There is a growing population of patients with combined heart-lung transplant. The rate of obstetric complications, including preeclampsia and premature labor, are higher than in the nontransplant population (1). This case report describes the peripartum management of a patient with history of heart-lung transplant.

A 28 year old G3P0 s/p heart-lung transplant for idiopathic PAH was admitted to the antepartum service at 29w1d for concern of graft rejection due to worsening PFTs and subtherapeutic tacrolimus levels. Her transplant team focused on medical management by titrating immunosuppressants. Unfortunately, early during the admission, the patient was ruled in for superimposed preeclampsia with severe-range blood pressures, and a multidisciplinary plan was made for the patient to remain inpatient with expectant management until delivery. Induction of labor occurred at 33 weeks due to concerns about thrombocytopenia, with platelet count of 104. At this time, patient’s CARPREG II score was 3. A DPE was placed and initially working well, but required replacement at 15 hours due to inadequate block. After 2 days of continued induction, the patient was recommended to have a cesarean delivery for fetal intolerance of labor. The anesthesia team was unable to achieve adequate surgical block with her labor epidural and replaced it with a CSE. During the case, patient remained stable with a phenylephrine infusion and 1.5L crystalloid. Her delivery was complicated by postpartum hemorrhage of 1.7L and she received oxytocin, carboprost, misoprostol, and two doses of tranexamic acid. She was stably discharged on postpartum day four.

There are many anesthetic considerations for patients with history of heart-lung transplantation. Immunosuppression agents put patients at higher risk for infections, and side effects of these medications include hypertension (as was present in this case) and myelosuppression. Fortunately, although thrombocytopenic, our patient’s platelet count remained appropriate for neuraxial block. From a cardiac standpoint, the transplanted heart is dependent on preload, which can be significantly affected by neuraxial procedures. Furthermore, patients have a denervated heart so indirect acting medications have a blunted effect. Thus, our team chose fluid boluses and phenylephrine to support blood pressure, rather than ephedrine (2). From a pulmonary standpoint, patients are prone to edema due to disrupted lymphatic drainage so fluid administration should be judicious. If possible, neuraxial anesthesia is preferred to avoid intubation and risk of disrupting surgical suture lines (3). Our patient ultimately had a successful cesarean delivery with a multidisciplinary team managing concern for graft rejection, preeclampsia, fetal intolerance of labor, and postpartum hemorrhage.