Authors: Amir M et al.
Journal: Cureus, Volume 18, Issue 1, Article e102667
Summary
This case report describes anesthetic management for an elective cesarean delivery with tubal ligation in a 35-year-old at 31 weeks’ gestation with severe dilated cardiomyopathy and markedly reduced left ventricular systolic function (EF 20–25%), along with severe IUGR. The central anesthetic goal was to avoid abrupt changes in preload and afterload, prevent tachycardia/arrhythmias, and maintain stable perfusion without triggering decompensation.
The team used a graded epidural technique to allow incremental dosing and a slower onset sympathetic block compared with spinal anesthesia. Preparation emphasized tight hemodynamic monitoring and rapid rescue capability: invasive arterial pressure monitoring, two large-bore IVs, vasoactive drugs immediately available, defibrillator readiness, and ICU backup. Neuraxial safety was addressed by confirming timing of the last LMWH dose.
Epidural placement was uncomplicated. Local anesthetic was administered in small incremental boluses to reach a T4 sensory level while observing blood pressure response. Intraoperative management focused on cautious fluid administration and early anticipation of postpartum autotransfusion effects. Oxytocin was administered slowly in small bolus dosing followed by infusion to reduce the risk of tachycardia and hypotension. The patient remained hemodynamically stable without vasopressor requirement, had appropriate urine output, and experienced no perioperative complications.
Postoperatively, the patient was monitored in the ICU for 24 hours with invasive blood pressure monitoring and ECG surveillance. Epidural analgesia with dilute local anesthetic supported pain control while helping avoid sympathetic surges. The course remained stable; the catheter was removed on postoperative day 1 and the patient was discharged in good condition.
What You Should Know
• Severe cardiomyopathy in pregnancy requires avoiding sudden drops in SVR and maintaining preload within a narrow range.
• A graded epidural can be advantageous versus single-shot spinal by allowing slower sympathectomy and titration.
• Invasive arterial monitoring and immediate access to vasopressors/inotropes are practical safeguards.
• Oxytocin should be given cautiously (slow, low-dose strategies) to limit tachycardia and hypotension.
• Postpartum period is high risk due to autotransfusion and fluid shifts; ICU observation is often appropriate.
Key Points
• Clinical problem: severe dilated cardiomyopathy (EF 20–25%) undergoing cesarean delivery.
• Technique used: carefully titrated graded epidural anesthesia with invasive arterial monitoring.
• Outcome: stable intraoperative hemodynamics without vasopressors; uncomplicated recovery with ICU monitoring.
• Practical takeaway: incremental neuraxial dosing plus meticulous monitoring can be a workable strategy in selected high-risk patients.
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