CASE REPORTUrgent cesarean delivery and prolonged ventilatory support in a parturient with Fontan circulation and undiagnosed pseudocholinesterase deficiency
Introduction
Parturients with congenital heart disease pose significant anesthetic challenges in the peripartum period. Pseudocholinesterase deficiency, which occurs in 1:3200 parturients, also complicates anesthetic management, especially if the condition is undiagnosed before induction of general anesthesia. This combination of conditions in a parturient presents unique challenges to the anesthesiologist and critical care physician in both ventilatory management and hemodynamic control. We describe a parturient with tricuspid atresia and Fontan circulation who underwent general anesthesia for urgent cesarean delivery and required prolonged postoperative mechanical ventilation for undiagnosed pseudocholinesterase deficiency. This case has been published by our obstetric colleagues,1 but in this report we discuss the implications of anesthesia and mechanical ventilation.
Section snippets
Case report
A 26-year-old 63 kg G3P0 parturient at 33 + 6 weeks of gestation presented for urgent cesarean delivery. Her cardiac history was significant for congenital tricuspid atresia with hypoplastic right heart, for which she underwent surgical palliation with Fontan circulation at age seven years. Her functional cardiac status before pregnancy was New York Heart Association (NYHA) class I, and she was able to participate in moderate regular exercise. Her past medical history was otherwise significant for
Discussion
The Fontan circulation is a single ventricle cardiac physiology in which blood flows passively into the pulmonary arteries (Fig. 1). Preload is therefore the most important determinant of cardiac output.2 The systemic ventricle may be either the morphologic right or left ventricle, depending on the type of congenital heart lesion. Common cardiovascular complications resulting from Fontan circulation include poor ventricular filling from restricted pulmonary or conduit flow, systolic or
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Cited by (6)
Urgent cesarean delivery and prolonged ventilatory support in a parturient with Fontan circulation and undiagnosed pseudocholinesterase deficiency
2012, International Journal of Obstetric AnesthesiaANMCO/SICP/SIGO consensus document: Pregnancy and congenital heart disease
2016, Giornale Italiano di CardiologiaAnesthetic Management of Parturients with a Fontan Circulation
2015, Seminars in Cardiothoracic and Vascular AnesthesiaFailed reversal of neuromuscular blockade despite sugammadex: A case of undiagnosed pseudocholinesterase deficiency
2015, Anaesthesia, Pain and Intensive Care