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 primi came to our hospital at 7th month of gestation for antenatal checkup.

Gave past h/o superior sagittal sinus thrombosis 4 years back.

Mild antithrombin III deficiency & was on tab.Warfarin

H/o iliofemoral deep 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 level27G Quincke needleSingle shotDrug: 0.5% Bupivacaine 2ml + 0.1mg morphine

Intraop-uneventfulFull 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.

DISCUSSIONBe 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/PEIVC 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.