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MITRAL STENOSIS WITH PREGNANCY
- DR. ANKITA PATNI
- ANAESTHESIOLOGY
INTRODUCTION
• Rheumatic mitral stenosis forms 88% of the heart
diseases complicating pregnancy in the tertiary
referral centre in India.
• Rheumatic mitral stenosis complicating
pregnancy is still a frequent cause of maternal
death.
• A better understanding of the physiological
changes in pregnancy and the pathological impact
of mitral stenosis over pregnancy and a
multidisciplinary approach; where the
anaesthesiologist plays a major role, in diagnosis
and management, reduce the mortality and
morbidity.
CARDIOVASCULAR CHANGES DURING PREGNANCY
Parameter Percentage of change
Cardiac output 40–50% Increase
Stroke volume 30% Increase
Heart rate 15–25% Increase
Intravascular volume 45% Increase
Systemic vascular resistance 20% Decrease
Systolic BP Minimal
Diastolic BP 20% Decrease at mid-pregnancyPre-pregnant values at term
CVP Unchanged
O2 consumption 30–40% Increase
HEMODYNAMICS DURING LABOUR
Parameter Stage of labour Percentage of change
Cardiac output Latent phase 10% Increase
Active phase 25% Increase
Expulsive phase 40% Increase
Immediate post-partum 75–80% Increase
Heart rate All stages Increase
CVP All stages Increase
HEMODYNAMICS DURING PUERPERIUM
Parameter Post-partum Percentage of Change
Cardiac output Within 1 h 30% above pre-labour values
24–48 h Just below pre-labour values
2 weeks 10% above pre-pregnant values
12–24 weeks Baseline pre-pregnancy values
Heart rate Immediate Decrease
2 weeks Pre-pregnant values
Stroke volume 48 h Remains above pre-labour values
24 weeks 10% above pre-pregnant values
MS PREGNANCY
DELIVERY
DECREASE LA
emptying
DECREASE LV
Filling
INCREASE HR
DECREASESV
DECREASECO
Fixed CO state; Heart cannot cope up with increased demand.
AUTOTRANSFUSION from uterus
PULMONARY CONGESTION
Long-standin
g
Irreversible chronic Pulmonary Hypertension
LA Dilates
LA pressure INCREASES
At DIASTOL
E
Pressure gradient develops between LA and LVHemodynamic Hallmark of MS
• MS- impairs left ventricular filling- decrease in EDV (pre-load)- decrease in SV- fall in CO.
• Reduced ventricular filling-decrease ventricular wall stress (after-load)- decrease in ESV
• Decrease in EDV > Decrease in ESV = Decrease in SV
SEVERITY GRADING OF MS
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
4-6 cms2
< 2.5 cms2
1.5- 2.5 cms2
1.0 – 1.5 cms2
< 1.0 cms2
Mild MS – 1.5 – 2.5 Cms2 (Dyspnea on severe exertion)Moderate MS – 1.0 – 1.5 Cms2 (PND ± pulmonary oedema)Severe/ Critical- < 1.0 Cms2 (Orthopnea – Class IV)
Symptoms start < 2.5 Cms2
Normal Orifice: 4 – 6 Cms2
MODIFIED NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION (NYHA)
Class I No functional limitation of activity
Asymptomatic except during severe exertion.
