Puerperal cardiomyopathy and pulmonary edema after cesarean section

A 26-year-old woman in the thirty-second week of her fifth pregnancy was admitted with diffuse sudden-onset abdominal pain. Examination revealed cervical dilation to 8 cm, a ruptured uterine cerclage and transverse presentation of the fetus, indicating a need for emergency cesarean section, which was performed under uneventful spinal anesthesia. Three days after surgery the patient presented signs consistent with acute pulmonary edema coinciding with blood transfusion. Echocardiography demonstrated left ventricular systolic dysfunction with an ejection fraction of 35%. The diagnosis was peripartum myocardiopathy with acute respiratory insufficiency due to heart failure. Furosemide and captopril were prescribed and the outcome was satisfactory. The discharge echocardiogram showed a left ventricle of normal size and thickness, and the ejection fraction was 55%. Peripartum myocardiopathy is a type of heart failure that develops during the third trimester or during the first six months after delivery, in the absence of signs of ventricular dysfunction or previous heart disease. Based on clinical presentation and echocardiographic findings, we believe that peripartum myocardiopathy was the cause of acute pulmonary edema in this patient.     

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.     

Epidural anesthesia for cesarean section in a patient with severe pulmonary hypertension

The case of a parturient previously operated on for transposition of the great arteries is reported. On account of Eisenmenger's syndrome with high pulmonary vascular pressures, she was admitted to hospital with hemoptysis in the 27th week of gestation. At the end of the 34th week the child was delivered by elective cesarean section under epidural block. Bupivacaine 0.75% was administered as local anesthetic, and small incremental doses of local anesthetic proved capable of maintaining hemodynamic stability for the duration of the operative procedure.     

Continuous spinal anesthesia for cesarean section in a parturient with severe recurrent peripartum cardiomyopathy

The anesthetic management of labor and delivery in patients with peripartum cardiomyopathy is not well defined. Using continuous spinal anesthesia in such a rare clinical situation has not been previously reported. A patient with recurrent peripartum cardiomyopathy presented in congestive heart failure for emergent cesarean section. Continuous spinal anesthesia was successfully employed as the anesthetic technique for the procedure. In addition, it also markedly reduced the patient's symptoms. Continuous spinal anesthesia is a reliable, rapidly titratable technique, which provides excellent analgesia with minimal undesirable hemodynamic changes for patients with peripartum cardiomyopathy undergoing cesarean delivery.     

Two cases of pulmonary edema during and after cesarean section

Pulmonary edema occurred during and after Cesarean section under general anesthesia in two pregnant women. They had no preoperative complication. After delivery, anesthesia was maintained with 66% N2O in oxygen and intravenous injection of pentazocine and diazepam. At the same time, 0.2 mg of methylergometrin was injected intramuscularly and 2,000 micrograms of prostaglandin F2 alpha was injected to the muscle of the uterus in order to induce uterine contraction. In one case, SpO2 dropped and airway pressure increased immediately after the administration. In another case, chest rale was auscultated on postoperative round at 2 hours after operation. The cases suggest that pulmonary edema was caused by a large quantity of oxytocics, which increased volume load on systemic circulation.     

Ruptured adenoma of the liver with severe pulmonary embolism discovered during a cesarean section

A ruptured adenoma of liver was detected during a caesarean in a multipara woman at full term with a severe pulmonary embolus. Therapy for this rare and curious case, with combined internal hemorrhage, severe pulmonary embolism and full term pregnancy in a multipara, is discussed.     

Anesthetic management of cesarean section in a patient with severe obesity

A 35-year-old pregnant woman (weight, 129.5 kg; height, 156 cm; 37 weeks of pregnancy) with a body mass index of 53 was scheduled for a cesarean section. It was thought that epidural or spinal anesthesia might result in complications due to her severe obesity. It was therefore decided to use general anesthesia following awake intubation. Her baby was delivered, and her Apgar scores at 1 and 5 minutes after delivery were 8 and 9 points, respectively. During surgery, she developed hypoxia due to upper shift of the diaphragm. After surgery, she was extubated after improvement of her oxygenation under spontaneous breathing. This case demonstrates that difficulties may be encountered during anesthetic management of a severely obese patient undergoing cesarean section.     

