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Analgesia de Parto em Paciente com Tetralogia de FallotNo Corrigida. Relato de Caso *

Labour Analgesia in Parturient with Uncorrected Tetralogy of Fallot.Case Report

Florentino Fernandes Mendes, TSA 1; Carlos Alberto T Farias 2; Daniel Segabinazzi3

RESUMOMendesFF, FariasCAT, Segabinazzi D - Analgesia de Parto emPaciente com Tetralogia de Fallot No Corrigida. Relato deCaso

JUSTIFICATIVA E OBJETIVOS: Embora a tetralogia de Fallotseja a mais comum das cardiopatias congnitas cianticas, aspublicaes nacionais, relacionando essa doena com aprtica anestsica so escassas. O objetivo deste relato apresentar um caso de analgesia de parto em pacienteportadora de tetralogia de Fallot no corrigida e diagnosticadadurante a gestao.

RELATO DO CASO: Paciente com 26 anos, 56 kg, 1,56 m,idade gestacional 32 semanas e 5 dias, com diagnstico detetralogia de Fallot realizado durante a gestao. Internou emtrabalho de parto. A conduta obsttrica foi a de parto via baixa,sendo realizada analgesia atravs de bloqueio peridural combupivacana a 0,125% e fentanil (100 g) e colocao decateter peridural. Aps 1h30 minutos do incio da analgesia,ocorreu o nascimento. O peso do recm-nascido foi 1485 g e ondice de Apgar 6 e 8 no primeiro e no quinto minutos,respectivamente. A paciente permaneceu estvel e semalteraes hemodinmicas e/ou eletrocardiogrficas.

CONCLUSES: A escolha da tcnica anestsica de funda-mental importncia no manuseio das pacientes com tetralogiade Fallot no corrigidas. Condies favorveis do colo e boadinmica uterina, particularmente naquelas pacientes semhistria de sncope, tornam-se imprescindveis para uma boa

indicao da analgesia de parto.Unitermos: ANALGESIA, Parto; DOENAS, Cardaca:tetralogia de Fallot; TCNICAS ANESTSICAS, Regional:peridural contnua

SUMMARYMendes FF, Farias CAT, Segabinazzi D - Labour Analgesia inParturient with Uncorrected Tetralogy of Fallot. Case Report

BACKGROUND AND OBJECTIVES: Although tetralogy ofFallot is the most common cyanotic congenital heart disease,national publications correlating this condition with anestheticpractice are scarce. This report aimed at presenting a case oflabor epidural analgesia in a patient with uncorrected tetralogyof Fallot diagnosed during gestation.

CASE REPORT: Patient 26 years old, 1.54 m, 56 kg, 32 weeksand 5 days of gestational age, who had been diagnosed withtetralogy of Fallot during gestation. Patient was admitted in la-

bour. After obstetric evaluation and decision for natural birth,epidural analgesia was performed with 0.125% bupivacaine as-sociated to 100g fentanyl through a catheter. Patient gavebirth 1 hour and 30 minutes after the procedure. The newbornweighed 1485 grams and had an Apgar score of 6 and 8 at oneand five minutes, respectively. Patient remained stable, with nohemodynamic or ECG changes.

CONCLUSIONS: Selecting the appropriate anesthetic tech-nique is extremely important when managing patients with un-corrected tetralogy of Fallot. Favorable uterine dynamics andcervical conditions, particularly in patients with no history ofsyncope, are critical findings for adequate labour analgesia in-dication.

