Physiology of pregnancy/ Epidemiology of Cardiac Problems in Pregnancy/ Diagnosis/ Management/ Anesthesia consideration in Cardiac & Non-cardiac Operations during pregnancy
2. Introduction
• Pregnancy in CVD patients is becoming more common: 1-
3% of pregnancies
• CVD is the leading cause of maternal mortality in the
developed world
• Iran: postpartum hemorrhage, infection emboli, stroke
• The main causes of cardiac death in pregnancy are
acquired heart disease: MI, aortic dissection, and
cardiomyopathy
• In developing world most frequent CVD is: RHD
• Pulmonary hypertension Mortality: 50%
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3. Non-cardiac operations
General concerns
• None of currently used anesthetics is teratogen in
any gestational age
• ?BZD, ?N2O, ?tramadol
• Fetal heart rate (FHR) for maternal positioning,
cardiopulmonary management, and decision for
delivery
• The best time for non-urgent surgery is later in 2nd
trimester
• Prophylactic tocolytic in 3rd trimester (intra
abdominal Sx increases the risk of preterm labor/
abortion): Mg, Beta+, TNG, PG-, Oxytocin-
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4. Non-cardiac operations
Statistics
• Incidence 1% in all pregnancies
• Most common:
- Appendicitis (1:2000)
- Cholecystitis (1:1250)
- Others (bowel obstruction, trauma, malignancies)
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8. ↑CO during delivery is due to ↑ autotransfusion
Hemodynamic determinants In patients with cardiovascular disease:
underlying cardiac pathology; gestational age; anesthetic agents; intravascular
fluid status; positioning of the patient; and the route, dose, and choice of
uterotonic agents
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13. Anesthesia & Pregnancy
• Non-cardiac operations
- Delivery and C-section
- Other non-cardiac
• Cardiac operations
• Fetal operations
• CPR in pregnancy
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14. Uteroplacental perfusion
Fetal oxygenation
Most important risk in surgery is fetal hypoxia
• Maternal oxygenation
• Maternal CO2 tension
• Uterine blood flow
Monitoring
• FHR (18-22 weeks)
• HR variability (> 25 weeks)
• Cardiotocography (CTG) in 3rd trimester
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15. high maternal or fetal risk
Congenital and genetic heart disease
Prior Fontan procedure
Severe pulmonary arterial hypertension
Cyanotic congenital heart disease
Complex CHD with sequelae: heart failure, valve disease, or the need for
anticoagulation
CHD with malignant arrhythmias
Marfan syndrome
Valvular heart disease
●Severe AS (valve area <1 cm2, mean gradient >40 mmHg) with or without symptoms
●MS with NYHA class II to IV symptoms
●AI or MR with NYHA class III to IV symptoms
●Aortic and/or mitral valve disease with severe LV dysfunction (LVEF <40%)
or severe pulmonary hypertension (PAP >75 % of systemic pressure)
●Mechanical prosthetic valve
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16. Prepartum anesthesia consultation
The majority of pregnant women with cardiovascular disease have
favorable outcomes
• Review of the patient's cardiovascular lesions prior reparative
procedures
• Pertinent cardiac testing to determine disorders that may impact
peripartum care
• In high-risk cases, the decision regarding transfer to a tertiary care
center
• plans for obstetric complications such as the need for emergency
cesarean delivery or postpartum hemorrhage, as well as plans for
cardiopulmonary complications
• When mother’s condition is tenuous or potentially terminal,
document the patient's resuscitative wishes in the event of
cardiopulmonary arrest
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17. Obstetric issues
• Induction vs Spontaneous labor (in high risk)
• Appropriate maternal monitoring devices
• Intravascular access
• Preparations for analgesia and anesthesia
(epidural catheter)
• semi recumbent position in women with
significant cardiovascular disease
• Lateral tilt during the intrapartum period
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18. Route of delivery
Vaginal delivery is generally preferred unless there is an obstetric
indication for cesarean delivery.
Neuraxial analgesia is generally required In high-risk cardiac patients
Cesarean delivery is rarely performed solely for a maternal cardiac
indication. Exceptions:
• Aortopathy (eg, aortic dissection, dilated aorta >4.5 cm, or
progressive aortic enlargement during gestation (the risk of aortic
dissection)
• Severe pulmonary hypertension or Eisenmenger syndrome (risk of
RHF & cardiogenic sock)
• Severe peripartum cardiomyopathy or LV dysfunction
• ? Class IV
• Maternal warfarin therapy (fetal intracranial hemorrhage)
• Vaginal cardiac delivery (no Valsalva maneuver)
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20. Monitoring
• Pulse oximetry especially for patients with cyanotic congenital heart disease or
right-to-left vascular shunting.
