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Pregnancy and Cardiac Disease

Pregnancy and Cardiac Disease. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Issues of Interest. Physiologic changes of pregnancy Factors affecting maternal morbidity/mortality Factors affecting neonatal outcome Fetal effects of maternal drug therapy Anticoagulation guidelines

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Pregnancy and Cardiac Disease

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  1. Pregnancy and Cardiac Disease www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. Issues of Interest • Physiologic changes of pregnancy • Factors affecting maternal morbidity/mortality • Factors affecting neonatal outcome • Fetal effects of maternal drug therapy • Anticoagulation guidelines • Indications for cardiac surgical intervention • Specific problems of specific lesions • Outline plan for labor analgesia and LSCS

  3. Physiologic Changes of Pregnancy • Gradual, disproportionate increase in CO (30-40%) • Increased plasma volume and RBC mass • SVR decreased due to placenta, hormones • Increase in SV due to reduced SVR and ventricular remodeling • Increase in HR • Fall of HCT • Further increase in CO during labor; increased blood volume and SVR after delivery

  4. Diagnosis of Heart disease • Difficult due to presence of similar, ’normal’ symptoms- fatigue, limited exercise tolerance, palpitations, edema, orthopnea • ‘Normal’ findings-murmurs, split S1, distended neck veins, radiologic and ECG changes • Symptoms + murmur>2/6 ECHO evaluation

  5. General outlines of management • Multidisciplinary assessment and risk evaluation • More frequent antenatal visits • Advise pregnancy termination in cyanotic HD, Primary pulmonary hypertension, Eisenmenger syndrome, Marfan syndrome with dilated aortic root, or more than 1 ‘High risk’ factors

  6. Maternal Effect of Cardiac Disease • Accounts for 10-15% mortality • 62% incidence of adverse events if ≥2 ‘High risk’ factors • High Risk Factors: Peripartum Cardiomyopathy with LVEF<40% Severe AS Previous CV event NYHA III/IV symptomatic Severe pulmonary hypertension: PPH or Systolic PA pressure≥75% systemic pressure Marfan syndrome with dilated aortic root Cyanotic HD with Hb>20g%, high RV pr & SpO2<85%

  7. Maternal cardiac status and riskof cardiac complications during pregnancy Low risk • Small left to right shunts • Repaired lesions without residual cardiac dysfunction • Isolated mitral valve prolapse without significant regurgitation • Bicuspid aortic valve without stenosis • Mild to moderate pulmonic stenosis • Valvar regurgitation with normal ventricular systolic function Intermediate risk • Unrepaired or palliated cyanotic congenital heart disease • Large left to right shunt • Uncorrected coarctation of the aorta • Mitral or aortic stenosis • Mechanical prosthetic valves • Severe pulmonic stenosis • Moderate to severe systemic ventricular dysfunction • History of peripartum cardiomyopathy with no residual ventricular dysfunction

  8. High risk • New York Heart Association (NYHA) class III or IV symptoms • Severe pulmonary hypertension • Marfan syndrome with aortic root or major valvar involvement • Severe aortic stenosis • History of peripartum cardiomyopathy with residual ventricular dysfunction.

  9. General outlines • Consider percutaneous surgical intervention • Optimizing loading conditions • Anticoagulation indications • Cardiac and Echo assessment every trimester • Aggressive control of exacerbating events • Replacing contraindicated medications

  10. General outlines • Admission in III trimester • Appropriate hemodynamic monitoring • Antibiotic prophylaxis • Senior anesthesiology staff to be involved • Plan for vaginal delivery • Careful consideration for indications for LSCS • Plan anesthesia (regional/GA) • Post operative care for 48-72 hrs in HDU

  11. Fetal effects of maternal cardiac disease • Increased incidence of IUGR and preterm delivery • Valvular stenoses and arrhythmias reduce uterine blood flow • Maternal drug effects • Respiratory distress syndrome • Intracerebral bleed • Fetal mortality 30% if mother NYHA IV • Increased morbidity if maternal age <20 or >35, maternal smoking, continued anticoagulants