Key Words: ANALGESIA, Labour; ANESTHETIC TECH-NIQUES: Regional: epidural continuous; DISEASES, Cardiac:

tetralogy of Fallot

INTRODUO

Atetralogia de Fallot uma cardiopatia congnita cianti-ca, caracterizada porobstruo sada do ventrculo di-reito, hipertrofia ventricular direita, defeito no septointerventricular e transposio artica varivel 1,2. A obstru-o via de sada ventricular direita em muitos pacientes devida estenose infundibular. Em pelo menos 20% a 25%dos pacientes tambm h estenose da valva pulmonar euma pequena percentagem tem algum elemento de esteno-

se supravalvar. A obstruo infundibular est aumentadaem situaes de tnus simptico elevado (varivel dinmi-ca); essa obstruo a provvel responsvel pela cianoseobservada em muitos pacientes jovens 3.A combinao de obstruo sada do ventrculo direito e acomunicaointerventricular(CIV)resultanaejeodesan-gueno-oxigenadodoventrculodireitoeoxigenadoatravsdaaorta.O shuntdireito-esquerdoquedeterminaograudehipoxemia e, conseqentemente, a gravidade da doena.Esta varia em funo de componentes fixos: grau de obstru-o do ventrculo direito, grau de dextroposio da aorta, ta-

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INFORMAO CLNICACLINICAL REPORT

Rev Bras Anestesiol2005; 55: 1: 95 - 99

* Recebido da (Received from) Maternidade Mrio Totta - Ncleo deAnestesia e Analgesia Obsttrica do Servio de Anestesiologia da San-

ta Casa de Porto Alegre - CET/SBA FFFCMPA, Porto Alegre, RS

1. Chefe do Servio de Anestesiologia da Santa Casa de Porto Alegre.

Mestre em Farmacologia pela FFFCMPA. Doutor em Medicina pela

FCMSCSP

2. Mdico do Servio de Anestesiologia da Santa Casa de Porto Alegre.Mdico Anestesiologista do Grupo Hospitalar Conceio

3. ME2 do CET/SBA da FFFCMPA

Apresentado (Submitted) em 03 de outubro de 2003Aceito (Accepted) para publicao em 27 de setembro de 2004

Endereo para correspondncia (Correspondence to)Dr. Carlos Alberto T. Farias

Av. Arnaldo Bohrer, 184/23 Bairro Terespolis

91720-130 Porto Alegre, RS

E-mail: carlostf@terra.com.br

Sociedade Brasileira de Anestesiologia, 2005

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manho da CIV - e variveis - resistncia vascular sistmica(RVS) e pulmonar (RVP), obstruo infundibular, retorno ve-nosoecontratilidademiocrdica 4.EventoscomaumentodaRVP, como acidose e aumento de presso nas vias areasdevem ser evitados 5.Amanutenodoscomponentesvariveispontoessencialnomanuseioanestsicode pacientescom a doenanocor-rigida, j que so os principais determinantes do equilbriohemodinmico desses indivduos.Oobjetivodesterelatoapresentarumcasodeanalgesiadeparto em pacienteportadora de tetralogia de Fallotno corri-gida e diagnosticada durante a gestao, relacionando oscuidados no manuseio anestsico desta doena.

RELATO DO CASO

Paciente com 26 anos, 56 kg, 1,56 m, primigesta, idade ges-tacional de 32 semanas e 5 dias, em trabalho de parto, comdinmica uterina de 3 contraes em 10 minutos e com 4 cmdedilataodocolouterino.Duranteopr-natalfoiausculta-

do importante sopro cardaco, sendo encaminhada parapr-natalemhospitalespecializadoondefoidiagnosticadaatetralogia de Fallot. Negava ter conhecimento prvio da do-ena. Referia dispnia leve e cianose de extremidades queseagravaram como decorrerda gestao,e seassociaramdor precordial aos mdios esforos, entretanto noincapacitantes.Durante a avaliao pr-anestsica apresentava-se com ci-anose central e de extremidades, baqueteamento digital.Negava alergias, cirurgias prvias e uso de medicaes. Oexame cardiotocogrfico e a ecocardiografia fetal eramnormais.A ecocardiografia materna, realizada com 27 semanas de

