Anesthesia for cesarean section in a patient with cor triatriatum

Cor triatriatum is a rare congenital cardiac anomaly, in which left ventricular filling is impeded by obstructive membrane in the left atrium. We administered spinal anesthesia for cesarean section in a patient with cor triatriatum (type III A1) with congestive heart failure. We optimized hemodynamics with the aid of pulmonary artery cathter. In general, cor triatriatum involves similar hemodynamic profiles to mitral stenosis and thus tachycardia should be avoided during anesthesia. However, in our patient, increasing the heart rate to 80-90 beats x min(-1) was beneficial in maintaining adequate systemic blood pressure and cardiac output. Spinal anesthesia could be a method of choice for cesarean section in a patient with cor triatriatum when adequate hemodynamic monitoring is available.     

Anesthesia for cesarean section in a patient with Holt-Oram syndrome

Holt-Oram syndrome is a rare genetic disorder affecting the heart and upper limbs (atriodigital dysplasia). The manifestations of the limb defects may vary in severity from subtle carpal bone defects and triphalangeal thumb to digit aplasia and upper extremity phocomelia. Cardiac abnormalities include atrial and/or ventricular septal defects, anomalies in pulmonary venous return and various dysrhythmias. We present the anesthetic management of a parturient with this syndrome who underwent elective cesarean section and tubal ligation, conducted under combined spinal-epidural anesthesia with a low dose of intrathecal bupivacaine. Our goal was to avoid an excessively high sympathetic block or excessive sympathetic stimulation accompanied by potential deleterious effects on cardiac rhythm. Cardiac monitoring was continued in the postoperative period for 6 h because of the possibility of dysrhythmia.     

Anesthesia for cesarean section in a patient with Ebstein's anomaly]

A 30-year-old woman with Ebstein's anomaly was scheduled for Cesarean section at 38 week gestation because of latent fetal distress. After arterial and central venous catheters were inserted, general anesthesia was started. Anesthesia was induced smoothly and rapidly through intravenous route. Following induction, her hemodynamics was stable until post-operative period. The baby weighed 1564g and had an Apgar score of 8 at 1 minute. A patient with Ebstein's anomaly during pregnancy and anesthesia has potential for a variety of hemodynamic disturbances. This case illustrates the importance of careful attention to the preoperative findings and the perioperative hemodynamic parameters.     

Anesthesia for cesarean section in a patient with von Hippel-Lindau disease

We report the case of a pregnant 38-year-old woman at full-term who had a history of von Hippel-Lindau disease with neurological symptoms. She had previously undergone surgical removal of cerebellar hemangioblastomas. A cesarean delivery performed under general anesthesia was uneventful and the outcomes were excellent for both mother and fetus. General anesthesia was chosen because patients with von Hippel-Lindau disease often have asymptomatic spinal cord and intracranial involvement. As such involvement could not be ruled out, we preferred to avoid the risks related to regional anesthesia. One of the main features of von Hippel-Lindau disease is the presence of central nervous system hemangioblastomas, which are highly vascularized, slow growing tumors that may become enlarged during pregnancy. We describe the implications of the disease for anesthesia.     

Anesthesia for cesarean section in a patient with transient diabetes insipidus

A 32-year-old pregnant female was admitted to our hospital at 32 week gestation and was scheduled for emergent cesarean section because of fetal distress. She had been suffering hydrodipsia and dry mouth, and had lost 4 kg in 2 weeks. Hypernatremia, hyperchloremia, and lower urinary specific gravity were preoperatively noted. Her electrolyte imbalance was partially corrected by the infusion of 1400 ml of 5% glucose solution and 500 ml of acetated Ringer's solution, but unexpected hyperglycemia; 440 mg.dl-1, appeared before surgery. Cesarean section was successfully performed with spinal anesthesia. A 1566 g male infant was delivered with 1 and 5 min Apgar scores of 2 and 1. Hyperglycemia and secondary hypoglycemia occurred in the infant in the neonatal ICU. The mother's fluid loss, including blood and amniotic fluid, was estimated at 784 ml. Five hundred milliliters of acetated Ringer's solution and 1000 ml of half saline solution with 2.5% glucose were infused before delivery, followed by the glucose solution containing a low concentration of sodium after delivery. After surgery, high serum osmotic pressure and paradoxically low urinary osmotic pressure were found. The plasma antidiuretic hormone level was normal against the high serum osmotic pressure. The electrolyte imbalance and urinary osmotic pressure were improved by using I-deamino-8-d-arginine vasopressin, and DI was finally diagnosed. Hormonal therapy was discontinued on day 20, and the patient was discharged on day 21. Some pregnancies are complicated by transient DI. Anesthesiologists have to consider DI when a pregnant female has symptoms of dehydration and a significant electrolyte imbalance.     

Anesthesia for cesarean section in a patient with spinal muscular atrophy

We describe the anesthetic management for cesarean section and tubal ligation of a 23-year-old primipara with type II spinal muscular atrophy (benign Werdnig Hoffmann). She was wheelchair-bound, had severe restrictive lung disease, and severe kyphoscoliosis, with Harrington rods extending from the thoracic to the sacral spines. A general anesthetic was given. We used propofol and alfentanil for rapid-sequence induction of anesthesia. We did not use any muscle relaxants intraoperatively. Postoperative care was provided in the intensive care unit. The patient made a good recovery.     