  12. Risk stratification for pregnant women with valvular disease High risk of adverse maternal and fetal outcomes • Prior cardiac event or arrhythmia • New York Heart Association class > 2 or cyanosis • Systemic ventricular dysfunction (ejection fraction <40%) • Pulmonary hypertension (pulmonary arterial systolic pressure > 50% systemic pressure) • Left heart obstruction -Severe aortic stenosis (valve area < 1/cm2, Doppler jet velocity > 4m/s) -Symptomatic or severe mitral stenosis • Severe aortic or mitral regurgitation with NYHA class III or IV symptoms Low risk of adverse maternal and fetal outcomes • Asymptomatic mild to moderate stenosis or regurgitation • Regurgitation with normal left ventricular size and function. Adapted from Siu et al12, Reimold and Rutherford5, Bonow et al12.

  13. Mitral Stenosis • Physiological changeshigh LA pressures, dyspnea, worsening of NYHA status • Diuretics, β blockers, oxygen, bed rest, digoxin • Treat anemia, infection • Rh fever prophylaxis, anticoagulation for AF • Adverse mat outcome-MVA<1.5cm2, poor NYHA • Intractable class IV symptoms/ hemoptysis-PMBV/CMV

  14. CMV/OMC/MVR • Severe MS, no MR, no clot, favourable Block score(<10):CMV/PBMV • Predominant commissural fusion, minimal calcification,minimal deformity:OMC • PBMV:Immediate hemodynamic effects; x ray exposure can be minimised by TEE; best for favorable valve anatomy;minimal fetal loss;if done pre-conception pregnancy tolerated well

  15. Procedure for PBMV • Best in II trimester • Trans-septal route • R IJV, L FA, R FV cannulated • Mother’s abdomen and pelvis shielded • Contrast ventriculography avoided

  16. Management of CMV/OMC/MVR • Pre oxygenation and meticulous technique • Avoid aorto caval compression • Expeditious surgery and hemostasis • Continuous FHR monitoring • PCWP monitoring perioperatively • Pump flows to be increased 30-40% • Mild hypothermia • Elective post op ventilation, adequate analgesia, tocolytics to ensure fetal O2 delivery

  17. Mechanical/Bioprosthetic valve • Mechanical: Starr-Edwards, Bjork-Shiley, St.Jude • Low valve loss, re operation • High maternal thrombo embolism (10-15%) and death (40%) • Porcine:high valve degeneration, re operation; low /no anticoagulation

  18. Timing of Valve surgery • High maternal mortality if done immediate post partum • Fetal loss more (10-30%) with open surgery and in I trimester • Surgical intervention at any time medical condition indicates need

  19. Labor and Delivery in MS • Vaginal delivery preferred • Epidural analgesia with low dose bupivacaine or ropivacaine • Assisted delivery to shorten II stage • Hemodynamic monitoring for NYHA III/IV • Oxygen, uterine displacement • No need for fluid loading

  20. Anesthesia for LSCS • Obstetric/medical reasons • Slow HR; prevent tachycardia of laryngoscopy, intubation, suction, extubation • Prevent pain, hypercarbia, acidosis • Etomidate, opioid, β blockers at induction • Avoid oxytocin as bolus • Marked fluid shifts post partum • Post partum analgesia (morphine), oxygen, fluid balance

  21. Aortic Stenosis-pertinent facts • Usually congenital (Rh takes time) • Reported mortality 17% • Poorly tolerated;High blood volume, low SVR high transvalvar gradient, high LAP, reduced coronary perfusion,myocardial ischemia • Pre conceptual symptoms/ LV-AO >50mm Hg-termination • Severe hemodynamic compromise during pregnancy-Valvuloplasty/AVR/Ross procedure