gestao revelou levocardia, arco artico esquerda, cone-xo AV concordante e modo normal, conexo ventrculo-ar-terial concordante e modo de conexo normal. Apresentavacomo defeito associado ampla CIV subartica que provoca-va desvio anterior e superior do septo interventricular, suge-rindo tetralogia de Fallot. Ventrculos e trios com dimen-s e s, e sp es su ra e m ov im en ta o n or ma l. Oeletrocardiograma apresentava inverso da onda Tntero-septal.A conduta obsttrica foi a de parto por via baixa com analge-sia.Amonitorizaoconsistiudeoxmetrodepulsoqueosci-lava em 89% a 78% de acordo com a presena ou no de di-nmicauterina,eletrocardioscopiaquemostravaritmoregu-

lar e inverso de onda T e presso arterial no-invasiva, evi-denciando nveis mdios de 120/60 mmHg. Os escores dedorforammonitorizadosatravsdeescalavisualanalgica.A tcnica anestsica utilizada foi bloqueio peridural realiza-do com a paciente sentada, com puno em L 2-L3 na linhamdia, utilizando agulha Tuohy16G. Aps a dose-teste de 3mLdelidocanaa2%comvasoconstritor,foiinjetadabupiva-canaa0,125%8mL(10mg)efentanil(100g)elogoemse-guida foi introduzido cateter peridural at atingir 5 cm no es-paoperidural.Apacientepermaneceumonitorizadaerece-bendo oxignio por cateter nasal a 2 L.min-1.

Aparturiente referiu alviodas dorescercade 5 minutos apso bloqueio, com mnima alterao sobre a dinmica uterina.Aps 30 minutos de analgesia, apresentava 9 cm de dilata-o do colo uterino e dor leve a moderadana regio perinealdurante as contraes. Os nveis tensionais no se altera-ram. A oximetria continuava oscilando durante as contra-esde88%para80%.Comumahoradeanalgesia,apaci-enteapresentava10cmdedilataodocolouterinoecome-ou a ter contraes mais efetivas. Os escores de dor au-mentaram e foi realizada injeo de 6,25 mg de bupivacanaa 0,125%, atravs do cateter peridural.Apacientefoicolocadaemposioginecolgicaeinstrudaano realizar esforo expulsivo durante as contraes, quan-do apresentava nveis de oximetria com valores de 76% a78%.Apsuma1h30minutosdoinciodaanalgesiaocorreuonascimento.Opesodorecm-nascidofoide1485geondi-ce de Apgar 6 e 8 no primeiro e no quinto minutos de vida,respectivamente.Aps o nascimento a paciente permaneceu estvel, sem al-teraes hemodinmicas ou eletrocardiogrficas, porm

houve aumento nos nveis da oximetria registrando 91% a93% de SpO2.A paciente realizou nova ecocardiografia no dia seguintecom o objetivo de revelar a via de sada do ventrculo direitoque, junto s alteraes previamente detectadas, evidenci-ou hipertrofia ventricular direita, ausncia de CIA, CIV comviade sada ampla,desvio anteriordo septo infundibularquegeravaobstruomoderadaevalvasAVnormaiscomfraodeejeonormal.Avalvapulmonarerahipoplsicaeesten-tica e a artica ectsica com cavalgamento artico de 50%.As artrias pulmonaresestavamaparentemente desobstru-das e confluentes. As artrias coronrias no foram revisa-das adequadamente. Concluso do exame: resultados

compatveis com tetralogia de Fallot.

DISCUSSO

A tetralogia de Fallot uma cardiopatia congnita caracteri-zadapordefeitodoseptoventricular,estenosepulmonar,ca-valgamento artico sobre a comunicao interventricular ehipertrofiadoventrculodireito.Estadoenarepresenta15%das cardiopatias congnitas, sendo a mais comum entre ascianticas.Aproximadamente 15% dos pacientes com tetra-logiadeFallottmumadeleodobraocurtodocromosso-ma22comocausagenticadadoenaeprobalidadede50%de transmisso aos descendentes 1,2,6,7.

