Elective cesarean delivery in non-dialyzed parturient with chronic renal failure
A 37-year-old, 34 week parturient (Weight: 60 kg; Height: 165 cm) with singleton pregnancy was scheduled for elective cesarean delivery. She had ADPKD for 15 years duration and was on oral nifedipine 20 mg daily for hypertension. She had undergone uneventful cesarean delivery under general anesthesia 10 years ago. Over the past five years, her kidney function had deteriorated. She was on oral calcitrol, calcium carbonate, ferrous fumarate, oral nifedipine 20 mg daily and on a low protein diet.\nA multidisciplinary case conference was held, which included an obstetrician, anesthesiologist, neonatologist and nephrologist to develop a management plan. At 32 weeks of gestation, she was hospitalized to monitor her blood pressure, renal function and fetal wellbeing. Early intervention was planned if she had maternal or fetal complications during her stay. The treatment plan, including anesthetic management, was discussed with the patient. She persistently refused dialysis.\nAt 34 weeks of gestation, she noted discomfort while breathing. Physical examination revealed mild pallor with a respiratory rate of 20 breaths/min, pulse of 82/min and a blood pressure of 138/74 mmHg. There was no facial puffiness, periorbital edema or bruises of the skin. Systemic examination, including airway and spine examination, was unremarkable. Laboratory investigations done prior to the cesarean delivery are given in . Abdominal ultrasonogram revealed bilateral cortical and medullary cysts consistent with polycystic kidney disease, singleton intrauterine pregnancy and severe polyhydramnios. The electrocardiogram and a transthoracic echocardiogram revealed no abnormalities.\nIn the operating room, baseline monitors including pulse oximetry, non-invasive blood pressure, and electrocardiogram were instituted. Using aseptic technique, an epidural catheter was sited at L4-L5 space and its position was confirmed. Adequate surgical blockade was achieved with a total of 15 ml of 2% lidocaine with epinephrine 5 mcg/ml, administered in fractionated doses of 3-5 ml each given over 15 minutes. Fentanyl 100 mcg was also administered through epidural route after the local anesthetic top up. The parturient's blood pressure was monitored every minute till the delivery of fetus, then every five min till the end of surgery as per our institutional practice. The drop in blood pressure with epidural anesthesia was managed with careful titration of intravenous crystalloids and aliquots of phenylephrine.\nA live neonate was delivered weighing 1800 g with Apgar scores of seven and eight at 1 and 5 min, respectively. Intravenous oxytocin was administered by slow infusion. She had an uneventful perioperative course and monitored in high dependence unit. She had an uneventful stay, resumed her routine medications and was discharged on 5th postoperative day. She was advised regular follow up and dialysis with possible renal transplantation in the postoperative period.