  22. Goals of Management • Identify patients early • Regular assessment of cardiac status • Clearly written and dated management plans • Provision for emergency delivery • Stipulate involvement of senior staff • Regular revision of plans

  23. Assessment of AS • Echo – AVA better than pressure gradient • Pressure gradient exaggerated due to high flow • Critical AVA < 0.6 cm2 • Pressure gradient may fall if LV fails • Rapid deterioration if high risk factors presents

  24. Anesthetic Management • Severe symptoms- cardiac OT • Arrange defibrillator • Avoid Tachy/bradycardia • Maintain vascular volume, venous return • Avoid systemic hypotension • Treat arrhythmias • Transvalvar gradient>75mm-arterial line, PA catheter, TEE, CVP line • Supplemental oxygen • Remember CPR in gravid patient with AS is formidable

  25. Regional Anesthesia • Single shot spinal / epidural contraindicated • Titrated regional techniques acceptable • Incremental spinal anesthesia in use • Minimal volume loading • Use vasopressors-phenylephrine better • Prevent AO caval compression • Disadvantage – rapid onset of sympathetic block, decrease in preload • Hypotension and its treatment both deleterious • Risk of inadequate analgesia • Sudden clinical deterioration may require intubation

  26. General Anesthesia • Didactic protocols to be avoided • Is not without problems! • “Rapid sequence”tachycardia;untitrated induction agent hypotension • High dose opioid (fentanyl, alfentanil, remifentanil), etomidate most widely reported • Advantage of GA – no preload adjustment needed • Disadvantage- neonate depressed due to opioid • Post delivery – avoid oxytocin bolus • Nurse in HDU ; continue invasive monitoring

  27. Advantages of CSA • Hemodynamic stability • Quicker to perform than CSE • Faster onset • Quality of block equal or superior to epidural

  28. Indications for LSCS • Deterioration in cardiac/medical status • Obstetric reasons • Further deterioration expected with trial of labor

  29. Regurgitant Lesions (AR,MR) • Pregnancy tolerated well due to ↑ HR, ↓ SVR • MV repair beneficial before pregnancy • Isolated AR managed by vasodilators, ACE • AR with Marfan’s syndrome: risk of medial aortopathy ↑ in pregnancy • Maternal mortality – 30%, fetal 22% • Even if asymptomatic, need echo surveillance • Dilated AO root indicates high risk

  30. Other Facts abouts Marfan’s • 50% aortic dissections occur in pregnancy • Causes – wide pulse pressure, ↑SV • 50% offspring inherit disorder • Lifespan of mother shortened • Normal aortic root does not protect against dissections

  31. Anesthetic Goals • Minimize pain (↑SVR, ↑regurgitation) • Maintain normal / slight tachycardia • Maintain volume, contractility • Labor analgesia: epidural well tolerated • ↓ afterload, promotes forward flow • General anesthesia: ketamine, pancuronium, opioids, etomidate, remifentanil

  32. Pregnancy and Prosthetic Valves • Maternal complications: -thromboembolic phenomena -valve failure/degeneration -endocarditis • Fetal complications: -teratogenecity (Warfarin syndrome) -hemorrhage -death • Porcine heterografts best for young mothers • Heparin does not cross placenta: less safe for mother • Warfarin: safer for mother

  33. Pregnancy in patient with mechanical heart valve Higher Risk First-generation prosthesis (e.g., Starr-Edwards, Bjork-Shiley in the mitral position Lower Risk Second-generation prosthesis (e.g., St. Jude Medical, Medtronic-Hall) and any mechanical prothesis in the aortic position Coumadin to INR 3.0-4.5 for 36 weeks followed by IV heparin to APTT of > 2.5-3.5 SC or IV heparin-APTT 2.5-3.5 for 12 weeks, Coumadin (INR 3.0-4.5) to 36th week IV heparin (APTT>2.5 SC heparin (APTT 2.0-3.0) for 12 weeks, Coumadin (INR 2.5-3.0) to 36th week SC heparin (APTT2.0-3.0) SC heparin (APTT 2.0-3.0) throughout pregnancy Recommendations for anticoagulation in women with mechanical prosthetic heart valve during pregnancy.

