|Year : 2014 | Volume
| Issue : 1 | Page : 60-62
Anesthetic management of a parturient with primary pulmonary hypertension for Cesarean section
Saya Raghavendra Prasad, Radhika Yadava, Chandrasekhar Pulala
Kurnool Heart and Multispeciality Hospital, Kurnool, Andhra Pradesh, India
|Date of Web Publication||10-Mar-2014|
Saya Raghavendra Prasad
Department of Anaesthesiology and Critical Care, Government General Hospital and Kurnool Medical College, Kurnool-518 002, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Primary pulmonary hypertension (PPH) is a rare disease found frequently in women of child bearing age and carries high peripartum mortality. Management of parturient with PPH presents a unique challenge to anesthesiologist, obstetrician, and cardiologist. We present a parturient with PPH who underwent elective cesarean section under epidural anesthesia.
Keywords: Caesarean section, epidural anesthesia, primary pulmonary hypertension
|How to cite this article:|
Prasad SR, Yadava R, Pulala C. Anesthetic management of a parturient with primary pulmonary hypertension for Cesarean section. J NTR Univ Health Sci 2014;3:60-2
|How to cite this URL:|
Prasad SR, Yadava R, Pulala C. Anesthetic management of a parturient with primary pulmonary hypertension for Cesarean section. J NTR Univ Health Sci [serial online] 2014 [cited 2020 Apr 7];3:60-2. Available from: http://www.jdrntruhs.org/text.asp?2014/3/1/60/128445
| Introduction|| |
Primary pulmonary hypertension is a rare disease with an incidence of two to five per million per year with higher incidence in women.  Long-term prognosis is poor with 5 year mortality being very high. Peripartum mortality is high when pregnancy is associated with PPH. When pregnancy is diagnosed early, termination is recommended.
We present a patient with PPH who has undergone lower segment cesarean section (LSCS) under epidural anesthesia. The intraoperative and postoperative course was uneventful.
| Case Report|| |
A 28-year-old term pregnant lady was admitted for elective LSCS. Patient complained of breathlessness New York Heart Association grade II. The patient was diagnosed as having PPH three years back during her first pregnancy when she underwent LSCS under general anaesthesia. One and half year back patient underwent surgery for left ovarian cyst torsion under epidural anaesthesia. Patient was on tab. Sildenafil 25 mg TID and tab. Diltiazem 30 mg TID. Perioperatively patient was started on inj. Enoxaparin 40 mg subcutaneous OD and was stopped 24 hours before surgery. On examination, patient's heart rate was 92 beats per min, blood pressure (BP) 124/76 mmHg, and respiratory rate 26/min. On systemic examination, there was pansystolic murmur in tricuspid area and lung fields were clear. There were no signs of right heart failure. Electrocardiogram showed right axis deviation, right ventricular hypertrophy, and right atrial enlargement. Echocardiogram showed dilated right atrium and ventricle, moderate to severe tricuspid regurgitation, right ventricular systolic pressure (RVSP) 60 mmHg, left ventricular diastolic dysfunction, normal LV systolic function, LV ejection fraction 60%, moderate pulmonary artery hypertension. hemoglobin was 11.2 g%, prothrombin time 11 (13 s), partial thromboplastin time 35 (29 s), platelet count 1.8 lakhs/mm 3 and rest other blood investigations were within normal limits. SpO 2 on room air was 95%.
After taking informed high risk consent, patient was taken to operation theatre. She was premedicated with inj. ranitidine 50 mg intravenous (IV) and inj. metoclopramide 10 mg IV. Monitoring included pulse rate, SpO 2 , noninvasive BP, ECG, urine output, and central venous pressure with CVP manometer. The patient was preloaded with 500 ml of ringer lactate. With patient in left lateral position epidural block was given at L2-3 interspace and catheter inserted. After a test dose of 3 ml of 2% lignocaine with 15 microgm of adrenaline, inj. bupivacaine 0.5% was given in incremental doses till a sensory level of T6 was achieved. Total 17 cc of 0.5% bupivacaine was administered. Live female baby weighing 2.6 kg was delivered. APGAR score was 7 and 9 at 1 and 5 min, respectively. After baby delivery, inj. oxytocin 10 unit was added to 500 ml of Ringer lactate. There was transient fall in BP (90/66 mmHg) intraoperatively after oxytocin infusion was started which was treated with phenylephrine 50 microgm IV. Postoperative analgesia was administered with 8 ml of 0.0625% bupivacaine and fentanyl (2 microgm/ml) when demanded by the patient for 48 h. Enoxaparin was resumed on day 3, 2 h after removal of epidural catheter. Oral anticoagulation was started on postpartum day 8, and enoxaparin was discontinued on postpartum day 10. Patient was discharged on 15 th postoperative day with tab. amiloride 2.5 mg OD, tab. frusemide 20 mg OD, tab. sildenafil 25 mg TID, tab. diltiazem 30 mg TID, and tab. acenocoumarol 2 mg OD.
| Discussion|| |
Pulmonary hypertension is regarded as a mean pulmonary artery pressure greater than 25 mmHg in the setting of normal or reduced cardiac output and a normal pulmonary capillary wedge pressure.  PPH has been defined by the World Health Organization as pulmonary arterial hypertension of unknown cause. 