Afisiopatologiadadoenadependedograudeobstruoaofluxo de sada do ventrculo direito. Com obstruo relativa-menteleve a apresentao deaumentodo fluxosangneopulmonar (tambm chamado de Tetralogia Rosa ou Fallotaciantica). Ocasionalmente esta a apresentao do adul-to8,9. A maior parte das crianas, porm, apresenta-se comobstruo significativa da via de sada do ventrculo direitocom conseqente shuntdireito-esquerdo e cianose.A gestao aumenta a mortalidade e a morbidade das paci-entes com tetralogia de Fallot no corrigida, principalmentenaquelas com histria de sncope, policitemia e hipertrofia

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ventriculardireita,o queno acontecenaquelasque tmsuadoena corrigida cirurgicamente1,3,8.Oriscomaiorquandoosnveisdesaturaoarterialdeoxi-gnioemrepousosomenoresdoque85%.Adiminuiodaresistncia vascular sistmica, durante a gestao, e o tra-balho de parto podem aumentar o shunt, agravando aacidose.Ograudehipoxemiaestdiretamenterelacionadogravida-deemagnitudedoshunt,osquaisdependedefatoresfixos-graudeobstruodoventrculodireito,graudedextroposi-odaaorta,tamanhodaCIV-evariveis-RVSeRVP,obs-truo infundibular, retorno venoso e contratilidade miocr-dica4.A indicao da tcnica anestsica para gestante portadoradetetralogiadeFallotnocorrigida,bemcomoocorretoma-nuseiodeeventuaisocorrnciasduranteoatoanestsico-ci-rrgicofundamentam-senoconhecimentodagravidadedasalteraes a fim de determinar-se o principal mecanismo doshunt. As drogas e tcnicas anestsicas podem modificarsignificativamente os componentes variveis, que determi-

nam o equilbrio hemodinmico desses pacientes 1,2.Astcnicasregionaispodemafetaresteequilbriodeacordocomonveldebloqueiosimpticoproduzido,quepoderau-mentaro shunt, atravs dadiminuioda RVSe, conseqen-temente diminuindo o enchimento ventricular e o dbito car-daco 2,5.Princpiosbsicosdaanestesiaobsttricadevemseraplica-dos, particularmente, nessas pacientes: analgesia adequa-da, manuteno da perfuso tero-placentria, evitandocompressoaortocavaeminimizaodobloqueiosimpticocom manuteno do volume intravascular. A manutenodos fludos venosos deve ser cuidadosamente monitorizadaa fim de evitar deficits ou excessos, provocando piora doshunte descompensao da paciente 2.Aescolhadatcnicaanestsicadeimportnciafundamen-talnomanuseiodaspacientescomtetralogiadeFallot.Quan-do h a possibilidade de realizar o alvioda dorcom mnimasalteraeshemodinmicas,comoseobservacomanalgesiade partocom anestesia peridurale baixasconcentraes deanestsicoslocais,estasetornadegrandevalornomanuseiodessas pacientes.A analgesia de parto com a tcnica combinada tambm semostra efetiva e segura ao permitir o uso de opiides lipofli-cos por via subaracnidea, como sufentanil, levando a umefeito analgsico mais rpido, menor bloqueio simptico,menorbloqueiomotorereduodasdosesdeanestsicolo-

cal utilizadas pelo cateter peridural 10-12.Contudo, necessrio que condies fisiolgicas e obsttri-cas sejam observadas para um bom andamento do trabalhode parto.Condiesfavorveis do colo e boadinmicauteri-na nessas pacientes,particularmente naquelas sem histriadesncope,tornam-seimprescindveisparaaboaindicaoda analgesia de parto.

Labour Analgesia in Parturient withUncorrected Tetralogy of Fallot. CaseReport

Florentino Fernandes Mendes, TSA, M.D.; Carlos Alberto T.Farias, M.D.; Daniel Segabinazzi, M.D.