Combined spinal-epidural anesthesia for cesarean section in a patient with dilated cardiomyopathy

We report successful anesthetic management of elective cesarean section in a 31-year-old patient with dilated cardiomyopathy (DCM) using combined spinal-epidural anesthesia (CSEA). After inserting an arterial catheter and central venous catheter, isobaric bupivacaine (0.5% ; 5 mg) with fentanyl 10 microg was injected intrathecally at the L4-5 interspace under administration of dopamine 3 microg kg(-1) min(-1). 10 min and later, a total of ropivacaine (0.5%; 70 mg) with fentanyl 50 microg was titrated at 2-3 min intervals through the epidural catheter inserted at the L1-2 interspace resulting in analgesic level of T4 25 min after induction of spinal anesthesia. A baby was delivered uneventfully with good Apgar score, and the patient's perioperative hemodynamic change was minimal. CSEA is a reliable, titratable technique, which provides excellent analgesia with minimal hemodynamic changes for patients with DCM undergoing cesarean section.     

Anesthetic considerations for cesarean section in the parturient with familial cardiomyopathy

Dilated cardiomyopathy (DCM) is a heart muscle disease characterized by ventricular dilatation and impaired systolic cardiac function. DCM is defined by the presence of: a) fractional myocardial shortening less then 25% (> 2 SD) and/or ejection fraction less than 45% (> 2 SD); and b) left ventricular end diastolic diameter (LVEDD) greater than 117% excluding any known cause of myocardial disease. Familial dilated cardiomyopathy (FDC) accounts for 20-48% of all DCM cases, and is defined by the presence of two or more affected relatives with DCM meeting the above diagnostic criteria or a relative of a DCM patient with unexplained sudden death before the age of 35 years. We herein present the first reported case in the literature of a parturient with FDC undergoing urgent Cesarean section (secondary to worsening cardiac function) and briefly highlight anesthetic considerations for parturients with this heart condition.     

Anesthetic management in a patient previously diagnosed with takotsubo cardiomyopathy

Takotsubo cardiomyopathy (transient apical ballooning of the left ventricle) is a recently described and often underdiagnosed entity. The syndrome is observed predominately in postmenopausal women and the clinical signs are similar to those of an acute anterior myocardial infarction. In most of the reported cases an emotional or physical stress event has been identified as a trigger, and perioperative stress has been suggested as the trigger in some of these cases. Outcome is favorable with the right treatment, though recurrences are possible. We report the anesthetic management of a 79-year-old woman with a previously diagnosed episode of Takotsubo cardiomyopathy, who was admitted to our hospital for total hip replacement. Care was taken to provide proper preoperative sedation before provision of hyperbaric spinal anesthesia, followed by sedation with intravenous propofol. Surgery and the early postoperative period were uneventful. We believe that minimizing perioperative anxiety should be a priority in these patients due to the possibility that a catecholamine discharge might trigger an episode of Takotsubo cardiomyopathy.     

Epidural anesthesia for cesarean section in a patient with dilated cardiomyopathy (DCM)

A 23-year-old patient with dilated cardio myopathy (DCM) was scheduled for a cesarean section. We inserted an epidural catheter at the L 2/3 interspace and injected 1.5% lidocaine 6 ml with epinephrine 30 micro g and fentanyl 50 micro g. The analgesic level 15 minutes after injection was achieved up to the eighth thoracic dermatome. Dopamin 5 micro g.kg-1.min-1 was infused simultaneously. Analgesia was sufficient for the surgery, and heart rate and blood pressure were stable throughout the operation. The infant's apgar scores were 9 and 10. Epidural anesthesia is one of the options for cesarean section in pregnant women with DCM.     

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.     

