Combined spinal and epidural anesthesia for emergency cesarean section in a woman with congenital absence of the pericardium

Abstract

　A woman in her twenties (height: 166 cm, weight: 64 kg) underwent inpatient management for congenital absence of the pericardium, which complicated her pregnancy. However, she developed chest pain, and emergency cesarean section was performed at 34 weeks and 4 days of gestation. An antecedent MRI revealed an approximately 3 cm defect in the left ventricular apex epicardium with ECG changes dependent on positioning. Preoperatively, the patient experienced chest pain in the left lateral decubitus position, while being asymptomatic in the supine position. Combined spinal and epidural anesthesia (CSEA) was selected, with the puncture performed in the right lateral decubitus position. There was no subsequent conversion to the supine position perioperatively. Intraoperatively, the patient did not report chest pain and palpitations, and the hemodynamic status remained stable. The pericardial defect at the left ventricular apex may have deviated due to the left lateral decubitus position, resulting in thoracic symptoms. Contributing factors to exacerbating symptoms may include physical factors associated with uterine enlargement throughout the pregnancy and increased pre-load due to augmented circulatory blood volume. Considering the uncertainty surrounding the impact of positive pressure ventilation on the mother and fetus, general anesthesia was avoided, and CSEA, which our institution is most proficient in, was selected for perioperative management for pericardial defect complicating pregnancy. While there is no definitive consensus regarding the selection of anesthetic techniques for cesarean sections in cases of congenital absence of the pericardium during pregnancy, this case demonstrated the feasibility of stable anesthetic management with CSEA.