• ECG Telemetry for patients at increased risk of developing arrhythmias and a five-
lead monitor with computerized ST-segment trending capability in patients at risk
for myocardial ischemia.
• External defibrillator pads in patients with a history of poorly-tolerated
tachyarrhythmias.
• Intra-arterial catheter prior to induction of either regional or general anesthesia
for cesarian delivery in high-risk patients and in laboring patients with
hemodynamic instability
• Temperature
• Peripheral nerve stimulator
• Blood sugar
• Capnography
• CVP line
• PA catheter
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21. Neuraxial approach
• Excellent analgesia is provided.
• Continuous infusion of local anesthetic and opioid in
the epidural catheter may be titrated to meet the
needs of the patient as labor progresses. Dense
analgesia can be achieved, thus minimizing
catecholamine release.
• A passive second stage of labor is possible because the
urge to push is diminished. (Vaginal cardiac delivery)
• Urgent cesarean delivery: a surgical block can be
established with minimal hemodynamic changes by
"dosing up" the epidural catheter with more
concentrated local anesthetic
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22. Neuraxial approach
for labor
• Labor analgesia with epidural or combined spinal–epidural (CSE)
results in a beneficial decrease in sympathetic stimulation.
• For CSE, fentanyl 15 to 25 mcg intrathecal with minimal
hemodynamic effect and faster onset of analgesia compared with
an epidural technique alone (eg, for a patient in active labor with
severe pain).
• If intrathecal local anesthetic is added for CSE (eg, for a multiparous
patient rapidly progressing into the second stage of labor), a
reasonable intrathecal dose is 1.5 to 2.5 mg of isobaric bupivacaine.
• For the labor epidural, we use a continuous infusion of 0.04 to
0.125% bupivacaine with 1 to 2 mcg/mL of fentanyl, administered
at a rate of 6 to 12 mL/hour.
• No Epinephrine in high risk CVD
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23. Neuraxial approach
for cesarian
In a hemodynamically stable, well-hydrated woman, a
low-dose CSE is preferable to epidural alone:
• We administer 3 mg isobaric bupivacaine with 15
mcg fentanyl and 0.15 mg preservative-
free morphine (or 50 to 100 mcg hydromorphone) into
the intrathecal space.
• Subsequently, very slow injection of epidural catheter
with a local anesthetic without epinephrine (eg, 3 to 5
mL of 2% lidocaine every five minutes) to achieve a T6
level
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24. General anesthesia
• Preoxygenation with 100 percent oxygen and a rapid sequence
intubation
• In high-risk cardiovascular for maintaining hemodynamic stability the
induction should proceed slowly
• Airway management in pregnancy
• The value of cricoid pressure is debatable/ Antacid/H2 blocker
• Induction: Short-acting hypnotic (eg, etomidate [0.2 to
0.3 mg/kg], ketamine [1 to 2.5 mg/kg], or propofol [1.5 to
2.5 mg/kg, in divided doses, titrated to effect])
• Phenylephrine boluses [50 to 100 mcg] or phenylephrine infusion [0.1
to 2 mcg/kg/minute]
• Succinylcholine 1 to 1.5 mg/kg for paralysis
• Ketamine should be avoided in preeclamptic patients because of the
sympathetic stimulation
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25. General anesthesia
In mother with CVD, Maternal hemodynamic stability is the priority:
• Preinduction treatment with lidocaine (50 to 100 mg) and narcotic
agents (eg, fentanyl, 1 to 2 mcg/kg) is typically avoided in cesarean
delivery
• In cardiovascular disease administration of these agents blunts the
sympathetic response to laryngoscopy and intubation
• Sevoflurane or desflurane at approximately 1 minimum alveolar
concentration (MAC)
• Nitrous oxide (N2O) is avoided in patients with elevated pulmonary
artery pressures and in patients with intracardiac shunts
• phenylephrine infusion (0.1 to 2 mcg/kg/minute), phenylephrine
boluses (40 to 100 mcg), or ephedrine boluses (5 to 20 mg) are options
to maintain BP as close to baseline as possible
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26. Antibiotic prophylaxis
• Antibiotic prophylaxis is not routine
• AHA guidelines does not recommend routine
endocarditis prophylaxis for C-section or
uncomplicated vaginal delivery
• Some centers do administer in women with
structural heart disease
• Most useful: mechanical/ bio valve, Hx of IE, TF, TGA
• Mod. Risk: HCM, valvular dysfunction, ASD, VSD, PDA
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27. Cardiac surgery
Time of major cardiac stress: 2nd & 3rd trimester
Indications
Severe valvular disease
Aortic aneurism
Aortic dissection
Severe congenital anomaly
Pulmonary thromboembolism
Severe coronary artery disease
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28. Cardiac surgery
Maternal risk factors
Hx of TIA, stroke, arrhythmia
NYHA FC III or IV
Lt heart obstruction:
- Mitral <2
- Aorta <1.5
- Peak gradient >30
LVEF <40%
Predictors of neonatal
complications
NYHA FC III & IV
Anticoagulation during
pregnancy
Smoking
Multiple gestation
Left heart Obstruction
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29. Fetal protection during CPB
• High pump flow rate >2.5 L/min/m2
• High perfusion pressure >70 mmHg
• Maternal hematocrit around 28%
• Limit hypothermia to 32°C
• Monitoring uterine tone & FHR
• Minimum CPB time
• Pulsatile perfusion
• Optimum acid-base, glucose, PaO2, PaCO2
• Alpha stat pH management
• ?corticosteroid
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31. Fetal surgery
Should be considered as transplantation surgery
Indications
Hydronephrosis
Hydrocephalus
Sacrococcygeal teratoma
Meningomyelocele
Diaphragmatic hernia
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32. CPR in pregnancy
• First priority is resuscitation of mother
• Left lateral tilt 15-30°
• Defibrilation is similar to non-pregnant patient.
