sodium bicarbonate has been reported to hasten epidural onset of chloroprocaine, lidocaine and bupivacaine while tris(hydroxymethyl) aminomethane (THAM) has been shown to delay the onset of epidurally administered chloroprocaine in parturients. The purpose of this study was to determine whether the addition of THAM to bupivacaine affected the onset, cephalad spread and incidence of hypotension following epidural administration in healthy pregnant patients during the first stage of labor. Three groups each consisting of 20 ASA I or II patients were studied. Group I received 0.5% bupivacaine with saline (0.06 ml/10 ml). Group II received bupivacaine buffered with THAM (0.06 ml/10 ml) to a pH of 6.8. Group III received bupivacaine buffered to a pH of 6.8 with sodium bicarbonate (0.05 ml+0.01 ml saline/10 ml). Statistical analysis used one-way analysis of variance and the appropriate post hoc test for multiple comparisons. A [Formula: see text] value less than 0.05 was considered significant. The onset of analgesia, the cephalad spread, and the incidence of hypotension did not differ between the groups. It is concluded that THAM does not affect the pharmacodynamics of 0.5% bupivacaine administered epidurally.

Caesarean section in undiagnosed Eisenmenger's syndrome. Report of a patient with a fatal outcome

An obstetric patient is described in whom the first sign of cardiac disease was unexplained hypoxaemia during emergency anaesthesia for antepartum haemorrhage, with an eventual fatal outcome. The case highlights the importance of patient information at the booking clinic, and the implications of a raised haemaglobin in early pregnancy.

Epidural anaesthesia for bilateral inguinal herniorrhaphy in Eisenmenger's syndrome

The successful management of a patient with Eisenmenger's syndrome undergoing bilateral herniorrhaphy is described, and some of the anaesthetic problems associated with this condition are considered. The case is reported because epidural anaesthesia is performed rarely in these patients. The use of subcutaneous heparin, the level of monitoring required, and the value of pulse oximetry are also discussed.

Eisenmenger's syndrome and pregnancy

Two cases of successfully managed Eisenmenger's syndrome during pregnancy are reported. A women suffering from Eisenmenger's syndrome who becomes pregnant should be advised to have her pregnancy terminated. On the basis of the available literature and our own experiences we suggest the following plan, if a woman, despite medical advice, chooses to continue her pregnancy: admission to hospital at approximately 25 weeks of gestation; bed rest during the remaining period of pregnancy; oxygen face-mask during episodes of dyspnoea; determination of serial blood gases to detect changes in the shunt flow. At the onset of labour, arterial and epidural catheters should be inserted, a fall in blood pressure should immediately be counteracted by the administration of norepinephrine and loss of blood by transfusion. The patient should remain in hospital for 7-14 days after delivery.

Primary pulmonary hypertension in pregnancy

Primary pulmonary hypertension (PPH) is an uncommon but serious disease. Most patients with PPH are young women and the disease is more serious and eventful in pregnant women. We have experienced a patient with PPH in pregnancy, who was delivered successfully but died suddenly on the 7th day after the delivery. We report the obstetric course and the clinical management for the delivery of the patient with PPH.

Anaesthesia for a patient with Down's syndrome and Eisenmenger's complex

A patient with Down's syndrome and Eisenmenger's complex presented for orthopaedic surgery on the elbow under general anaesthesia. During pre-oxygenation, in order to prevent a subsequent fall in systemic vascular resistance, metaraminol 1 mg was administered intravenously. The patient immediately developed bradycardia, mild hypertension and became deeply cyanosed. His condition rapidly improved after atropine 0.6 mg was given intravenously. Following induction of anaesthesia with thiopentone and tracheal intubation facilitated by suxamethonium, anaesthesia was maintained by mechanical ventilation of the lungs with nitrous oxide and oxygen (40%) with intravenous increments of fentanyl for analgesia and pancuronium for muscle relaxation; residual neuromuscular blockade was reversed with neostigmine. The patient made an eventful recovery. Although general anaesthesia is tolerated by patients with Eisenmenger's complex, powerful vasoactive drugs should not be administered unless specifically indicated.

Low thoracic epidural anaesthesia for elective cholecystectomy in a patient with congenital heart disease and pulmonary hypertension

A 52-year-old male with pulmonary hypertension secondary to partial anomalous pulmonary venous return unassociated with atrial septal defect was given thoracic epidural anaesthesia for elective cholecystectomy. Partial anomalous pulmonary venous return is a rare congenital anomaly characterized by increased pulmonary blood flow which in severe cases results in pulmonary hypertension subjecting the right ventricle to strain. An epidural catheter was placed at the T11-T12 interspace and anaesthesia was established to the T4 dermatomal level with bupivacaine (180 mg) and lidocaine (100 mg). Central venous pressure, pulmonary artery pressure, radial artery pressure, and cardiac output were monitored. There was minimal change in pulmonary arterial pressure, although there was a significant drop in systemic arterial pressure. Thoracic epidural block is recommended for upper abdominal surgery in clinical situations with pulmonary hypertension.

Clinical problems of postoperative pulmonary vascular disease

The younger the patient with a large left to right shunt at the time of operation, the greater the likelihood that pulmonary vascular resistance will fall to normal thereafter. In older patients, the degree to which the pulmonary vascular resistance is elevated before operation is a critical factor determining operability and prognosis. Patients at particularly high risk for the development of significant pulmonary vascular obstruction early in life are those with certain forms of cyanotic congenital heart disease, such as complete transposition of the great arteries with ventricular septal defect and patent ductus arteriosus, and truncus arteriosus. Other conditions in which pulmonary vascular obstruction appears to progress rapidly include large ventricular septal defect, complete atrioventricular canal defect and left to right shunt lesions in an environment of high altitude or associated with unilateral pulmonary arterial absence of the Down's syndrome. In this report the framework is reviewed for recognizing that important pre- and postnatal modifiers of the pulmonary vascular bed may be lesion-dependent. Thus, the growth and development of the pulmonary vascular bed during fetal and early postnatal life, as well as the morphologic alterations described in detail by Heath and Edwards, are likely to determine the ultimate intensity and magnitude of pulmonary vascular obstruction. Commentary is also provided concerning the management of patients with high pulmonary vascular resistance during pregnancy and delivery, their response to exercise, and the possibility of medical treatment designed to reduce pulmonary vascular resistance, and perhaps prolong life and enhance its quality.