1. PERIOPERATIVE MANAGEMENT OF A PARTURIENT WITH PRIOR H/O PULMONARY EMBOLISM AND IVC FILTER IN SITU DR.KRANAPPU SOLOMON,DNB PG DR.RENU DEVAPRASATH,DNB (Anesth) DR.V.SANKARASUBRAMANIAN,M.D.(Anesth) DR.JEYASEKHARAN HOSPITAL &NURSING HOME, NAGERCOIL

2. CASE SCENARIO  21 year old primi came to our hospital at 7 th month of gestation for antenatal checkup.  Gave past h/o superior sagittal sinus thrombosis 4 years back.  Mild antithrombin III deficiency & was on tab.Warfarin  H/o iliofemoral deep venous thrombosis extending into IVC upto renal veins level.  H/o pulmonary embolism, thrombolysed and prophylactic permanent transjugular IVC filter deployed prior to discharge with oral anticoagulants.

3. ANTENATAL SCENARIO  As soon as pregnancy was confirmed warfarin was stopped,started on inj.fondaparinux 2.5mg OD sc as per physician advice.  Antenatal checkup continued in our hospital.  Advised to get admitted 3days prior to anticipated time of delivery.

4. PREOPERATIVE PREPARATION  Coagulation workup done  Adequate fresh blood & fresh frozen plasma arranged  Inj.Fondaparinux stopped 48 hours prior to elective LSCS.  Risk of maternal haemorrhage & recurrent DVT/ PE in the postop. period explained.  Discussed with Obstetrician.

5. ANESTHETIC MANAGEMENT  Two peripheral IV lines secured  Informed consent obtained for regional anaesthesia  SUBARACHNOID BLOCK  sitting position,  L3-4 level  27G Quincke needle  Single shot  Drug: 0.5% Bupivacaine 2ml + 0.1mg morphine  Intraop-uneventful  Full term baby delivered

6. POSTOP.MANAGEMENT  Analgesia lasted for 20 hours.  Inj.Fondaparinux started after 24 hours.  Tab.Warfarin restarted.  PT,INR checked & maintained around 2.5-3.5  Patient had an uneventful postop. & discharged home.

7. DISCUSSION  Be prepared to take the new role as perioperative physician.  Update on new drugs essential -FONDAPARINUX.  Patient on anticoagulants: plan early to avoid mishaps.  Pregnancy:high risk of DVT/PE  IVC Filter.  Anaesthetic technique of choice – choose the best technique that suits the patient and of course you.

8. ANSWERS FOR THE ANTICIPATED PROBLEMS  Maternal bleeding.  Emergency caesarean.  Recurrent DVT/PE.  Dislodgement of IVC filter?  Anaesthesiology Clinics.vol.26,pg.1-22  Anaesthesiology Clinics of North America. vol.21,pg.99,165  Evidence-Based Practice Of Anesthesiology. Lee A.Fleisher,pg.218.