Pregnancy complicated by cardiac massive mass cesarean section anesthesia in a case
YU Jiacheng1, ZHANG Juan2, YANG Xuelin2, HAO Jing2, SUN Yu'e2, MA Zhengliang2, GU Xiaoping2
1Gulou Clinical Medical College, Nanjing Medical University
2Department of Anesthesiology, Gulou Hospital, Nanjing University School of Medicine
Corresponding author: Sun Yu'e
Email: [email protected]
Fund:National Natural Science Foundation of China (81870871,82071229)
Mother, 30 years old, height 162 cm, weight 64 kg, ASA class IV. He was admitted to the hospital due to "31+1 weeks of menopause, palpitation and chest tightness for more than 7 months, and found that the heart occupied for 1 month". The patient has developed palpitation and chest tightness since pregnancy, can tolerate only a small amount of daily activities, and needs to sleep on his side at night. Cough cough up sputum, occasionally blood in sputum. One month ago, a large atrial occupancy was detected in the outer hospital, and he had a history of bilateral pulmonary tuberculosis, bronchial asthma and bronchiectasis, and now budesonide powder spray is inhaled twice a day. 7 years ago, due to severe scoliosis, he underwent V-shaped osteotomy and orthopedic internal fixation fusion in our hospital. Physical examination: HR 100 beats/minute, BP 94/60 mmHg, sputum sounds on auscultation of both lungs. Cardiac ultrasound: left and right atrium huge mass (nature to be determined), left atrial mass distributed along the atrial septum and atrial wall, occupying most of the left atrial cavity, an area of about 44.1 cm2, right atrial mass is connected to the left atrial mass, and the boundary with the atrial septum is not clear, the mass area is 19.7 cm2. Moderate pulmonary hypertension (55 mmHg) with moderate regurgitation of the two and tricuspid valves. Plain CT chest scan: bronchiectasis with infection in both lungs, localized emphysema in both lungs, enlarged cardiac shadow, and mass shadow in the right anterior superior mediastinal area. The current diagnosis is: late pregnancy (G2P1 pregnancy 31+3 weeks to deliver LOA), cardiac insufficiency (WHO class IV; NYHA grade III), cardiac mass, moderate pulmonary hypertension, bronchial asthma, bronchiectasis with infection. Caesarean section is proposed with nerve block and intravenous anesthesia.
When the woman enters the room, the face is flushed, shortness of breath, can not lie flat, take the head high and feet low left tilt, auscultation of the left lung can see obvious sputum sounds. Routine ECG monitoring: HR 96 bpm, BP 118/52 mmHg, RR 20 bpm, SpO2 96% (oxygen 5 L/min). Two peripheral venous accesses were opened, oxygen was mixed through a mask and 0.002 5% nitric oxide, and invasive arterial pressure (IBP) of 121/58 mmHg was measured by radial artery puncture under local anesthesia. Bedside transthoracic cardiac ultrasound assessment of cardiac function, structure, and inferior vena cava volume showed that the left atrial mass obstructed about one-third of the mitral valve orifice (maintaining the patient's admission) and the mass did not move with the blood flow (figure 1). Ultrasound-guided bilateral lateral block of the quadratus lumbar muscle, 20 ml of 0.375% ropivacaine was injected on each side, T9-L1 of the block plane was measured after 20 minutes, esketamine was given 25 mg intravenously before resection, and 10 mg of esketamine was added 10 minutes at intervals to maintain the depth of anesthesia (patients can communicate throughout the process). After the second addition of esketamine, the patient had HR 93 times/minute, IBP 146/89 mmHg, and SpO2 100%. After the fetus is delivered, sandbags are placed on the abdomen to relieve the sudden decrease in abdominal pressure. Oxytocin 10 U diluted intravenously and slowly instilled, according to maternal vital signs monitoring to closely regulate the infusion rate of oxytocin, butorphanol tartrate injection 1 mg intravenous drip. During the operation, the mother's vital signs were stable and did not fluctuate significantly. HR 85~93 times/min, SBP 124~146 mmHg, SpO2 99%~100%, hydropower acid-base balance. The postoperative patient-controlled intravenous analgesia (PCIA) regimen was diluted to 100 mL of fentanyl 1 mg, ondansetron 8 mg, and dexamethasone 10 mg. The operation time was 40 min, and 700 ml of sodium, potassium, calcium, magnesium, glucose injection, 200 ml of normal saline, blood loss of 350 ml, and urine output of 150 ml were supplemented during the operation. The newborn weighed 1 720 g and scored 8 and 9 points at 1 min and 5 min after birth, respectively. After the operation, the mother was awake and transferred to the ICU ward.
