A case series of the anesthetic management of parturients with surgically repaired tetralogy of Fallot.

BACKGROUND: Most case reports of pregnancies after surgical repair of tetralogy of Fallot have focused on cardiovascular and obstetric concerns, with relatively few authors focusing on specific intrapartum and postpartum anesthetic management strategies. METHODS: The Mayo Clinic Congenital Heart Disease Clinic and the Boston Adult Congenital Heart Disease Service databases were cross-referenced with the Mayo Clinic and the Brigham and Women's Hospital Department of Anesthesiology databases to identify patients with tetralogy of Fallot who delivered at their respective hospital from January 1, 1994, to January 1, 2008. We reviewed each medical record to evaluate parturient care during pregnancy, labor, and delivery with a focus on anesthetic management. RESULTS: During the 14-year study period, a total of 27 deliveries in 20 patients with repaired tetralogy of Fallot were identified. Twenty-one deliveries (78%) among 15 parturients (75%) involved a trial of labor; all parturients received neuraxial analgesia for labor and delivery, including 18 (86%) epidural, 2 (10%) combined spinal-epidural, and 1 (5%) continuous spinal anesthetic after an unintended dural puncture. Of the 21 patients undergoing labor, 3 (14%) received invasive arterial blood pressure monitoring; 5 (24%) received continuous telemetry; 3 (14%) experienced congestive heart failure that required diuresis; 4 (19%) had obstetric or neonatal complications; and 3 (14%) had anesthesia complications. Cesarean delivery was required in 4 patients (19%) because of labor complications. Concurrent cardiovascular, obstetric, and anesthetic complications in 1 patient resulted in neonatal death. Six (22%) parturients underwent elective cesarean delivery; 4 received epidural and 2 received spinal anesthesia; no anesthetic or immediate obstetric complications occurred. Among all parturients, 5 deliveries in 5 separate parturients (19% of deliveries) reported symptoms of congestive heart failure at the time of delivery. CONCLUSIONS: Pregnancy outcomes for patients with repaired tetralogy of Fallot were found to be generally favorable. All patients undergoing a trial of labor or cesarean delivery had neuraxial analgesia or anesthesia. Recognition and management of congestive heart failure was necessary in 19% of deliveries.

Anesthetic management of parturients with congenitally corrected transposition of the great arteries: three cases and a review of the literature.

Women with congenitally corrected transposition of the great arteries (CCTGA) have a propensity for congestive heart failure and cardiac dysrhythmias during pregnancy, labor, and delivery. We report the successful obstetric and anesthetic management of three women with CCTGA, review the pertinent medical literature, and discuss important issues surrounding the anesthetic management of parturients with CCTGA.

Obstetric anesthesia: outside the labor and delivery unit.

The maternal mortality rate in the United States has stagnated for the past 2 decades. To further lower morbidity and mortality, we must take a broader perspective. When a pregnant woman is treated in a nonobstetric part of the hospital, care must adapt quickly to her special needs. Excessive concern as to medication, radiation, and litigation may render her care neither safe, timely, efficient, effective, nor patient-centered. Anesthesiologists can significantly improve the care of the pregnant patient by applying their uniquely broad-based skills, experience, and knowledge outside the labor unit.

Urinary podocyte excretion as a marker for preeclampsia.

OBJECTIVE: The objective of this study was to examine whether podocyturia, which is the urinary excretion of viable podocytes (glomerular epithelial cells), is present in urinary sediments of patients with preeclampsia. We also aimed to compare the test characteristics of podocyturia to those angiogenic factors that have been shown to play an important role in the pathogenesis of preeclampsia (s-Flt-1, PlGF, and endoglin). STUDY DESIGN: Serum angiogenic factors were measured in 44 patients with preeclampsia and 23 normotensive control patients. In a patient subset (15 cases and 16 control patients), urinary proteinuria were identified and quantified on the basis of their expressions of podocyte-specific proteins. RESULTS: Urinary podocyte excretion occurred in all patients with preeclampsia. The positive predictive value for the diagnosis of preeclampsia was greater for podocyturia than for any of the measured angiogenic factors. CONCLUSION: Podocyturia is a highly sensitive and specific marker for preeclampsia. It may contribute to the development of proteinuria in preeclampsia.

Intrathecal injection of epidural blood patch: a case report and review of the literature.

Epidural blood patch (EBP) is a commonly performed procedure for the treatment of persistent severe post- dural-puncture headache (PDPH). It has a high success rate with a low incidence of complications. We report the case of a 27-year-old woman who developed progressive back pain and radicular symptoms after an EBP was performed for PDPH. An emergency MRI showed a subarachnoid hematoma. Gradual recovery occurred without the need for intervention. To our knowledge, this is the only case demonstrating the MRI findings of a rare complication of a common procedure. Radiologists may benefit from familiarity with epidural blood patching, including the technique, risks, benefits, and potential complications