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Case Reports: Case Report

Lateral Position for Cesarean Delivery Because of Severe Aortocaval Compression in a Patient With Marfan Syndrome: A Case Report

Coffman, John C. MD*; Legg, Russell L. MD*; Coffman, Catherine F. MD; Moran, Kenneth R. MD*

Author Information
doi: 10.1213/XAA.0000000000000437
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Abstract

Aortocaval compression by the gravid uterus is an important anesthetic consideration in the term pregnant patient. Patients are generally placed in 15° of leftward tilt for cesarean delivery,1 although some patients may require additional tilt or lateral positioning to relieve hypotension.1,2 We report a rare case of cesarean delivery being performed in the lateral position under general anesthesia after severe hypotension and syncope resulted from aortocaval compression. This novel solution enabled good maternal and fetal outcomes.

Written patient consent for the publication of this case was obtained and is kept on file at our institution.

CASE DESCRIPTION

A 35-year-old gravida 2 para 1 (weight 85 kg; height 1.873 m; body mass index 24.2 kg/m2) with a history of Marfan syndrome and hypertension presented at 36 weeks of gestation in active labor, and the obstetric plan was for cesarean delivery of a breech fetus. Four years before this presentation for delivery, she was diagnosed with Marfan syndrome after a type B aortic dissection that required graft repair of the descending thoracic aorta, 6 cm of abdominal aorta, and the right iliac artery. One year before delivery, her aortic root had enlarged to 4.6 cm in diameter, and she underwent valve-sparing aortic root replacement with coronary artery reimplantations. A transthoracic echocardiogram obtained 2 weeks before the delivery revealed stable aortic root grafts, a stable aortic root diameter of 3.5 cm, and an ejection fraction of 40% to 45%. She maintained normal functional capacity during pregnancy and had no significant physical examination findings other than tall stature and disproportionately long arms and fingers. She had no neurologic symptoms, although lumbar spine magnetic resonance imaging (MRI) was requested to assess for dural ectasias that commonly occur in Marfan syndrome3 and can negatively impact neuraxial anesthesia. Unfortunately, MRI was not completed before delivery.

A radial arterial line and two 18-gauge peripheral IV lines were placed preoperatively. Her preoperative blood pressure (BP) was 170 to 180/80 to 90 mm Hg with heart rate (HR) 70 to 75 beats per minute (bpm). A combined spinal–epidural was placed at the L3–4 interspace without difficulty and the spinal dose (0.75% bupivacaine 0.5 mL [containing 8.25% dextrose], 15 µg fentanyl, and 100 µg morphine) was administered. A low-dose spinal followed by incremental epidural catheter dosing was planned to induce neuraxial blockade in a gradual manner and minimize the risk of abrupt hemodynamic changes given the increased risk of aortic dissection or aneurysm in parturients with Marfan syndrome. Epidural catheter aspiration and test dose (2% lidocaine 3 mL) were negative for intrathecal or IV placement. The test dose did not contain epinephrine given that a positive IV test dose response to epinephrine could have potentially been very harmful in this patient. She was positioned supine with 15° of leftward table tilt. Phenylephrine at 25 µg/min was initiated to prevent spinal-induced hypotension and 2 L/min nasal oxygen was initiated as a part of routine practice at our institution. Epidural 2% lidocaine with 1:200,000 epinephrine 20 mL was administered in four 5-mL doses over 10 minutes. Intermittent assessments noted minimal to no development of motor or sensory blockade. She became nauseated during epidural dosing, and her BP was noted be 90 to 100/40 to 50 mm Hg and HR 70 to 80 bpm. The phenylephrine infusion was increased to 50 µg/min, and she was placed in increasing degrees of leftward tilt up to the point of being in full left lateral position. Her BP returned to her preoperative baseline with lateral positioning and the phenylephrine infusion was discontinued. No concerning fetal heart rate (FHR) patterns were observed. It was initially suspected that the hypotension resulted from neuraxial blockade, although no significant motor or sensory blockade was observed. Her clinical improvement with left lateral positioning strongly suggested that aortocaval compression had caused her hypotension.

The epidural catheter was replaced without difficulty at the L2–3 interspace, but not yet tested or dosed. She was again positioned supine with 15° of leftward tilt. Immediately after positioning, she lost consciousness, arterial line BP was 40 to 50/20 to 30 mm Hg, HR 30 to 40 bpm, and a FHR deceleration to 90 to 100 bpm was observed. She was immediately placed in the left lateral position, given IV 20 µg epinephrine, and placed on 8 L/min facemask oxygen. Her mental status, hemodynamics, and the FHR all returned to baseline within a minute of these interventions. After discussion with the obstetricians, it was decided that the surgery could only be safely conducted with the patient in the lateral decubitus position. A complete lack of sensory and motor blockade was reconfirmed before proceeding with epidural catheter dosing. Catheter aspiration and test dose (2% lidocaine 3 mL) were again negative for IV or intrathecal placement. Three percent 2-chloroprocaine 20 mL, given in 5-mL increments over 10 minutes, was administered at this point to minimize risk of local anesthetic toxicity because chloroprocaine undergoes rapid metabolism by plasma enzymes. She still did not develop adequate blockade for cesarean delivery and the plan transitioned to general anesthesia.

