Case Description

A 38-year-old female with HHT presented for preoperative anesthesia evaluation before oocyte retrieval. 

 

HHT with cutaneous telangiectasias, epistaxis, NSAID-induced gastritis, iron deficiency anemia, and migraines.

Initially diagnosed due to family history. Recent echocardiogram showed normal heart function with a small PFO, no intrapulmonary shunt or AVM.  

Three recent episodes of epistaxis and mild palpitations, self-limited, with in-clinic EKG showing sinus rhythm. Slight reduction in exercise tolerance.  

No active bleeding sites or upper airway anomalies. 

ENT Clearance: Flexible laryngoscopy confirmed absence of upper airway telangiectasias. ENT advised substituting Flonase with a gentler nasal spray.

 

Cardiac & Pulmonary Screening: Echocardiogram revealed a small PFO without significant shunt or pulmonary AVMs. Palpitations evaluated as benign.

 

Epistaxis Consideration: Additional nasal care was advised to reduce dryness and prevent bleeding.

MAC vs. GA: Given the minimally invasive nature of oocyte retrieval, Monitored Anesthesia Care (MAC) was the initial choice. General Anesthesia (GA) prepared as a backup for complications.

 

Airway Management: No telangiectasias detected in the upper airway, but contingency plans developed for potential intubation complications/bleeding.

Bleeding Control: Local vasoconstrictors and nasal packing for potential epistaxis

 

Pulmonary AVM Screening: Re-screening advised if pregnancy is achieved due to the increased vascular load during pregnancy. 

 

Pregnancy Risks: Should pregnancy occur post-retrieval à increased risks of bleeding and cardiovascular complications (e.g., heart failure, pulmonary hemorrhage, stroke), especially later trimesters.

Discussion