anaesthesia for pregnant patients with Mitral stenosis posted for LSCS

1. Pregnancy with mitral stenosis-case discussion
1
Dr Swastika Swaro
Professor
Department of Anaesthesiology
IMS&SUM Hospital
Bhubaneswar

2. 2
Patient details
Name: Mrs. X
Age: 27 years
Sex: female
G1P1L0A0 with 37 weeks gestation
Chief complaints
Patient is admitted with chief complaints of
1. Breathlessness since 10 days
2. Fatigue since 7days

3. History of Presenting Illness
• Breathlessness-gradual onset,aggravated on lying down,relieving on
sitting , progressive,since 10 days
• Feeling of weakness since 7days
• No history of Cough, haemoptysis,Palpitation,Leg
Swelling,chestpain
3

4. • History of past illness
• History of Rheumatic Heart Disease since 10 years of age.
Took treatment in the form of Penicillin injections every 21 days
for 10 years till age 20 and then discontinued.
• No history of HTN,DM, TB, Bronchial Asthma or Epilepsy
Family History-Nothing suggestive
Personal history-
• Housewife,poorsocioeconomic status
• Bowel & Bladder: Normal.
• Sleep: disturbed
• Habits: No addiction
4

5. General examination
• Alert, concious and co-operative
• Build-average
• Weight – 58 Kgs
• Height – 155 cms
• Pallor-mild
• Icterus- absent
• Cyanosis-absent
• Clubbing-absent
• Facies-normal
• Spine-normal.
5

6. • Pulse rate – 90/min,regular,good volume,no
radiofemoral delay,arterial wall normal
• Blood pressure – 110/70 mm of Hg;left arm,supine
• Respiratory rate – 16/min;thoracoabdominal
• Temperature-98.6F,Rt axilla
6

7. 7
•
Cardiovascular examination
Inspection – no deformity.
•
•
•
Palpation –
ApexbeaT-left 5thICS ½ inch medial to left
MCL.
Tapping
Diastolic thrill -in mitral area,best felt in left
lateral position at end of expiration.
Auscultation– S1-short,sharp,accentuated
S2-Heard
P2-Loud

8. -Opening snap heard just after S2
-Low pitched mid diastolic rumbling
murmur
.with presystolic accentuation in the
mitral area .without any radiation.
.Best heard with the bell of the
stethoscope,
. left lateral position
.at height of expiration and mild exercise.
8

9. Respiratory system
Normal Vesicular Breath Sounds heard, No added
sounds.
Examinationof nervous system
9
Higher function intact
Power-normal in all 4 limbs
Deep tendon reflexes-normal.
Examination of cranial nerves-normal.
Abdominal examination
Abdomen-soft,36wk of fundal height
-umbilicus-central position
-No visible veins
-no other palpable lump
-fluid shift-absent.
-peristaltic sound-present

10. Airwayexamination:
10
Mouth opening-3 fingers.
No loose tooth/artificial denture.
Mallampati- grade II.
Thyromental distance-6 fingers.
Neck movement-within normal limits.

11. Provisional diagnosis
11
Mitral stenosis of rheumatic origin
without any evidence of congestive
heart failure and in sinus rhythm in
a primi para term mother posted for
LSCS.

12. Investigations
• Hb: 12.0 gm%
• Differential count: Neutrophils – 71
• Lymphocytes – 24
• Monocytes – 02
• Eosinophils – 03
• Total count – 9, 800
• Platelets: 2.73 lakhs/ mm3
• PT INR: 1.0
• BT: 3’ 00”
• CT: 4’ 00” 12
RBS: 99 mg/dl
Urea: 30 mg/dl
Creatinine: 1.1 mg/dl
Na+: 135mEq/l K+:
4.8mEq/l Cl-: 104mEq/l
HIV 1 & 2: Not detected
HBsAg,HCV: Not detected

13. 13
ECG: Within normal limits, Sinus rhythm,Heart rate: 80/min
2D ECHOCARDIOGRAPHY: Normal Left Ventricular systolic
function
No Regional Wall Motion abnormalities
Ejection fraction: 56 %
Mitral Valve Area – 2.0 cms2 Transvalvular
Pressure – 6 mm of Hg.
Chest X – Ray: Prominent bronchovascular markings.
Management plan Regional anaesthesia for elective LSCS

14. Mitral stenosis at a
glance
14

15. Severity grading of MS
15
Measurement Normal Mild Moderate Severe
Mitral valve area
(cm2)
4.0–6.0 1.5–2.5 1.0–1.5 <1.0
Mean pressure
gradient (mmHg)
<2 2–6 6–12 >12
Pulmonary artery
mean pressure
(mmHg)
10–20 <30 30–50 >50