On the first day after surgery, the mother complained of dreamy nights, poor sleep, still coughing up sputum, blood in sputum, T9-L1 plane still had analgesic effect, no obvious nausea, vomiting, dizziness, and good range of motion in the limbs. Retrospective women have no memory for most of the procedure. On the second postoperative day, the mother's cough was reduced, her sleep was good, her mental state was good, and there was no other discomfort. On the 3rd postoperative day, the quadratus lumbar block still had a certain analgesic effect, and the woman recovered well and was transferred back to the obstetrics general ward, and was successfully discharged on the 7th postoperative day. In order to further confirm the diagnosis of cardiac mass, a cardiac tumor was diagnosed after 1 month of cardiology.
Discussion Pregnancy with cardiac disease is the leading cause of death in pathologic obstetrics in developed countries and second only to postpartum haemorrhage in developing countries [1]. Cardiac mass during pregnancy is rare, its clinical manifestations are less specific, and symptoms and signs depend mainly on cardiac mass effects (size, location, nature, mobility, etc.). Mass of the left atrium can obstruct the mitral valve orifice, resulting in increased left atrium and pulmonary venous pressure, secondary to pulmonary hypertension. Right atrial mass can cause tricuspid orifice obstruction and chronic right heart failure. Women with heart disease often require cesarean section to terminate pregnancy, and anesthesia management directly affects the prognosis of the mother and fetus.
In this case, neuraxial anesthesia should not be performed after scoliosis surgery, and the woman has a history of bronchial asthma, bronchiectasis, and bilateral lung infection, and has been coughing, sputum and coughing up blood, and endotracheal intubation may aggravate lung infection after general anesthesia, and delayed extubation may occur after surgery, even life-threatening. Therefore, a bilateral quadratus block combined with esketamine intravenous anesthesia was developed to minimize the impact of anesthesia on cardiovascular function, and eliminate the sympathetic nerve excitement caused by pain as much as possible and aggravate the cardiac load. Esketamine has a good postoperative analgesic effect on women undergoing cesarean section, without affecting maternal spontaneous breathing, and the antidepressant effect of esketamine helps to improve maternal postpartum depression [2-3]. Bilateral quadratus lumbar block can provide satisfactory intraoperative and postoperative analgesia for women, and bilateral quadratus lumbar block is better than transverse abdominis level block, which can reduce postoperative opioid use and improve maternal comfort [4], and the woman still has a good analgesic effect on the third postoperative day.
According to the mother's usual preferred position and acceptable position, the left decubitus position of the mother's head height is always maintained throughout the operation process to avoid circulation fluctuations caused by changes in position. Intraoperative inhalation of nitric oxide through a mask improves pulmonary circulatory resistance and reduces pulmonary artery pressure. Secondary moderate pulmonary hypertension slows the drip rate of oxytocin and reduces the effect of oxytocin on pulmonary artery pressure. In order to prevent acute heart failure caused by a sudden increase in the amount of blood returning to the heart after the delivery of the fetus, intraoperative fluid replacement follows the principle of volume and in-out, appropriately negative balance, and strictly controls the total amount of fluid [1]. The liquid type was selected crystalloid, which avoided albumin or colloidal liquid, which increased the osmotic pressure of colloidal and increased circulating blood volume, and increased the burden on the heart [5].
There is still room for improvement in postoperative fine management, and the sleep status of women after surgery is not paid attention to, and nighttime dreams may be related to neuropsychiatric adverse effects of the anesthetic drug ketamine. Poor sleep can aggravate maternal heart disease, induce malignant arrhythmias and cardiovascular and cerebrovascular events. Low-dose dexmedetomidine intravenous pumping on the first night of ICU transfer is expected to improve maternal sleep quality and prognosis.
In summary, the perioperative anesthesia management of pregnant women with huge cardiac tumors focuses on: paying attention to anesthesia evaluation before surgery, clarifying cardiac mass effect, and formulating individualized anesthesia plans; Actively reduce pulmonary vascular resistance during surgery to avoid the occurrence of malignant events such as pulmonary hypertension crisis and acute heart failure; Develop a multimodal analgesic plan after surgery to avoid all adverse stress reactions, strengthen monitoring, and ensure perinatal safety.
Bibliography omitted. DOI:10.12089/jca.2023.07.022
Typesetting | Cheng Mengwei
Responsible Editor | Zhang Wei
Content moderation | Wan Ru
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