INTRODUCTION

Tetralogy of Fallot is a cyanotic congenital heart diseasecharacterized by right ventricular outflow obstruction, rightventricular hypertrophy, interventricular septum defect andvariable aortic transposition 1,2. The obstruction of right ven-tricularoutletisduetoinfundibularstenosisinmanypatients.Atleast20%to50%ofpatientsalsopresentpulmonaryvalvestenosis and a low percentage has some supravalvarstenotic element. Infundibularobstruction is increased in sit-uations of increased sympathetic tone (dynamic variable)

andis probably responsible forcyanosis observed in severalyoung patients 3.The combination of right ventricular outlet obstruction andinterventricular communication (IVC) results in the ejectionof right ventricular non-oxygenated bloodand aortic oxygen-ated blood. Right- left shunt determines the level of hypoxemia and, as a consequence, the severity of the dis-ease, which varies as a function of fixed components: rightventricular obstruction level, aortic dextroposition level, IVCsize - as well as variable components: systemic vascular re-sistance (SVR), pulmonary vascular resistance (PVR),infundibular obstruction, venous return and myocardial con-tractility 4. Events with increased PVR, such as acidosis and

increased airway pressure, should be avoided 5.The maintenance of variable components is critical foranes-thetic management of patients with uncorrected disease,since they aremajordeterminants of their hemodynamic bal-ance.This report aimed at describing a case of labour analgesia inuncorrected tetralogyof Fallotpatient diagnosed during ges-tation, and at listing the cares for anesthetic management ofthis disease.

CASE REPORT

Patient 26 years old, 56 kg, 1.56 m, 32 weeks and 5 days ofgestational age, in labor, with uterine dynamics of 3 contrac-tionsin10minutesandwith4cmcervicaldilatation.Prenatalevaluation has revealed severe heart murmur and patientwas referred to a specialized hospital were tetralogyof Fallotwas diagnosed. Patient denied having previous knowledgeabout the disease. Patient referred mild dyspnea andcyanosis of extremities, which have worsened along gesta-tion and were associated to not disabling precordial pain atmoderate effort.

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At preanesthetic evaluation patient presented with centraland extremities cyanosis and clubbed fingers, denying aller-gies, previous surgeries and use of medications. Fetalcardiotocography and echocardiography were normal.Maternalechocardiography,performedat27weeksofgesta-tion has revealed levocardia, aortic arch to the left, agreeingandnormalAVconnection,agreeingventricular-arterialcon-nection and normal connection mode. Patient had broadsubaort ic IVC as associated defect , which causedinterventricularseptum anterior and superior deviation, sug-gesting tetralogy of Fallot. Ventricles and atria had normalsize,thicknessandmovement.ECGshowedantero-septalTwave inversion.Afterobstetricevaluationanddecisionfornaturalbirth,moni-toring consisted of pulse oximetry varying from 89% to 78%according to presence or absence of uterine dynamics, ECGwith regular rhythm and T wave inversion, and noninvasivebloodpressurewith mean levelof 120/60mmHg. Pain scoreswere monitored with visual analog scale.

Anesthetic technique was epidural block performed at L2-L3with patient in the sitting position and using 16G Tuohy nee-dle. After a test dose with 3 mL of 2% lidocaine withvasoconstrictor, 8 mL of 0.125% bupivacaine (10 mg) andfentanyl (100 g) were injected andepidural catheter wasin-serted 5 cm into the epidural space. Patient remained moni-tored and receiving 2 L.min-1 oxygen via nasal catheter.Patient referred pain relief approximately 5 minutes afterblockade with minor uterine dynamics change. After 30 min-utes patient presented 9 cm cervical dilatation and mild tomoderate perineal pain during contractions. Pressure levelswere not changed. Oximetry continued oscillating duringcontractionsfrom88%to80%.Withonehourofanalgesiapa-

tient presented 10 cm cervical dilatation and started to havemore effective contractions. Pain scores increased and6.25mgof0.125%bupivacainewereinjectedthroughtheepiduralcatheter.Patientwasplacedinthegynecologicalpositionandorientednot to push during contractions when oximetry levels were76% to 78%. Patient gave birth 1h30m after analgesia. New-bornweightwas1486gandApgarscoreatoneandfivemin-utes was 6 and 8, respectively.After delivery patient remained stable, withno hemodynamicor ECG changes, however with increased oximetry levels of91% to 93%.