16. Clinical assessment of severity
16
1.Assessing the A2 - OS gap.
2.Assessing the severity of PAH.
3.duration of the diastolic murmur.
A2-os >120ms
100-120ms
80-100 ms
<80 ms

17. Diagnosis
17
X-Ray (P-A View)
1. Left Atrial Enlargement – Mitralisation of heart
2. Straightening of Left Heart Border
3. Elevation of Left mainstem Bronchus
4. Evidence of Mitral Calcification, Evidence of
pulm.edema, Pulmonary Vascular Congestion.
5. Kerley’s Blines
Kerleys
B lines
LAA: Left atrial appendages, MPA: Main
pulmonary artery, LPA: left pulmonary artery,
RPA: Right pulmonary artery, Ao- Aortic
knuckle (Ao)

18. 18
Kerleys Bline

19. ECG
• In sinus rhythm large biphasic(broad notched) P waves( P mitrale)
indicative of left atrial enlargement, especially in lead I & II
• RVH
• atrial fibrillation (Fibrillary waves)
19

20. ECHO
• 2DEchocardiography
• the area of the mitral valve,
• size of the left atrium,
• presence of thrombus and
• the size and function of the left ventricle
• right-sided chambers.
• Doppler
• the severity of the stenosis,
• the presence of other associated valve lesions
• the degree of pulmonary hypertension

21. 21

22. 22

23. MANAGEMENT
23
MEDICAL
DIURETICS, β-
BLOCKERS
AF- DIGOXIN,
ANTI- COAGULANTS
SURGICAL
VALVULOPLASTY
VALVE
REPLACEMENT
OBSTETRICAL
VAGINAL
CAESAREAN
SECTION

24. Treatment
24
1. Mild Mitral stenosis
-Rest,oxygen
– Diuretics(Furesamide)
-Salt-restricted diet
-B blockers-propranolol,atenolol(decreases incidence of
pulmonary edema without foetal adverse effect) Kannan M,
Vijayanand G. Mitral stenosis and pregnancy: Current concepts in anaesthetic practice.
Indian J Anaesth2010;54:439-44.
2. When in Atrial Fibrillation – Digoxin (0.25 mg tablet)
-β- Blockers
-Cardioversion(if pharmacological T/M fails)
-Anticoagulation –prevent systemic

25. 25
4. Percutaneous balloon valvuloplasty,Surgical commisurotomy Valve
reconstruction- if dyspnoea or Pulmonary hypertension develops
-done in second trimester
5.Valve replacement -severeMS with calcified valve,mural thrombus
6. Endocarditis prophylaxis –Only if h/o endocarditis or presence of any
infection
IV Ampicilline and gentamicin or oral Amoxicilline
If allergy-Vancomycin and gentamicin

26. 26

27. Anticoagulation
27
Indication
-Patient with AF(> 48 hrs)
-Prior embolic event
-SevereMS with LAdimension 55 mm on ECHO
Heparin SC/IV- 12 wks(APTT=1.5 to 2.5 times of normal)
Warfarin -12-36 weeks(INR 2.5 to 3 times)
heparin -After 36wks ( titrated to APTT)
LMWH -alternative to heparin
long half life(once daily dosing)
more bioavailability

28. Heparin
• Discontinue at start of labour
• Restart after 4-6 hrs if no contraindications
• If labor occurs PRETERM when patient is on anticoagulants-
LSCS done with reducing INR to 2
avoid vaginal delivery-risk of Foetal intracranial bleeding
28

29. PREGNANCY
29
↓ LA
emptying
INCREASE
HR
↓ LV
Filling
DECREASE
SV
DECREASE
CO
Fixed CO state; Heart cannot
cope up with increased
demand.
AUTOTRANSFUSION from
uterus
DELIVERY
PULMONARY
CONGESTION
Long-
standing
Irreversible
chronic
Pulmonary
Hypertension
LA Dilates
↑LA
pressure
At
DIASTOLE
Pressure
gradient
develop
between LA
andLV
HAEMODYNAMIC
hallmark of MS
MS

30. Why does pregnancy aggravate
30
the symptoms of mitral stenosis?
-↓in SVR 20%-reflex tachycardia
-↑HR 15-25%– reduced diastolic filling time of LV
-↑ CO by 30-50%-↑ transvalvular gradient→ ↑LA pressure
-↑ blood volume by 30- 50% → ↑ capillary-Hydrostatic
pressure → pulmonary edema.
-During labour and delivery→sympathetic stimulation- ↑ HR
and CO
-Sudden ↑↑ venous return due to autotransfusion and IVC
decompression
-LA enlargement in pregnancy– atrialfibrilation
-Hypercoagulability→thromboembolic

