PERIOPERATIVE MANAGEMENT OF A PARTURIENT WITH PRIOR H/O PULMONARY EMBOLISM AND IVC FILTER IN SITU DR.KRANAPPU SOLOMON,DNB PG DR.RENU DEVAPRASATH,DNB (Anesth) DR.V.SANKARASUBRAMANIAN,M.D.(Anesth) DR.JEYASEKHARAN HOSPITAL &NURSING HOME, NAGERCOIL
CASE SCENARIO • 21 year old primicame to our hospital at 7th month of gestation for antenatal checkup. • Gave past h/o superior sagittalsinus thrombosis 4 years back. • Mild antithrombin III deficiency & was on tab.Warfarin • H/o iliofemoraldeep venous thrombosis extending into IVC upto renal veins level. • H/o pulmonary embolism, thrombolysed and prophylactic permanent transjugular IVC filter deployed prior to discharge with oral anticoagulants.
ANTENATAL SCENARIO • As soon as pregnancy was confirmed warfarin was stopped,started on inj.fondaparinux 2.5mg OD sc as per physician advice. • Antenatal checkup continued in our hospital. • Advised to get admitted 3days prior to anticipated time of delivery.
PREOPERATIVE PREPARATION • Coagulation workup done • Adequate fresh blood & fresh frozen plasma arranged • Inj.Fondaparinux stopped 48 hours prior to elective LSCS. • Risk of maternal haemorrhage & recurrent DVT/ PE in the postop. period explained. • Discussed with Obstetrician.
ANESTHETIC MANAGEMENT • Two peripheral IV lines secured • Informed consent obtained for regional anaesthesia • SUBARACHNOID BLOCK • sitting position, • L3-4 level • 27G Quincke needle • Single shot • Drug: 0.5% Bupivacaine 2ml + 0.1mg morphine • Intraop-uneventful • Full term baby delivered
POSTOP.MANAGEMENT • Analgesia lasted for 20 hours. • Inj.Fondaparinux started after 24 hours. • Tab.Warfarin restarted. • PT,INR checked & maintained around 2.5-3.5 • Patient had an uneventful postop. & discharged home.
DISCUSSION Be prepared to take the new role as perioperative physician. Update on new drugs essential -FONDAPARINUX. Patient on anticoagulants: plan early to avoid mishaps. Pregnancy:high risk of DVT/PE IVC Filter. Anaesthetic technique of choice – choose the best technique that suits the patient and of course you.
ANSWERS FOR THE ANTICIPATED PROBLEMS • Maternal bleeding. • Emergency caesarean. • Recurrent DVT/PE. • Dislodgement of IVC filter? • Anaesthesiology Clinics .vol.26,pg.1-22 • Anaesthesiology Clinics of North America. vol.21,pg.99,165 • Evidence-Based Practice Of Anesthesiology. Lee A.Fleisher ,pg.218.