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FCB-131
Pericardial effusion and morbidly adherent placenta: a delicate balance

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Introduction: 

A small pericardial effusion may be present in up to 28% of parturients in late pregnancy. The compliance of the pericardium determines the effusion volume precipitating cardiac tamponade (Figs. 12and 2).
Parturientswith a large effusion may pose significant anesthetic challenges.  While increased blood volume in pregnancy may offset tamponade physiology, administration of anesthesia may favor it. Further, hemorrhage may provoke further cardiovascular collapse.

Clinical History: 

40 year old G2P1 at 38 weeks with asymptomatic pericardial effusion (PE)
Large PE incidentally diagnosed (3 years prior to 1stpregnancy) for workup of ovarian mass.  Early tamponade physiology seen on trans-thoracic echocardiogram (TTE); percutaneous drainage of 660mL fluid; partial re-accumulation (RA) followed conservatively
1stpregnancy (moderate to large effusion @ 15 wks):
RA of large PE  followed with serial TTE; no pericardial drainage
Delivery in cardiac hybrid OR with epidural anesthesia, uneventful; the   PE was decreased significantly on TTE done 3 months postpartum.
2ndpregnancy (2 years later): moderate to large effusion @ 14wks
Twin gestation (1 viable, 1 fetal demise @ 15 wks with suspected accreta)
Serial TTEs with RA of moderate to large pericardial effusion
 
Case management: 

ANTENATAL: Multidisciplinary Planning:  elective repeat cesarean delivery (CD) in hybrid OR with surgical prep to the xiphoid, regional anesthesia, blood products prepared.

DAY OF CD: Patient admitted with tachycardia to130s, low grade fever, TTE with moderate effusion, no tamponade (Fig 3).

PRE-PROCEDURE:  Large-bore IV access x 2, 5% albumin,

Midazolam for anxiolysis followed by arterial line placement.

ANESTHETIC: Dural-puncture epidural (DPE) using 2% lidocaine with epinephrine, co-load 5% albumin; controlled epidural administration to achieve T4 level

INTRA-OP: Substantial blood loss of 6L, massive transfusion (Table) with intermittent phenylephrine. Hysterectomy performed; regional anesthesia maintained with patient awake and comfortable under minimal sedation.

POST-OP: mild dyspnea, fever, chest X-ray with pulmonary edema, possible pneumonia, furosemide with good effect; monitored bed.

POST-OP Day 1: TTE with early tamponade physiology, stable vital signs with mild dyspnea; expectant guarded management.

POST-OP day 4: Stable and discharged home.

2 MONTHS POSTPARTUM: Trivial effusion on TTE.

Key points: 

A small pericardial effusion is a relatively  common occurrence in pregnancy.  Pericardial compliance can accommodate slow accumulation of fluid, thereby abating acute tamponade. However, slow progression to tamponade remains.
Parturientswith a moderate to large effusion may pose significant anesthetic challenges. Both regional and general anesthesia counter the hemodynamic goals to minimize tamponade physiology (i.e. maintaining cardiac filling pressures,  a higher heart rate, and systemic vascular resistance).
Mindful titration of DPE minimizes undesirable hemodynamic effects of neuraxial blockade while producing adequate anesthesia. 
Drainage of large asymptomatic pericardial effusion is controversial. 3Echocardiographic findings do not always correlate with symptoms.
Multidisciplinary planning is essential and should include location of delivery, availability of cardiac personnel, and preparation for potential adverse events.




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