Non-cardiogenic pulmonary edema associated with severe diabetic ketoacidosis

Non cardiogenic pulmonary oedema occurs rarely in patients with diabetic ketoacidosis, except in conjunction with an infection. A case is reported of non cardiogenic pulmonary oedema in a patient with severe diabetic ketoacidosis, which resolved within 72 h with oxygen supply only. There were no objective facts which could explain its pathogenesis, despite the important pulmonary asymmetry due to a unilateral diaphragmatic paralysis.     

Target controlled infusion of remifentanil and propofol for cesarean section in a patient with multivalvular disease and severe pulmonary hypertension

A 36 year old parturient with known valvular heart disease was admitted with respiratory distress and fatigue after 35 weeks of pregnancy. Echocardiography revealed severe tricuspid regurgitation, mitral stenosis and aortic valve insufficiency. Following clinical examination and insertion of a radial and pulmonary artery catheter it was decided to perform a Caesarean Section. The pulmonary artery pressure upon arrival in the operating theatre was 105/50 mm Hg whereas cardiac output was 3.5 l/min. Induction of anesthesia was performed with a target controlled infusion of remifentanil and propofol combined with rocuronium bromide. Haemodynamic variables remained very stable during and after intubation. The lungs of the apnoeic baby were manually ventilated until spontaneous respiration began at 1 minute post delivery. Apgar scores were 3, 7 and 9 after 1, 5 and 10 minutes respectively. Umbilical artery pH was 7.29. The patient's haemodynamic status gradually improved over the following few days. Two months following delivery she underwent unevenful valvular surgery.     

Subarachnoid hemorrhage complicated with neurogenic pulmonary edema and takotsubo-like cardiomyopathy

Patients with poor-grade subarachnoid hemorrhage (SAH) are often complicated with acute cardiopulmonary dysfunctions, particularly neurogenic pulmonary edema (NPE) and takotsubo-like cardiomyopathy (TCM). This study retrospectively investigated the incidence, demographics, clinical characteristics, and outcomes of patients with SAH complicated with both NPE and TCM (NPE-TCM). The effects of aneurysm location and other clinical variables on the incidence of NPE-TCM were also investigated. Among 234 SAH patients treated during 5-year period, 16 (7%) presented with NPE, and transthoracic ultrasonography revealed that 14 of these 16 patients (88%) also had TCM. All 14 patients with NPE-TCM had poor-grade SAH (World Federation of Neurosurgical Societies grades IV and V). Ruptured posterior circulation aneurysm was predictive of NPE-TCM, but other clinical variables were not. Eight of the 14 patients with NPE-TCM could undergo treatment for ruptured aneurysm. Long-term outcomes were favorable in 5 of the 8 patients. Grade IV SAH patients had significantly better outcomes than grade V patients. TCM develops frequently in SAH patients presenting with NPE, and transthoracic ultrasonography should be conducted routinely in that population. Patients with ruptured posterior circulation aneurysm may have elevated risk of developing NPE-TCM. Endovascular obliteration of the aneurysm may be preferable to open surgery, but the optimal treatment modality needs to be evaluated further. Considering the limited number of SAH patients complicated with NPE-TCM, a multi-center cooperative study may be required.     

Dental management of a patient with takotsubo cardiomyopathy: a case report.

Takotsubo cardiomyopathy (TCM) is a relatively new concept in cardiovascular disease. The clinical symptoms of TCM are similar to those of a myocardial infarction, but both the mechanism and the management of TCM are different from those of myocardial infarction. The cause of TCM is unclear, but it is suggested to occur in conjunction with excessive circulating catecholamines due to stress. Thus, control of the stress reaction and restriction of catecholamine levels are considered important for prevent of TCM onset. We report the dental management of a patient with intellectual disability who had anamnesis of TCM and cardiopulmonary arrest under restraint during a previous dental appointment in another dental clinic. We used intravenous sedation with both midazolam and propofol, by which the excessive hormonal reaction that caused TCM onset and cardiopulmonary arrest was controlled, for dental treatment in our facility. All planned dental treatment was then performed without any problems.