Treatment for a patient with PPH include oxygen, anticoagulants, and vasodilators like calcium channel blockers (diltiazem, nifedipine, amlodepine), prostacyclins, phosphodiesterase inhibitors (sildenafil), endothelin receptor antagonist (bosentan). Diuretics are indicated in right ventricular failure. Lung transplantation is reserved for patients who do not respond to vasodilators.
Therapies approved for functional class II patients are sildenafil and subcutaneous and IV treprostinil. Due to ease of administration and relative efficacy, sildenafil may be the first choice for functional class II patients.  Our patient belonged to NYHA class II and was on diltiazem and sildenafil.
The choice of anesthesia for LSCS in patients with PPH is controversial. Regional anesthesia reduces venous return which impairs output from the right ventricle. General anesthesia may reduce pulmonary blood flow, especially in the presence of failing right ventricle. Narcotic based technique for general anesthesia has the disadvantage of slow induction in a patient with potentially full stomach, neonatal respiratory depression, and undesirable hemodynamic effects of positive pressure ventilation.
Bonnin and colleagues  administered anesthesia for 15 cases of PPH for LSCS. Four patients were given general anesthesia of which two patients worsened in postoperative period and remaining 11 patients were given epidural and combined spinal and epidural anesthesia of which four patients worsened in postoperative period. Many others have used epidural anesthesia in patients with PPH with successful maternal and fetal outcome. ,,
Harsoor et al.,  reported administration of epidural anesthesia to a patient with PPH with successful maternal and fetal outcome.
Weiss et al.,  administered epidural anesthesia for a patient with severe PPH. Perioperatively, inhaled aerosolized iloprost was used.
Khan et al.,  administered epidural anesthesia for two patients with severe PPH with successful outcome.
Our patient had medium grade (grade 2, NYHA class II ) pulmonary artery hypertension (RVSP = 60 mmHg).  Case reports of successful use of epidural anesthesia ,,, made us to consider epidural anesthesia as an alternative to general anesthesia. The stress of laryngoscopy and intubation, the effects of nitrous oxide on PAP and the effect of volatile anesthetics on cardiac contractility are avoided.
Intraoperatively hypotension was managed with IV phenylephrine. In patients with PPH, hypotension should be aggressively treated with systemic vasoconstrictors such as phenylephrine or vasopressin in order to avoid decreased RV coronary perfusion. 
Anticoagulation is recommended in PPH and chronic thromboembolic PH. Gestational hypercoagulability and increased pulmonary thrombogenicity of PPH indicate a thromboembolic prophylaxis in periparturm period.  One of the major concern of treatment represented the insertion and removal of the epidural catheter and subcutaneous enoxaparin, with its potential to induce epidural hematoma.
The stress of surgery and postoperative pain can result in high maternal mortality in patients with PPH. Epidural anesthesia seems to be a safe alternative to general anesthesia for cesarean section in patients with PPH. Further investigational study with invasive hemodynamic monitoring is necessary to arrive at a definitive conclusion.
| References|| |
|1.||Rich S, Dantzker DR, Ayres SM, Bergofsky EH, Brundage BH, Detre KM, et al. Primary pulmonary hypertension: A national prospective study. Ann Intern Med 1987;107:216-23. |
|2.||Barst RJ, McGoon MD, Torbicki A, Sitbon O, Krowka M, Olschewski H, et al. Diagnosis and differential assessment of pulmonary arterial hypertension. J Am Coll Cardiol 2004;43:40S-47S. |
|3.||In: Hatano S, Strasser T, editors. Primary pulmonary hypertension: Report on a WHO meeting. Geneva, World Health Organization; 1975. p. 7. |
|4.||Badesch DB, Abman SH, Simonneau G, Rubin LJ, McLaughlin VV. Medical therapy for pulmonary arterial hypertension: Updated ACCP evidence-based clinical practice guidelines. Chest 2007;131:1917-28. |
|5.||Bonnin M, Mercier FJ, Sitbon O, Roger-Christoph S, Jaïs X, Humbert M, et al. Severe pulmonary hypertension during pregnancy: Mode of delivery and anesthetic management of 15 consecutive cases. Anesthesiology 2005;102:1133-7. |
|6.||Harsoor SS, Joshi SD. Anaesthetic management of parturient with primary pulmonary hypertension posted for caesarean section - a case report. Indian J Anaesth 2005;49:223-5. |
|7.||Weiss BM, Maggiorini M, Jenni R, Lauper U, Popov V, Bombeli T, et al. Pregnant patient with primary pulmonary hypertension: Inhaled primary vasodilators and epidural anesthesia for cesarean delivery. Anesthesiology 2000;92:1191-4. |
|8.||Khan MJ, Bhatt SB, Kryc JJ. Anesthetic consideration for parturient with primary pulmonary hypertension, review of literature and clinical presentation. Int J Obstet Anesth 1996;5:36-42. |
|9.||Rosenkranz S. Pulmonary hypertension: Current diagnosis and treatment. Clin Res Cardiol 2007;96:527-41. |
|10.||Pritts CD, Pearl RG. Anesthesia for patients with pulmonary hypertension. Curr Opin Anaesthesiol 2010;23:411-6. |
|11.||Weiss BM, Zemp L, Seifert B, Hess OM. Outcome of pulmonary vascular disease in pregnancy: A systematic overview from 1978 through 1996. J Am Coll Cardiol 1998;31:1650-7. |