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Cardiac19 / 22

Repaired coarctation with residual narrowing for caesarean29-year-old woman, 72 kg, 38 weeks, first pregnancy

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Repaired coarctation is mWHO class II–III in pregnancy.
  • After a subclavian flap, the left arm may under-read; use the right arm.
  • Coarctation carries risks of aortic dissection and intracranial aneurysm rupture.
  • Postpartum headache with hypertension: exclude pre-eclampsia and stroke.

The patient

29-year-old woman, 72 kg, 38 weeks, first pregnancy, for elective caesarean delivery for breech. Coarctation repaired at age 3 with a left subclavian flap; residual gradient 30 mmHg; right-arm hypertension; bicuspid aortic valve, ascending aorta 4.1 cm. Drugs: metoprolol. Vitals: BP 148/86 right arm, 112/70 leg; HR 74, SpO2 98%, RR 16. Platelets 210 ×10⁹/L, no proteinuria.

The examiner asks

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  1. Consider

    What are your concerns?

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    • A 29-year-old at 38 weeks with repaired coarctation, residual narrowing and a bicuspid valve, for caesarean. Patient
    • At term, aortocaval compression cuts her venous return, and her baby depends on her pressure.
    • Repaired coarctation is mWHO II–III, so she delivers in a centre with cardiac services. Disease
    • Coarctation brings dissection and intracranial aneurysm bleeding, both driven by hypertension.
    • Her bicuspid valve and 4.1 cm ascending aorta add to the dissection risk.
    • Her lower body runs on collateral flow, so it needs adequate pressure.

  2. Prepare

    How will you prepare?

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    • A cardio-obstetric team plans her delivery with obstetric and cardiac anaesthetists. (Disease)
    • Metoprolol continues; beta-blockers lower dissection risk in aortic disease in pregnancy.
    • Right radial arterial line: her left arm supply may be reduced after the flap repair.
    • Arm and leg pressures recorded before the block as her baseline gradient.
    • Phenylephrine infusion ready, starting at 25–50 mcg/min.
    • Oxytocin 1–3 IU IV given slowly after delivery; no rapid bolus.

  3. Plan

    What is your anaesthetic plan?

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    • Neuraxial, built up slowly: an epidural or low-dose CSE titrated in steps, never a single-shot spinal. Disease
    • Slow onset lets me match the sympathectomy with phenylephrine and protect her leg perfusion.
    • Left uterine displacement throughout to protect her venous return.
    • Hypotension: phenylephrine 100–150 mcg boluses on top of the infusion.
    • Hypertension with pain or at delivery is treated promptly to protect her aorta and brain.
    • HDU for 24–48 hours with the arterial line kept in. After surgery

  4. Crisis

    Ten minutes after an epidural top-up, right-arm BP is 86/50, HR 96, the leg cuff won't read, and she feels sick. What do you do?

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    • The block has dropped her pressure, and her collateral-fed lower body is losing perfusion. (Crisis)
    • More left uterine displacement and a fluid bolus.
    • Phenylephrine 100–150 mcg IV now, and turn the infusion up.
    • No further top-ups until her arm and leg pressures recover.
    • Fetal heart checked; obstetrician told.

  5. Crisis

    Two hours after delivery she has a severe headache; right-arm BP 182/108, HR 88. What do you do?

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    • Headache with severe hypertension: pre-eclampsia, a bleed and dissection are my first concerns. Crisis
    • Treat now, aiming below 160/110: labetalol 5, then 10, then 20 mg IV.
    • Urine protein, platelets and liver tests; if pre-eclampsia, magnesium 4–6 g IV over 20–30 minutes.
    • Full neurological examination; any focal sign means urgent brain imaging for an aneurysm bleed.
    • New chest or back pain or unequal pulses: CT angiography for dissection.
    • HDU with the arterial line; cardiology and neurology involved early. After surgery

Fatal mistakes

  • A rapid single-shot spinal causing sudden sympathectomy.
  • Trusting a left-arm reading after her subclavian flap repair.
  • Missing dissection or an intracranial bleed behind her headache.
  • A rapid oxytocin bolus.

Checked against: Stoelting 8e · Barash 9e · Miller 10e

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