CASE REPORT
Urgent cesarean delivery and prolonged ventilatory support in a parturient with Fontan circulation and undiagnosed pseudocholinesterase deficiency

https://doi.org/10.1016/j.ijoa.2010.11.006Get rights and content

Abstract

A parturient with Fontan circulation required general anesthesia for urgent cesarean delivery and subsequent prolonged postoperative ventilation for newly-diagnosed pseudocholinesterase deficiency. Anesthetic management necessitated a thorough understanding of the hemodynamic principles of the Fontan circulation and physiologic adaptations during surgical delivery and recovery in the intensive care unit.

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

References (29)

  • A. Gamillscheg et al.

    Inhaled nitric oxide in patients with critical pulmonary perfusion after Fontan-type procedures and bidirectional Glenn anastomosis

    J Thorac Cardiovasc Surg

    (1997)
  • J. Cai et al.

    Nitric oxide and milrinone: combined effect on pulmonary circulation after Fontan-type procedure: a prospective, randomized study

    Ann Thorac Surg

    (2008)
  • J.F. Nitsche et al.

    Pregnancy and delivery in patients with Fontan circulation: a case report and review of obstetric management

    Obstet Gynecol Surv

    (2009)
  • M. Gewillig et al.

    The Fontan circulation: who controls cardiac output?

    Interact Cardiovasc Thorac Surg

    (2010)
  • View full text