Anewechographywas performedthe next dayaimingat find-ing right ventricular outflow which, together with previouslydetected changes, has evidenced right ventricular hypertro-phy, lack of IAC, IVCwith broad outflow, anterior infundibularseptumshiftgeneratingmoderateobstructionandnormalAVvalves with normal ejection fraction. Pulmonary valve washypoplasticandstenoticandaorticvalvewasectaticwithaor-tic 50% riding. Pulmonary arteries seemed to be unob-structed and confluent. Coronary arteries were not ade-quately reviewed. Test conclusion was: results compatiblewith tetralogy of Fallot.

DISCUSSION

Tetralogy of Fallot is a congenital heart disease characterizedby ventricular septum defect, pulmonar stenosis, aortic rid-ing on interventricular communication and right ventricularhypertrophy. This disease represents 15% of congenitalcardiopathiesandisthemostcommonamongcyanoticheartdiseases. Approximately 15% of tetralogy of Fallot patientshavea deletionof the short arm ofchromosome22 asthe ge-netic cause of the disease and there is 50% probability oftransmission to offsprings 1,2,6,7.Disease pathophysiology depends on the level of right ven-tricular outflow obstruction. With relatively mild obstruction,presentation is increased pulmonary blood flow (also calledRose Tetralogy or acyanotic Fallot). Occasionally this is theadult presentation 8,9. Most children, however, have signifi-cant right ventricular outflow obstruction with consequentright-left shunt and cyanosis.Gestation increases mortality and morbidity rates of uncor-rected tetralogy of Fallot patients, especially those with his-

tory of syncope, polycythemia and right ventricular hypertro-phy, what is not true for those surgically corrected 1,3,8.Risk is increased when arterial oxygen saturation levels atrestarebelow85%.Decreasedsystemicvascularresistanceduring gestation and labour may increase shunt and worsenacidosis.The level of hypoxemia is a direct function of shunt severityandmagnitude,whichdependonfixedfactors-rightventricu-lar obstruction level, aortic dextroposition level, IVC size -and variable factors - SVR and PVR, infundibular obstruc-tion, venous return and myocardial contractility 4.The indication of the anesthetic technique for uncorrectedtetralogy of Fallot patients, as well the adequate manage-

ment of possible intraoperative events, are based on the un-derstandingoftheseverityofthediseasetodeterminemajorshuntmechanism.Anestheticdrugsandtechniquesmaysig-nificantly change variable components determining thehemodynamic balance of such patients 1,2.Regionaltechniquesmayaffectthisbalanceaccordingtothelevel of sympathetic blockade, which may increase shunt bydecreasing SVRand, as a consequence, decrease ventricu-lar filling and cardiac output 2,5.Basic obstetric anesthesia principles should be particularlyapplied to these patients: adequate analgesia, maintenanceof uterine-placental perfusion preventing aortocaval com-pression and minimization of sympathetic block by maintain-

ing intravascular volume. Intravenous fluids should be care-fully monitored to prevent deficits or excesses, leading toshunt worsening and patients decompensation 2.The choice of the anesthetic technique is critical to managetetralogy of Fallot patients. When pain may be relieved withminor hemodynamic changes, as it is the case with labourepiduralanalgesiaandlowlocalanestheticsconcentrations,thiswouldbevaluableforthemanagementofthesepatients.Combined labour analgesia is also effective and safe be-cause it allows the use of subarachnoid lipophylic opioids,such as sufentanil, leading to faster analgesic effect, lower

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sympathetic and motor block, in addition to lower local anes-thetics via epidural catheter10-12.However, physiological and obstetric conditions have to beobservedforgoodlabouroutcome.Favorablecervicalcondi-tionsandgooduterinedynamicsinthesepatients,especiallythose with no history of syncope, are indispensable for ade-quate indication of labour analgesia.