31. Predictors of mortality and morbidity
31
Severe- 67%
Moderate- 38%
Mild- 26%
Severity of MS NYHA Class
Class I and II- <1%
Class III and IV- Between 5 and 15%
Class III and IV- Perinatal mortality- 20-
30%

32. Anaesthetic management
• Multidisciplinary approach with
involvement of
obstetrician,cardiologist,anaesthesist
• Detailed counselling of patient nd her
family
32

33. Anaesthetic goals
1.Maintenance of acceptable HR(60-70bpm)
2.Maintain sinus rhythm(immediate treat if acute AF)
3.Maintain SVR(AVOID rapid fall)
4.Maintain adequate preload/Venous return
5.Avoid aortocaval compression
6.Avoid pain,hypoxia,hypercarbia,acidosis(↑PVR)
33

35. Obstetric management
35
VAGINALDELIVERY
• Tachycardia secondary to
labour pain, increases
flow across the mitral
Valve producingSudden
• The second stage of delivery should be cut short by
instrumentation.
• leftuterine displacement
• Supplemental oxygen , pulseoximetry monitoring
fetal heart rate monitoring
• Invasive cardiac monitoring-radial artery
cannulation&
pulmonary catheter- especially in NYHA III and IV Pt
• Sudden↓SVR-small bolus doses of phenylephrine,
with volume expansion when necessary.
rises in LApressure, leading
toacute pulmonary oedema.
Good LABOUR
ANALGESIA is must.
Epidural CSE(intrathecalopid
withmodestdoseLA)

36. •Anaesthesia for LSCS
36
• Evidence-based data on the ideal anesthetic and
analgesic for theparturints with MS is lacking.
Management must be individualized
to optimize patient outcome.
• The degree of monitoring should be based on the
severity of the disease and the parturient condition.
severe MS needs invasive monitoring

37. 37

38. 38
Caesarean
section
Epidural/Spinal
Combined Spinal
Epidural
General
Anaesthesia
Only for obstetric
reasons
• slow induction, delay in the
onset of action- not be possible in
an emergency situation.
• large volume of local anesthetic
is needed for adequate blockade.
rapid onset of extensive
sympathetic blockade with intense
vasodilatation, sudden
hypotension
Technique of choice. CSE
offers rapid onset and
improved analgesia

39. EPIDURAL ANAESTHESIA
39

40. 40
-The segmental blockade sparesthe lower extremity “muscle pump,” aiding
in venous return, and also decreases the incidence of thromboembolic
events.
• Maternal haemodynamic stability maintained by-
Invasive haemodynamic monitoring,
judicious intravenous administration of crystalloid
administration of small bolus doses of phenylephrine
• major advantages
-administered in incremental doses and the total dose could be
titrated to desired sensory level.
-Slower onset of anaesthesia

41. Phenylephrine induced vasoconstriction
of placental vessel is not
clinically significant because of large
vascular reserve in a
Normal placenta.
Moran DH, Perillo M, La Porta RF, et al. Phenylephrine in the
prevention of hypotension following spinal anesthesia for cesarean
deliery. J Clin Anesth 1991;3(4):301–305 .
41

42. • Anesthetic management of cesarean section in parturients
with severe mitral stenosis: A case series
• Saxena, et al.: Epidural analgesia for parturiients with severe MS for CS© 2019 Journal of Obstetric
Anaesthesia and Critical Care | Published by Wolters Kluwer – Medknow
• The use of graded epidural for cesarean delivery in parturients
with severe MS is safe for both the mother and the baby
• They used 10-14 ml of 2% xylocaine with adrenaline after a test
dose of 3ml nd a level of T6 achieved in 15 -20 mins
Regional anaesthesia in severe MS is still controversial?
better general anaesthesia
42

43. 43
Combined spinal-epidural

44. 44
20-30 microgm of fentanyl along with 2.5 -5mg of 0.5% bupivacaine intrathecal is
given. epidural catheter 3 ml of 2% xylocaine with epinephrine is given.
• POST OPERATIVE ANALGESIA is maintained as shown in the table below
INITIAL INJECTION
10-15 ML OF 0.25%-0.125% SOLUTION
CONTINUOUS INFUSION
0.0625%-0.125% SOLUTION AT 6-8ML/HR
10-15 ML OF 0.1%-0.2% SOLUTION
1-2 microgm/ml of LA solution
0.1-0.2% SOLUTION AT 8-15 ML/HR
DRUG
• BUPIVACAINE
ML/HR
• ROPIVACAINE
• FENTANYL

45. Ghai B, Krishnamoorthy R, Bansal D, Suri V, Vijayvergiya R, Wig J. Efficacy and safety of combined
spinal: Epidural versus combinedspinalepidural technique for labor analgesia in parturients with
rheumatic valvular heart disease. Indian J Pain 2013;27:80-5
45
Both epidural and CSE are equally effective and safe for labor analgesia in
parturients with rheumatic valvular heart disease. However, CSE technique
provides a faster onset of analgesia.

