Anesthetic Management of Delivery in Women With Pregnancy[1]

8/12/2019 Anesthetic Management of Delivery in Women With Pregnancy[1]

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Anesthetic management of

delivery in women withpregnancy associated

myocardiopathyBy Dr. Schwartz Andrei, MD senior lecturer

Ben Gurion University of the Negev

Faculty of Health Sciences.Soroka Medical Center Division of Anesthesiology

and Critical Care.Beer Sheva. Israel


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Introduction

Heart disease is now the second commonest cause ofmaternal death in the U.K. ( 1 )

Death from cardiomyopathy accounts for rising proportionof maternal death .

The situation is mirrored in USA where cardiomyopathycausing 7.7 % of pregnancy related death.

In 1991 1997, 70% of death were due to peripartum

cardiomyopathy.

There are two main types of cardiomyopathy,

dilated ( PPCM), and hypertrophic ( HOCM) .


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A . Dilated peripartum cardiomyopathy ( PPCM)

1. Diagnostic criteria for PPCM

congestive heart failure developed in last month ofpregnancy or first five months post partum, in a womenwith no history of cardiac disease, with no identificable

cause.

impared left ventricular function on echocardiography

ejection fraction of less than 65 %

end diastolic dimension of greater than 2.7 cm /m2

body surface area


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2. Epidemiology

Elkayam and Et Al ( 8 ) described an identicalclinical condition that apperead earlier inpregnancy at 17 36 weks of gestation and didnot differ clinically from women with the usual

presentation of PPCM.

Is a rare form of cardiomyopathy.

Recent raports suggest an estimated incidence of

one case per 299 livebirth in Haiti, one case per1000 livebirth in South Africa and one case per2800 to 4000 livebirth in USA. ( 4 )


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Risk factors associated with PPCM have included :

advanced age gravidity

african origine

toxaemia or hypertension of pregnancy use of tocolitics

twin pregnancy (4)


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3. Aetiology

The cause and mechanism of pathogenesis ofPPCM remain unknown

- autoimmune mechanism ?

- inflamation ( miocarditis) ?- viral trigger for development of PPCM ? ( 12 )

- nutritional disorders,such as deficiencies in

selenium ? ( 18 )


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4. Clinical presentation

Symptoms and signs of systolic heart failure :

- dependent edema

- dyspnea on exertion

- ortopnea- abdominal disconfort secondary to passive

congestion of the liver

- later : postural hypotension- ECG: left ventricular hypertrophy


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Early signs and symptoms of heart failure can be

obscured by pregnancy.

Delayed diagnosis can be associated with

increased morbidity and mortality !

Left ventricular thrombus is common in PCCMpatients . Peripherial embolism then become

possible to any part of body.


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5. Management and prognosis

Treatment aims to reduce afterload, preload,increase of myocardial contractility

- Angiotensin converting enzime

- Hydralazin- Beta blockers

- Diuretics

- Heparin


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PPCM have higher rate of spontaneous recoveryof ventricular function however .

In a single center prospective study of 100 SouthAfrican patients, 15 % died and only 23 %recovered to normal left ventricular function after

6 months of treatment . ( 18 )

Lampert and Lang ( 19 ) pooled data from 13

studies comprising 419 cases of PPCM andreported that 50 % to 60 % of patients showedcomplete or near complete clinical recovery,usualy within the first 6 months post partum .


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TK Misrhra,Swain S, in their study ( 3 ) on the 56patients, showed that 23 % of the patients died .

The mortality rate in the USA has ben reported torange from 25 50 %, the majority of deathoccuring within 3 months after delivery ( 2 )


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Long term prognosis

One of the greatest concerns of PPCM patients isthe safety of additional pregnancies ( 4 )

Elkayam and Et Al ( 8 ) have followed patients

with PPCM ,who became pregnant again andreported during subsequent pregnancies thatmortality was very high .

In their series, 44 % of patients had symptomaticdeterioration and 19 % died.


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Anaesthetic management

There is scant information in the literature regarding

the anesthetic management of peripartumcardiomyopathy.

The main purpose of anaesthesia is to prevent

further cardiac depression and uncontrolled changesin afterload and preload. ( 18 )

Delivery of fetus reduce the haemodynamic stress of

the heart.

The mode of delivery for patients with PPCM isgenerally based on obstetric indications (7)


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Vaginal delivery

Slow induction of epidural analgesia is a safe andeffective analgesic technique. ( 16 )

Effective pain management is a necessity to avoidfurther increase in cardiac output from pain andanxiety .


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Caesarian section

The original anaesthetic management of womanwith PPCM requiring caesarian section depend onits severity .

Early refferal to an obstetric anesthesist is

important, if PPCM is diagnosed in the last monthof pregnancy .

Close liasson with the patient cardiologist and

obstetrician is essential.

Early ( preoperative ) critical care referal isessential for unstable patients and critically ill

patients.


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Intraoperative monitoring may include :

- AL

- CVP

- PWP

- TTE

- TEE

There is not any consensus for the anaesthetic

management of the peripartum cardiomyopathicpregnancies.


