Continuous Spinal Anesthesia for Cesarean Section in a Parturient with Peripartum Cardiomyopathy

Sir, Peripartum cardiomyopathy (PPCM) is rare, with an incidence of 1 in 10,000 pregnancies. It usually presents in the last trimester or up to 5 months postpartum.[1] The etiology of PPCM is not clear and is assumed to be due to abnormal hemodynamic response to changes in pregnancy. Risk factors include obesity, advanced age, multiple pregnancies, pre-eclampsia, tocolytic therapy, and viral infection.[2] We report a 31-year-old parturient at 36 weeks gestation with PPCM. The pregnancy was uneventful till 35 weeks, when she developed severe respiratory distress. She had bilateral basal crepitations and was referred for further evaluation. Echocardiogram revealed global left ventricular hypokinesia with an ejection fraction (EF) of 40%. The diagnosis of dilated cardiomyopathy with left ventricular failure was confirmed. She was managed with furosemide infusion and metoprolol. Her symptoms improved and were planned for elective cesarean section. She was premedicated with aspiration prophylaxis and diuretic was omitted. A slow intravenous infusion of ringer's lactate was started. ECG, pulse oximeter, and invasive blood pressure monitoring were performed. Oxygen was supplemented with a face mask. A continuous spinal catheter was placed in L3–L4 space. The backflow of CSF was confirmed. The filter was flushed with 0.5% heavy bupivacaine. A baseline infusion of 0.2 µgm/kg/min noradrenaline was started via peripheral line. 5 mg of 0.5% heavy bupivacaine with 10 µgm fentanyl was given via the spinal catheter. The level of the block was checked, and a further 2.5 mg of bupivacaine was given. Hypotension was managed with noradrenaline infusion and phenylephrine boluses. After delivery, oxytocin infusion was started. The patient was shifted to the cardiac intensive care unit (CCU). The postoperative period was uneventful and was discharged from the hospital after 2 weeks. PPCM causes severe myocardial dysfunction. Criteria for diagnosis are heart failure developing toward the end of pregnancy, absence of a cause for cardiac failure, and an EF <45%.[3] Beta-blockers, nitrates, hydralazine, digoxin, and loop diuretics are used for treatment. Angiotensin-converting enzyme inhibitors (ACE inhibitors), calcium channel blockers, and aldosterone antagonists are teratogenic and avoided during pregnancy. They are prone to arrhythmias and thromboembolism, hence early delivery is indicated.[4] Parturients can deliver vaginally or by cesarean section. The goals are to minimize the negative inotropic effect of drugs, maintain preload, avoid increase in afterload, and maintain perfusion. Safe use of regional and general anesthesia is reported. Low-dose spinal anesthesia or combined spinal-epidural anesthesia is usually used. General anesthesia with opioid induction or etomidate is preferred if the EF is <30% and in fetal distress. Continuous spinal anesthesia (CSA) is now becoming popular as it offers several advantages for obstetric patients.[5] Cerebrospinal fluid aspiration allows confirmation of correct catheter placement. It has a rapid onset, better hemodynamics, and denser sensory block than epidural anesthesia. The level of the sensory blockade can be titrated and extended. It can be utilized for postoperative analgesia. Postoperatively, they are monitored in CCU for 72 hours. The use of anticoagulation is recommended. To conclude, a multidisciplinary approach involving obstetricians, obstetric anesthesiologists, cardiologists, and neonatologists is required in the management of these parturients for successful obstetric and neonatal outcomes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.