46. 46

47. Advantages
• Speedof induction
• Control of the airway
• superior hemodynamics
• High fio2 -which will reduce PVR
• Ventilation controlled – avoid hypoxia and hypercarbia-increase
PVR
• Elective post operative ventilation to tide over the CCF that may
be possible after parturition 47

48. Complications of GA
• Neonatal depression
• Delayed recovery
• Anaesthetic drug interactions
• Increased incidence of PONV
• Prolonged stay ICU
• Aspiration( more common in
unprepared cases)
48
• Risk of pulmonary
hypertension is more due to
PPV
• Arrhythmia- inhalational
agents
• Useof poly pharmacy and
anaphylaxis
• Uterine atony with inhalation
• Need for adequate post
operative Analgesia

49. Intra-op monitoring
• ECG
• pulse oxymetry
• Capnography
• NIBP and CVP - mild to moderate cases
• intra-arterial BP,PA catheterization-In moderate/Severe MS
• Temperature
49

50. Coduct of general anaesthesia
• Premedication
• Aspiration prophylaxis
• Sedative/anxiolytics-so judicious use of BZD & opioid
• Avoid atropine. Glycopyrrolate may be used.
• Infective endocarditis prophylaxis if needed
50

51. •Induction
• beta-adrenergic antagonist and an adequate dose of opioid-
before induction
• Esmolol -rapid onset and short duration of action,
better in controlling tachycardia.
- foetal heart rate should bemonitored.
• opoids (Remifentanil or fentanyl )
-abolish hemadynamic response to intubation
-also decreases requirement of induction agents
• Induction agent to be given slowly in titrated doses, etomidate is
best agent for hemodynamic stability.AVOID KETAMINE ×
51

52. • Maintenance
• Volatile anesthetics- isoflurane, desflurane, or sevoflurane(<1 MAC)
with muscle relaxant and added dose of fentanyl if reqd
• Halothane avoided due to arrythmogenic potential
• N2O is best avoided in pt with pulmonary artery hypertension.
52

53. • Muscle relaxant
• Vecuronium/Cisatracurium are NDMR of choice - least effect on HR.
• Pancuronium avoided ×-causes tachycardia due to vagolytic effect.
• Atracurium may ↓BP secondary to histamine release and reflex ↑HR
• Succinylcholine can be used.
53

54. • To maintain BP & HR -
• Titrated doses of vasopressor like phenylephrine - maintain BP
• Short acting β-blocker (esmolol or metoprolol) or CCB (diltiazem) to
control HR.
• To prevent increase in PVR-
• Avoid- hypoxia, hypercarbia,acidosis, lighter plane of anesthesia,
hypervolemia.
• If PVR critically elevated→ NTG, SNP, amnirone, prostaglandin E1,
tolazoline
54

55. Peri-operative AF
• Control of AF with rapid ventricular response- metoprolol, esmolol,
diltiazem, amiodarone.
• If pt is unstable immediate cardioversion
• In case of acute AF no need to anticoagulate but if it is present for
more than 48 hr STAT anticoagulation prior to cardioversion.
55

56. 56
Fluid Management:
• Avoid Hypervolemia - -> Worsens pulmonary edema
• Avoid Hypovolemia - -> further ↓left ventricular filling ↓CO.
( Hypovolemia secondary to blood loss to be repalced)
Uterotonic agents
• oxytocin 10–20 u in 1,000 ml of crystalloid @ rate of 40– 80 mu/min.
lower the SVR as well as elevate PVR
• Methylergometrine or 15-methylprostaglandin F2 → ↑BP,HR, PVR
Extubation-avoid tachycardia

57. Post-operatively
 Avoid pain → hypoventilation→respiratory acidosis,
hypoxemia → ↑ HR and PVR
 24 hrs Monitoring-immediate Postpartum periods are at
high risk of PCWP↑especially in SevereMS(NYHAclass
IIIandIV).
 The lowest possible dose of uterotonic agent-
significant adverse Cardiovasculareffects.
 May need ionotropic support or ventilatory support 57

58. Our institutional practice
• Mild MS-EPIDURAL/CSE(in emergency CSE better for faster onset)
• Moderate MS-EPIDURAL/GA
• Severe MS-GA
58

59. References
59
Miller’s Anaesthesia,
7th Edition, Vol 1
Morgan’s Clinical
Anaesthesiolo
gy
Kaplan’sCardiac
Anesthesia

60. 60