She was preoxygenated in the lateral position before the induction of general anesthesia with 16 mg etomidate, 140 mg succinylcholine, 50 µg fentanyl, and 30 mg esmolol. Esmolol and fentanyl were administered to minimize hypertension and tachycardia from laryngoscopy and intubation. A McGrath video laryngoscope enabled 6.0 mm endotracheal tube placement without difficulty. The obstetricians made a vertical midline skin incision from 2 cm above the symphysis pubis to just below the umbilicus. After the peritoneum was entered, the abdomen was visualized and explored digitally to assess for any uterine displacement resulting from patient positioning. No appreciable displacement of the uterus or other structures was apparent. A low transverse uterine incision was made and extended laterally with manual traction. Delivery of a healthy 3061-g neonate and the placenta was uncomplicated. After delivery, she was gradually transitioned to lesser degrees of leftward tilt and was eventually repositioned supine. Her vital signs remained stable throughout the operative course and during transition to the supine position with BP range of 120 to 140/65 to 80 mm Hg and HR 60 to 80 bpm. Further questioning postoperatively revealed that she regularly slept on her side in the third trimester, but she did not report any adverse symptoms with supine positioning. After delivery she was monitored uneventfully in a cardiac unit and was discharged with her neonate 4 days postoperatively without any complications.

DISCUSSION

Aortocaval compression by the gravid uterus with supine positioning can lead to diminished venous return resulting in hypotension, tachycardia, nausea, dizziness, syncope, and reduced uteroplacental perfusion.4 However, many pregnant women have adequate compensatory increases in systemic vascular resistance and HR to prevent these symptoms from occurring.4 It is uncertain why the first occurrence of aortocaval compression syndrome in this patient occurred at the time of delivery. She did not have polyhydramnios, fetal macrosomia, multiple gestation, or other conditions that may increase aortocaval compression.

Prompt recognition and management of severe aortocaval compression was essential in this case, but the critical intervention enabling safe delivery was the ability of obstetricians to operate in the lateral position. Neither the anesthesiologists nor the obstetricians present had experience with performing a cesarean delivery in the lateral position, although this unique strategy proved to be effective in preventing further hypotension because of the aortocaval compression. We are aware of only 1 previous case series describing cesarean delivery in the lateral position.5 The authors report that patients were positioned lateral before surgical field preparation and induction of anesthesia. It appears that general anesthesia was provided without complications in these cases, although the anesthetic details are lacking.5 They report using Pfannenstiel, midline, and paramedian skin incisions and recommend careful attention to uterine position and rotation given the potential for anatomic structures to shift in the lateral position.5 Large abdominal circumference or overhanging pannus may limit visualization and the ability to operate in the lateral position. Low transverse uterine incisions were made before uncomplicated deliveries, and surgical closure was accomplished in the lateral position.5 In our case, we felt that gradual transition back to the supine position with careful observation of vital signs would facilitate surgical closure. Some evidence indicates that uterine displacement may be more effective if patients are moved from the left lateral position to leftward tilt as compared with moving from supine to leftward tilt.6 Our patient may have benefitted from an attempt at gradually moving from full lateral to a lateral tilt position before delivery, although the severity of hypotension and a brief syncopal episode prompted us to proceed in the lateral position.

Neuraxial anesthesia was desirable in this patient with Marfan syndrome and previous aortic grafts given the potential advantage of minimizing undesirable rises in BP, myocardial contractility, and aortic wall stress because of sympathetic stimulation accompanying laryngoscopy, intubation, and surgery. Unfortunately, attempts to establish neuraxial blockade were unsuccessful. Marfan syndrome is associated with dural ectasias in up to 92% of cases,3 which has been associated with failed spinal anesthesia,7,8 but there are also reports of inadequate epidural anesthesia.9,10 The presence of dural ectasia was suspected to have contributed to the failed neuraxial blockade in our patient, but unfortunately this suspicion was not confirmed by MRI.

This case presented a unique challenge given the severe hypotension relieved by lateral positioning. Lateral position is not practical for routine cesarean deliveries, although our case suggests that it is possible and may be effective in managing patients with severe symptoms of aortocaval compression.

DISCLOSURES

Name: John C. Coffman, MD.

Contribution: This author helped complete the manuscript.

Name: Russell L. Legg, MD.

Contribution: This author helped complete the manuscript.

Name: Catherine F. Coffman, MD.

Contribution: This author helped complete the manuscript.

Name: Kenneth R. Moran, MD.

Contribution: This author helped complete the manuscript.

This manuscript was handled by: Mark C. Phillips, MD.

Acting EIC on final acceptance: Thomas R. Vetter, MD, MPH.

REFERENCES

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