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There are reports of anaesthetic managementtechniques that include:

- general anaestesia with inhalational agents ( 6 )

- general anaesthesia with remifentanil ( 2 )

- general anaesthesia with etomidate ( 13 )

- spinal anaesthesia ( 1 )

- combine epidural and spinal anaesthesia withcontinous epidural catheter.


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The anesthesist main goal is to reducepreload and afterload and increasemyocardial contractility ( 1 )


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a. General anaesthesia ( GA)

May be necessary for urgent CS.

The general anaesthesia carrie the advantage of secureairway, more predictable haemodynamic status, in caseof necessity the oportunity of transesophagealechocardiography. ( 2, 15 )

Balanced anesthesia with inhalational agents may causemyocardial depression from mild to severe andintravenous agents can pass the fetoplacentar barrier,causing fetal depression.

In literature it has been reported that there are cases ofmyocardial depression and cardiac arrest due to generalanaesthesia. ( 15 )


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CPMc Carrol et al ( 2 ) used succesfully the TIVAwith a target controlled infusion of remifentanil, ina case of one women with PPCM and ejection

fraction of 15 % .

Remifentanil , a sinthetic opoid, has severaldistinctive pharmacokynetic properties .

The autors concluded that with remifentanil couldprovide anaesthesia that significantly reduce thestress response and subsequent possible

detrimental effect on SVR .

The use of remifentanil would, in theory throughits metabolism and short duration of action, avoidthe neonatal depression.


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Bilemjani E ( 13 ) published the case of one

women with PPCM and EF of 10% , at 32 weeksof gestation, that GA for caesarian section wasinduced with etomidate and maintanend withremifentanil infusion safely, without any adverse

outcome on mother or newborn.


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b. Regional anaesthesia

A regional technique has the advantage ofreducing afterload ,which may improve ventricularfunction ( 1 )

Epidural anaesthesia ( EA )

There has been a report of the succesful use ofslow titrated epidural, where the sensory block wasallowed to develop over 10 h. ( 20 )


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Spinal anaesthesia ( SA )

Clearly a regional technique with a rapid onset ofsensory and sympathetic block with associatedhypotension is inappropiate.

In the studies that compare the single shot spinalanaesthesia with continous spinal anaesthesia it hasbeen concluded that continous spinal anaesthesiaelicits better hemodynamic stability, ( 14, 15 ) eventhere is a study which report that this stability isequal to epidural anaesthetic management ( 16 )


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Combined spinal & epidural anaesthesia

( CSE )

The administration of small intrathecal dose of localanaesthetic followed by epidural supplementationallows a controlled onset of sensory andsympathetic block and should avoid potentialdangerous and dramatic falls in systemic vascularresistence and arterial pressure .

Shnaider R, Ezri T. et al , preferred CSE to epiduralanaesthesia because that has a lower failure rate,than EA. Some autors report a lower incidence ofhypotensive episodes with CSE, compared to EA.(3)


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Conclusions

PPCM can affect women of various ethnicbackground at any age; it is more common inwomen over 30 years of age.

Strong association with gestational hypertension

and twin pregnancy should raise the level ofsuspicion for development of cardiomyopathy inpatients with these condition who developsymptoms of heart failure

Left ventricular function is markedly depressed atthe time of diagnosis and normalizes in more thanhalf of the patients .


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Early recognition of PPCM should allow a timelydiagnosis and appropiate care of this life

threatening condition.

It is not idealy anaesthetic management ; themain purpose of anaesthesia is to prevent furthercardiac depression and uncontrolled changes inafterload an and preload.

Collaboration among obstetrician, cardiologist,anaesthesiologist is essential to optimize care .


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B. Hyhertrophic miocardyopathy

Definition:

Hypertrophic obstructive cardiomyopathy ( HOCM )

is a myocardial disorder, caracterised by leftventricular hypertrophy.

The diagnosis of HOCH is made byechocardiography, demonstrating unexplainedasymetrical myocardial hypertrophy. ( 14 )


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Incidence

The disorder has ben estimated to occurin 0.05 - 0.2 % of general population. ( 11 )

In a pregnant women is 1 in 500 to 1 - 1000 ( 1 ).

In less than half the women, the condition isdiagnosed before the first pregnancy .


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Symptoms and diagnosis

Disease severity is in direct proportion to the degreof left ventricular outflow obstruction.

Dyspnea, orthopnea, paroxismal nocturnal dyspneaare the result of congestive heart failure.

Arrhythmia may occur causing syncope ,dizzines oreven sudden cardiac death ( 11 ).


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Prognosis and mortality

Majority of the woman make a good outcomewith a much lower mortality than with PPCM,

arround 4 %

A th ti t


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Anaesthetic management

Collaboration with the obstetrician and cardiologist is essential.

In the UK ( 11 ) most women with HOCM were delivered bycaesarian section and received general anaesthesia.

Drugs such inotropes, that can worsen the outflow gradient arerelative contraindicated in HOCH .

For cardio-vascular stability, small dose of phenylephrine isindicated.

Pryn A., Bryden F. et al, used succesfuly combined spinalepidural anaesthesia in a case of pregnant women with HOCH.

Epidural anaesthesia also have been reported in women withHOCH . ( 19 )


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Documents

Anesthetic Management of Delivery in Women With Pregnancy[1]