title: Cesarean section in a mother with uncorrected congenital coronary to pulmonary artery fistula.
abstract: OBJECTIVE
  We report a case of a 33 yr old woman with pulmonary hypertension secondary to uncorrected right coronary artery to pulmonary artery fistula who underwent two successful operative deliveries under general anesthesia.
  
  
  METHODS
  This woman underwent an emergency Caesarean section at 32 wk gestation because she presented in NYHA Class IV, heart failure and premature labour. She did not have antenatal follow-up. For her second pregnancy, she was managed from the first trimester of pregnancy by the cardiologist, obstetrician and anesthesiologist. She received oral furosemide and digoxin from eight weeks gestation. Pregnancy was managed to term before she progressed to NYHA Class IV and cardiac failure at 37 wk gestation. She had a Caesarean section under general anesthesia. She received rapid sequence induction of anesthesia and tracheal intubation with 0.1 mg x kg(-1) etomidate, 2 mg x kg(-1) succinylcholine and maintenance with nitrous oxide 50% in oxygen, isoflurane 1% and 0.1 mg x kg(-1) vecuronium. Fentanyl, 2 microg x kg(-1) helped to obtund the hypertensive response to intubation. Analgesia was provided with 1 mg x kg(-1) morphine. Glyceryl trinitrate infusion, 10-30 microg x min(-1) was used in addition to the anti-heart failure therapy. End-tidal capnography, electrocardiogram, pulse oximetry, continuous arterial blood pressure and pulmonary arterial catheter provided hemodynamic monitoring. The lungs were mechanically ventilated for 24 hr postoperatively. She received anti-heart failure therapy which she continued after discharge. She was NYHA class II upon discharge. She defaulted from further follow-up.
  
  
  CONCLUSIONS
  Although the literature advocates, in this situation, controlled vaginal delivery utilising epidural analgesia, we describe the successful outcome for operative delivery under general anesthesia in a patient with secondary pulmonary hypertension and heart failure.
authors.affiliation: Department of Anesthesia & Surgical Intensive Care, Singapore General Hospital, Singapore. ganobc@sgh.gov.sg
authors.forename: S M
authors.initials: SM
authors.lastname: Tay
authors.forename: B C
authors.initials: BC
authors.lastname: Ong
authors.forename: S A
authors.initials: SA
authors.lastname: Tan
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000769:Anesthesia, Inhalation; D000771:Anesthesia, Intravenous; D000773:Anesthesia, Obstetrical; D001159:Arterio-Arterial Fistula / Q000151:congenital*; D001794:Blood Pressure / Q000502:physiology; D002303:Cardiac Output, Low / Q000209:etiology; D002316:Cardiotonic Agents / Q000627:therapeutic use; D002585:Cesarean Section; D003330:Coronary Vessel Anomalies / Q000150:complications*; D004077:Digoxin / Q000627:therapeutic use; D004232:Diuretics / Q000627:therapeutic use; D005260:Female; D005665:Furosemide / Q000627:therapeutic use; D006801:Humans; D006976:Hypertension, Pulmonary / Q000209:etiology; D007442:Intubation, Intratracheal; D009020:Morphine / Q000627:therapeutic use; D019148:Neuromuscular Blockade; D005996:Nitroglycerin / Q000627:therapeutic use; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular; D011651:Pulmonary Artery / Q000002:abnormalities*; D012121:Respiration, Artificial; D014665:Vasodilator Agents / Q000627:therapeutic use
chemical_list: D000701:Analgesics, Opioid; D002316:Cardiotonic Agents; D004232:Diuretics; D014665:Vasodilator Agents; D004077:Digoxin; D009020:Morphine; D005665:Furosemide; D005996:Nitroglycerin