A 31-year-old woman (161 cm, 59.2 kg, 48 kg before pregnancy, gravida 1, para 0, abortus 0) who was receiving digoxin and sotalol for TTFT was scheduled to undergo an elective cesarean section.
Fetal tachyarrhythmia was first identified at 26 weeks and 0 days of gestation, and the fetus was found to have hypoplastic left heart syndrome (HLHS), hydrops, and tachycardia with a heart rate (HR) of around 250 beats per minute (bpm). The mother received digoxin (0.75 mg/day) and sotalol (320 mg/day) for TTFT from 26 weeks and 1 day of gestation to the day of surgery. The fetal tachycardia and hydrops immediately improved, and the fetal HR stabilized at 140–150 bpm. The maternal HR was in the 60 s before starting TTFT and in the 50 s after starting TTFT. The maternal blood concentration of digoxin remained at 1.3–1.5 ng/mL, and she experienced no adverse events. The cesarean section was scheduled at 37 weeks and 5 days of gestation to facilitate the treatment schedule of the infant’s HLHS.
Combined spinal-epidural anesthesia (CSEA) was chosen for the cesarean section. The ClearSight™ system (Edwards Lifesciences Corp., Irvine, CA, USA) was used in addition to the standard hemodynamic monitoring. The ClearSight™ finger cuff was placed on the mother’s left middle finger, and a non-invasive blood pressure (NIBP) monitor (IntelliVue MP70; Philips Electronics Japan Corp., Tokyo, Japan) was placed on her right upper arm. Intravenous access was established using a 20 G cannula. The patient was given 400 mL of 6% hydroxyethyl starch 130/0.4/9 (Voluven®□, Fresenius Kabi, Bad Hamburg, Germany) from when she arrived in the operating theater until the start of the operation. CSEA was performed with the patient in the left lateral decubitus position. An epidural catheter was inserted at the T12–L1 level using an 18G Tuohy needle. Spinal anesthesia was performed at the L3–4 levels using a 27 G Quincke needle, and 0.5% hyperbaric bupivacaine 9 mg and fentanyl 15 mcg were administered intrathecally. The surgery began after confirming the loss of cold sensation up to the T8 dermatome.
We sought to maintain the mother’s systolic blood pressure (SBP) at ≥ 90% of the baseline value. If her SBP fell below 90% of the baseline, we planned to administer phenylephrine if her HR was > 60 bpm or ephedrine 4–8 mg if her HR was < 60 bpm. Her baseline blood pressure was 116/71 mmHg by the ClearSight™ system, and her SBP as measured by the ClearSight™ system stayed over 115 mmHg until the infant’s birth. The SBP value measured by the NIBP cuff was somewhat lower than that measured by the ClearSight™ system, but the difference was within 10%.
The duration of anesthesia was 94 min, and the duration of surgery was 52 min (Fig. 1). The total amount of fluid administered was 1055 mL, which comprised crystalloid 655 mL and colloid 400 mL. The total blood loss, including amniotic fluid, was 745 mL and the mother produced 200 mL of urine. The infant’s birth weight was 2618 g, and the Apgar scores were 8, 8, and 8 at 1, 3, and 5 min, respectively. The infant’s initial umbilical artery pH was 7.252. The fetal HR was in the 140 s before entering the operating theater, and the infant’s HR was in the 130 s upon admission to the neonatal intensive care unit. Sotalol was administrated to the infant from the first day of life to prevent tachyarrhythmia and the infant’s HR remained stable at 120–150 bpm.
The infant underwent a pulmonary artery banding operation at 4 days of age, the Norwood operation at 20 days of age, and the bidirectional Glenn operation at 3 months of age. The mother was found to have an elevated D-dimer level (21.66 μg/mL) on postoperative day (POD) 7. Lower extremity venous ultrasonography and contrast-enhanced computed tomography were performed to rule out deep vein thrombosis; however, there were no abnormal findings and she was discharged home on POD 10.