  34. Primary pulmonary hypertension (PPH) • PPH and pregnancy are a lethal combination • Counseling / termination in I trimester • Vital to admit early, joint consultation • Mortality 50% for vaginal delivery,100% for LSCS • RV CO critical;avoid↑ in PAP, PVR • Maintain RV preload, RV + LV contractility

  35. Regional Anesthesia in PPH • Epidural anesthesia reported (Smedstad, 1994, CJA) • Epidural ropivacaine (Olofsson, 2001) • Intrathecal sufentanil also used • Vaginal delivery preferred • Monitoring –admit in HDU, radial artery, PA catheterization

  36. Problems with PA catheter • PADP does not reflect PCWP/LAP • Impossible to wedge catheter • Risk of PA rupture • Severe TR makes CO, SVR, PVR inaccurate • However recent texts advocate PA cath • TEE more useful as empty LV with high PAP requires different mgement (volume)

  37. Measures to reduce PAP • Nitroglycerin infusion • Prostacyclin 2-5 ng/kg/min (can be aerosolized) • SNP-hypotension,cyanide toxicity • Ca channel blockers • Inhaled NO

  38. Indications for LSCS • Medical reasons • Worsening clinical condition • Obstetric reasons • GA-Alfentanil, fentanyl, etomidate

  39. Eisenmenger syndrome • Vasodilation of pregnancy ↑cyanosis • Maternal mortality 30-40% • Causes: embolism, arrhythmia, RV overload, MI, acute↓ in SVR • Early pregnancy-termination • Multidisciplinary approach • Anticoagulation recommended

  40. Goals of management • Maintain CO • Invasive hemodynamic monitoring • PCWP may not reflect LAP • Pulm vasculature less responsive to vasodilators than PPH • Bio impedance CO monitoring used with regional analgesia

  41. Anesthetic techniques for LSCS • The majority require operative delivery • GA: IPPV, V/Q mismatch,↑PAP, myocardial depression,dysrhythmias,inadequate pain control • Choice of agents-as in PPH • Epidural analgesia- (Ghai etal Int J Obst Anesth 2002) • Incremental spinal anesthesia(Cole, BJA 2001)

  42. Post partum Management • Slow or no oxytocin • Uterine massage • Ephedrine not desirable • Phenylephrine, norepinephrine preferred • Monitoring for 72 hrs in HDU • 80% mortality occurs in 1st 24 hours

  43. Congenital Heart Disease • Maternal and fetal outcome in pregnancy is affected by a) Functional status: NYHA III/IV account for 85% of all deaths Significant cardiac complications in 30% Sudden profound deterioration b) anatomic diagnosis

  44. b)Anatomic diagnosis • PDA, small ASD/VSD tolerate pregnancy well • Uncorrected coarctation-3% maternal mortality • Uncorrected large ASD/VSD-55% maternal mortality • Marfan syndrome- aortic dissection • Uncorrected TOF-3-5% mortality, 30% fetal death

  45. Other determinants • High PA pressures • Hb>20g% • SpO2 <80% • Recurrent syncope

  46. Principles of management • Multidisciplinary approach • Rest, antenatal visits • Aggressive tt of CHF, dysrhythmia, anemia, infection • Specific monitoring for lesion • Aim for vaginal delivery • Good analgesia with epidural/opioid infusion • Incremental epidural analgesia with opioids favored

  47. Special precautions for septal defects • De airing of fluid lines • Use saline for LOR technique • Antibiotic prophylaxis • Supplemental oxygen www.anaesthesia.co.inanaesthesia.co.in@gmail.com

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