41. COMBINED SPINAL AND EPIDURAL ANESTHESIA (CSE) FOR CAESAR SECTION IN WOMEN WITH CARDIOVASCULAR DISEASE
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Abstract
Introduction: Neuraxial anesthesia is often preferred for cesarean section in parturients with cardiovascular disease, although anesthetic techniques should be individualized. Spinal anesthesia causes significant hemodynamic changes; therefore, combined spinal-epidural (CSE) or sequential CSE to the surgical level of T4-T6 is recommended. Prophylactic vasopressor administration after achieving adequate anesthesia and titration to maintain a heart rate >60 bpm and mean arterial pressure close to baseline during surgery offers multiple benefits.
Case Report: A 22-year-old parturient, PARA 0000, experienced dyspnea in the early morning, while walking, and during strenuous activities throughout pregnancy. She was diagnosed with ventricular premature contractions in January 2024 and was on Betaloc 25 mg/day.
Examination:
- The patient was alert, well-oriented, and experienced dyspnea with exertion, without cyanosis.
- Bilateral lower limb edema was noted.
- Regular heart sounds were detected, with no clear murmur.
- 4D fetal ultrasound: Estimated fetal weight of 3100 g, normal placenta and amniotic fluid.
- Electrocardiogram (ECG): Sinus rhythm with occasional ventricular premature contractions, heart rate 100 bpm, no atrial or ventricular hypertrophy.
- Echocardiography: Mild mitral regurgitation, irregular heart rhythm, left ventricular dilation (Dd 50 mm), ejection fraction (EF) 50%.
Anesthetic Technique:
The patient underwent invasive arterial blood pressure monitoring and received sequential combined spinal-epidural anesthesia (CSE). The administered doses were:
- Spinal anesthesia: Bupivacaine 3 mg + fentanyl 10 mcg intrathecally.
- Epidural anesthesia: Test dose with lidocaine 70 mg (first dose), followed by 50 mg (second dose).
After 15 minutes, sensory blockade reached the T6 level, and surgery commenced. The patient remained awake, comfortable, and did not experience any distress during the procedure. Continuous intravenous infusion of phenylephrine was used to maintain hemodynamic stability, with mean arterial pressure (MAP) at 80-90 mmHg, heart rate at 80-90 bpm, and SpO₂ at 99%.
A healthy newborn weighing 3300 g was delivered, with Apgar scores of 8 at 1 minute and 9 at 5 minutes.
Postoperatively, the patient remained stable, received postpartum care for three days, and was discharged. Follow-up was advised in case of abnormal symptoms or at three months post-discharge.