No significant shock is delivered to fetus
• Remove CTG leads prior to defibrilation
Perimortem CS
• CS after CPR
• To be done within 4-6 minutes
• No chance of complete survival after 30 minutes
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36. Post-dural puncture headache
Introduction
The most common complication of regional anesthesia
• With pencil-point needles since 2 decades ago it is
more common in epidurals with inadvertent dural
puncture
• Incidence 1%, in US with 60% epidural labor with 50-
80% risk of PDPH the number is 20000-50000/year
• PDPH syndrome is in deed severe and often more long-
lasting, with some potentially life-threatening
complications (cerebral hemorrhage)
• the only clearly effective treatment being the epidural
blood patch
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37. Post-dural puncture headache
diagnosis
• Headache after childbirth is extremely common, occurring in 30%
• Causes: lack of sleep, caffeine withdrawal, tension, or migraine headaches
• Within 72 h after meningeal puncture in 90% of patients
• Typically worsening within 20 s of standing or sitting and resolving within
20 s of recumbency
• headache as self-limited, resolving within 14 days (usually less than a
week)
• Usually dull in nature and frontal in location (75% of the time), but
occipital pain also occurs which may, or may not, radiate into the neck and
shoulder area
• Associated symptoms occur in more than half of patients and include
nausea, tinnitus, vertigo, and photophobia
• These headaches can be severe and debilitating
• Age of the patient, size and type of the needle and direction of insertion
are risk factors
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39. Post-dural puncture headache
Management
• Lying down, supine position
• Methylxanthine derivatives, including caffeine or
theophylline (blocking adenosine receptors, which results
in cerebral vasoconstriction)
• IV or oral Caffeine (300–500 mg) once or twice daily, cup of
coffee contains 50–100 mg
• Fluids
• gabapentin (300 or 400 mg) administered to patients with
documented PDPH, every 8 h for 4 days
• ?Sumatriptan and other “triptans”/ ACTH/ Hydrocortisone
• Epidural blood patch
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40. FAQ
• Can general anesthesia in the first trimester
of pregnancy cause a birth defect?
There have been at least 5 studies that have
looked at the risk for birth defects in women
who had surgery and anesthesia in the first
and early second trimester of pregnancy.
None of the studies showed an increased risk
for birth defects
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41. FAQ
• Can exposure to anesthesia from a surgery
cause a miscarriage?
A review of the same 5 studies suggests there
may be a small increase in miscarriage in
women who had surgery in the first half of
pregnancy. However, it is unclear whether the
anesthesia, the reason for the surgery, or an
illness in the mother impacted the pregnancy
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42. FAQ
• I work in an office that uses general
anesthesia. Would that affect the baby?
Larger facilities, such as hospital operating
rooms, generally have ventilation systems that
lead to minimal exposures. While there were
early studies that suggested that exposure to
inhaled anesthetic gases, particularly to
nitrous oxide, could lead to an increase in
miscarriage, later studies did not confirm this
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NO
43. FAQ
• I am breastfeeding and need to have
anesthesia for a procedure. Can I continue to
breastfeed?
Yes. Most anesthetic medications are removed
from the body quickly. Although there are few
studies looking at breastfeeding after a
procedure, most experts suggest that
breastfeeding can be restarted as soon as the
mother recovers from the anesthesia and is
feeling well enough to breastfeed
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YES
44. FAQ
• Can neuraxial anesthesia cause low back pain
and/ or peripheral neuropathy?
Pregnancy induced low back pain rate
approaches 60%
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45. FAQ
• Can general anesthesia cause cognitive
dysfunction?
YES
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46. FAQ
• Does anesthesia related cognitive
dysfunction have permanent effects?
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