REFERNCIAS - REFERENCES

01. Presbitero P, Somerville J, Stone S et al - Pregnancy in cyanoticcongenital heart disease. Outcome of mother and fetus. Circu-lation 1994;89:2673-2676.

02. Kuczkowski KM - Labor analgesia for the parturient with cardiacdisease: what does an obstetrician need to know? Acta ObstetGynecol Scand, 2004;83:223-233.

03. Carvalho JCA, Matias RS, Siaulys MM et al - Anestesia paracesrea em portadoras de tetralogia de Fallot corrigidacirurgicamente. Rev Bras Anestesiol, 1992;42:429-431.

04. Brickner ME, Hillis LD, Lange RA - Congenital heart disease in

adults. Secondof twoparts. N Engl J Med, 2000;342:334-342.05. Warner MA, Lunn RJ, OLeary PW et al - Outcomes of

noncardiac surgical procedures in children and adults with con-genital heart disease. Mayo Clin Proc, 1998;73:728-734.

06.PayneRM,JohnsonMC,GrantJWetal-Towardamolecularun-derstanding of congeni tal heart d isease. Ci rculat ion,1995;91:494-504.

07. Galli KK, Myers LB, Nicolson SC - Anesthesia for adult patientswith congenital heart disease undergoing noncardiac surgery.Int Anesthesiol Clin, 2001;39:43-71.

08. Pozzi M, Trivedi DB, Kitchiner D et al - Tetralogy of Fallot: whatoperation, at which age. Eur J Cardiothorac Surg, 2000;17:631-636.

09. Sohn S, Lee YT - Outcome of adults with repaired tetralogy ofFallot. J Korean Med Sci, 2000;15:37-43.

10. Harsten A, Gillberg L, Hakansson L et al - Intrathecal sufentanilcompared with epidural bupivacaine analgesia in labour. Eur JAnaesthesiol, 1997;14:642-645.

11. Arkoosh VA, Cooper M, Norris MC et al - Intrathecal sufentanildose response in nulliparous patients. Anesthesiology,1998;89:364-370.

12. Nageotte MP, Larson D, Rumney PJ et al - Epidural analgesiacompared with combined spinal-epidural analgesia duringlaborin nulliparous women. N Engl J Med, 1997;337:1715-1719.

RESUMENMendes FF, Farias CAT, Segabinazzi D - Analgesia de Parto enPaciente con Tetralogade Fallot No Corregida. Relato de Caso

JUSTIFICATIVA Y OBJETIVOS: Aunque la tetraloga de Fallotsea la ms comn de las cardiopatas congnitas cianticas,las publicaciones nacionales, relacionando esa enfermedadcon la prctica anestsica son escasas. El objetivo de esterelato es presentar un caso de analgesia de parto en pacienteportadora de tetraloga de Fallot no corregida y diagnosticadadurante la gestacin.

RELATO DEL CASO: Paciente con 26 aos, 56 kg, 1,56 m,edad gestacional 32 semanas y 5 das, con diagnstico detetraloga de Fallot realizado durante la gestacin. Intern en

trabajo de parto. La conducta obsttrica fuela de partova baja,siendo realizada analgesia de parto a travs de bloqueoperidural con bupivacana a 0,125% y fentanil (100 g) ycolocacin de catter peridural. Despus de 1h30 minutos delinicio de la analgesia, ocurri el nacimiento. El peso del recinnacidofue1485 g y el ndicede Apgar 6 y 8 enel pr imer oy enel quinto minutos, respectivamente. La paciente permanecie s ta bl e y s i n a l te ra c io n es h e mo di n m i ca s y / oelectrocardiogrficas.

CONCLUSIONES: La eleccin de la tcnica anestsica es defundamental importancia en el manoseo de las pacientes contetraloga de Fallot no corregidas. Condiciones favorables delcuello y buena dinmica uterina, particularmente en aquellaspacientes sin historia de sncope, se vuelven imprescindiblespara una buena indicacin de la analgesia de parto.

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