Anesthesia for cesarean section in a Marfan patient with complicated aortic dissection

We report the anaesthetic management of a 32-year-old pregnant women with aortic dissection and Marfan syndrome for caesarean section. The patient has presented at 31 weeks gestation of a first pregnancy an aortic dissection that required an emergency aortic replacement. Three years later, she presented at 31 weeks gestation with aortic dissection, mitral valve dysfunction and acute pulmonary oedema. She was treated in intensive care unit with deslanoside, diuretic and twice a day echographic examination. Delivery was planned by caesarean section after haemodynamic stabilisation on the sixth day. Combined spinal and epidural anaesthesia was performed after monitoring. The initial intrathecal injection of bupivacaine, morphine and fentanyl provided rapid onset of analgesia. Epidural anaesthesia was used with diluted lidocaine and fentanyl boluses. With appropriate preoperative care and monitoring, uneventful combined spinal and epidural anaesthesia for Caesarean section was achieved in a patient with Marfan syndrome in the presence of aortic dissection complicated by mitral valve dysfunction and acute pulmonary oedema.     

An emergency cesarean section using general anesthesia for a patient with schizophrenia

A 27 year-old female in 39th week gestation with schizophrenia underwent an emergency Cesarean section using general anesthesia. A diagnosis of schizophrenia was made two years previously, since then oral anti-psychotic drugs such as chlorpromazine had been given to her. In June 1989 she suddenly became excited and generalized muscle rigidity was observed without any triggering episodes. Her excitement was so marked that we had to administer intramuscular levomepromazine 75 mg and diazepam 10 mg to her, but they failed to sedate her adequately. Emergency Cesarean section was scheduled to overcome this situation. Spinal or epidural anesthesia was not indicated because of her vigorous excitement, and anesthesia was induced with thiopental 350 mg and succinylcholine 40 mg. Induction-delivery time was 12 minutes. Pentazocine 30 mg in combination with nitrous oxide was given for the maintenance of anesthesia. Plasma levomepromazine levels were 46.9 ng.ml-1 in the mother and 11.3 ng.ml-1 in the umbilical vein, respectively. The baby's Apgar score was 9 and 1 min and 9 at 5 min after the delivery. The baby developed slight generalized tremor until next day, probably due to effect of levomepromazine given before the Cesarean section. The patient was discharged without any cardiorespiratory trouble and her baby has been doing well so far.     

Anesthesia for cesarean section in a patient with placenta previa and methylenetetrahydrofolate reductase deficiency

We describe the anesthetic management of a patient with placenta previa presenting for a cesarean section, who had methylenetetrahydrofolate reductase (MTHFR) deficiency. Methylenetetrahydrofolate reductase deficiency increases homocysteine levels in the body and, therefore, predisposes to thrombosis. After a cerebrovascular accident at 8 weeks of gestational age, the patient received anticoagulants throughout the course of her pregnancy. Bleeding from the placenta previa occurred at 30 weeks of gestational age. Although general anesthesia was indicated for this patient because of her hemodynamic instability and an anticoagulated state, nitrous oxide is contraindicated in such patients. Thus, we chose a subarachnoid block because the patient remained hemodynamically stable, and anticoagulation had been stopped 8 hours before surgery. To our knowledge, there is no reported case of a parturient with MTHFR deficiency complicated with a cerebrovascular accident and associated with placenta previa presenting for a cesarean section. Anesthetic considerations are discussed in patients presenting with placenta previa associated with MTHFR deficiency.     

Anesthesia for cesarean section in a patient with McArdle disease and hereditary dilated cardiomyopathy

A caesarean section was indicated in a 29-year-old parturient affected by a muscular deficit in myophosphorylase responsible for a type V glycogen storage disease (McArdle disease). This metabolic myopathy had been diagnosed two years previously, whereas the patient already suffered from a hereditary form of dilated cardiomyopathy. The muscular disease was invalidating on the functional level with exercise intolerance. The cardiopathy was little symptomatic but the dysfunction of the left ventricle worsened during the pregnancy with an ejection fraction calculated to 43%. In this case, we report the realization of a general anaesthesia in a patient who had epidural anaesthesia for a previous caesarean section.     

Perioperative management for emergency cesarean section of a patient with reexpansion pulmonary edema

A 27-year-old woman with 39 week gestation was admitted because of cough and dyspnea accompanied by massive right-sided pleural effusion. Following the right thoracocentesis, about 2000 ml of bloody pleural effusion was drained. Just after the thoracocentesis, the fetal heart rate (FHR) temporarily showed a variable deceleration pattern but the rate was restored spontaneously. One hour later, cough and dyspnea became worse. Changes in FHR pattern indicated the premature separation of the normally implanted placenta. Accordingly, an emergency cesarean section was performed under general anesthesia. Massive foamy tracheal secretion was drained from the tracheal tube during surgery. As her chest X-ray showed signs of pulmonary edema in the right lung, her status was diagnosed as reexpansion pulmonary edema (RPE). She was transferred to the intensive care unit and treated with mechanical ventilation, prednisolone and diuretics. Extubation was performed on the 2nd day after the surgery. On reexpansion of the collapsed lung, it is always necessary to consider not only the hemodynamic changes just after reexpansion but also RPE following reexpansion.     

Perioperative retinoic acid syndrome in a patient with acute promyelocytic leukemia

All-trans retinoic acid (ATRA), a vitamin A derivative, is prescribed for induction of chemotherapy in patients with acute promyelocytic leukemia. Like other chemotherapy agents, ATRA has an adverse effect known as retinoic acid syndrome. The case of a 22 year old woman with acute promyelocytic leukemia, who received ATRA and subsequently developed retinoic acid syndrome, is presented. The patient's symptoms resolved after administration of dexamethasone, allowing the completion of chemotherapy without further complications.