Low Dose Combined Spinal Epidural for Caesarean Section in Peripartum Cardiomyopathy - A Case Report with Review of Literature

Peripartum cardiomyopathy (PPCM) is a rare but life threatening condition and anaesthetic management of a patient with PPCM for caesarean section is often a major challenge. We discuss the case of a 33-yr-old fifth gravida with gestational hypertension who had been diagnosed with PPCM at 34 weeks of pregnancy, when her echocardiography revealed global hypokinesia with severe left ventricular systolic dysfunction (ejection fraction 25%). She had then been started on medications digoxin, furosemide, spironolactone and carvedilol. At 37 weeks she presented for elective caesarean section for placenta previa, which was done under low dose combined spinal epidural (CSE) with 6 mg hyperbaric bupivacaine and 25 mcg fentanyl given intrathecally. Non-invasive monitoring was used for observing patient's vital parameters. The low dose CSE technique provided adequate intraoperative anaesthesia and postoperative analgesia without causing significant hemodynamic variations, and the surgery and postoperative recovery were uneventful. There is a growing literature suggesting that low dose CSE preserves the maternal hemodynamics and hence may be a suitable regional anaesthesia technique for CS in high risk obstetric patients with cardiac disease. We briefly review here the literature on anaesthetic management in PPCM and the use of low dose CSE in high risk obstetric cases.