Class II Mild limitation of physical activity
Symptomatic with moderate activity
Class III Marked limitation of physical activity
Symptomatic with minimal activity
Class IV Severe limitation of physical activity
Symptomatic at rest
PREDICTORS OF MORTALITY AND MORBIDITY
Severity of MS
Severe- 67%
Moderate- 38%
Mild- 26%
NYHA Class
Class I and II- <1%
Class III and IV- Between 5 and 15%
Class III and IV- Perinatal mortality- 20-
30%
CARPREG SCORE• THE CARDIAC DISEASE IN PREGNANCY (CARPREG) RISK SCORE (TABLE I) CAN BE
CALCULATED TO ESTIMATE A WOMAN'S CARDIAC RISK DURING PREGNANCY. IT
IS IS BASED ON 4 RISK PREDICTORS:
Mortality:
0 point-5%,1 point-27%,>1 point-75%
AETIOLOGY OF MS
1. RHEUMATIC HEART DISEASE
2. CONGENITAL – PARACHUTE MITRAL
VALVE
3. HUNTER’S SYNDROME
4. HURLER’S SYNDROME
5. DRUGS – METHYSERGIDE
6. CARCINOID SYNDROME
7. AMYLOIDOSIS
8. MITRAL ANNULAR CALCIFICATION
9. RHEUMATOID ARTHRITIS
10. SYSTEMIC LUPUS ERYTHEMATOSIS
11. INFECTIVE ENDOCARDITIS WITH
LARGE VEGETATIONS.
12. LUTEMBACHER’S SYNDROME:
ATRIAL SEPTAL DEFECT (ASD) + MITRAL
STENOSIS (MS) RHEUMATIC ORIGIN
SYMPTOMS OF MS
1. DYSPNOEA
2. ORTHOPNEA
3. PAROXYSMAL NOCTURNAL
DYSPNEA
4. PALPITATION
5. FATIGUABILITY
6. HAEMOPTYSIS
7. RECURRENT BRONCHITIS
8. COUGH
9. CHEST PAIN
10. RIGHT HYPOCHONDRIAL PAIN
(HEPATOMEGALY)
DIAGNOSIS OF MS
DIAGNOSTIC TOOLS
Clinical Examina
tion
ECG
Chest X-Ray
Echocardiography
Doppler examinati
on
Cardiac Catheteriz
ation
Echocardiography provides information regarding the area of the mitral valve, size of the left atrium, presence of thrombus and the size and function of the left ventricle and right-sided chambers.
Doppler examination provides information about the severity of the stenosis, the presence of other associated valve lesions and the degree of pulmonary hypertension
Diagnostic cardiac catheterization is necessary only when echocardiography is non-diagnostic or results are discordant with clinical findings.
GENERAL PHYSICAL EXAMINATION
OEDEMA
SEVERE MITRAL
STENOSIS
ULTIMATELY
LEADS TO RIGHT
HEART FAILURE.
HEPATOMEGALY
SEEN IN RIGHT
VENTRICULAR
FAILURE AND
PULMONARY
HYPERTENSION.
MITRAL FACIES
LOW CARDIAC OUTPUT IN MITRAL STENOSIS CAUSES PERIPHERAL
VASOCONSTRICTION PRODUCING PINKISH PURPLE PATCHES ON CHEEKS.
MITRAL FLUSH DUE TO VASODILATATION (VASCULAR STASIS) IS
SEEN
SEEN IN FAIR SKINNED INDIVIDUALS
CARDIOVASCULAR EXAMINATION-INSPECTION
• PRECORDIAL BULGE INDICATES EARLY ONSET AND LONGER
DURATION OF CARDIAC DISEASE.
• SCAR MARKS REVEAL PREVIOUS SURGERIES
• ENGORGED NECK VEINS INDICATE HIGH RIGHT HEART PRESSURES
CARDIOVASCULAR EXAMINATION-PALPATION
• TAPPING CHARACTER OF THE APEX BEAT (PALPABLE S1) IS TYPICAL.
• PALPABLE DIASTOLIC THRILL IN MITRAL AREA BEST FELT IN LEFT LATERAL
POSITION IN FULL EXPIRATION.
• PARASTERNAL HEAVE
• IF ONE FINDS ENGORGED SUPERFICIAL VEINS LOOK FOR DIRECTION OF FLOW.
CARDIOVASCULAR EXAMINATION-AUSCULTATION
• S1 IS SHARP, SHORT, ACCENTUATED
• OPENING SNAP AFTER S2
• LOW PITCHED MID-DIASTOLIC RUMBLING MURMUR WITH
PRESYSTOLIC ACCENTUATION IN MITRAL AREA.
• MURMUR BEST HEARD AT CARDIAC APEX WITH BELL OF
STETHOSCOPE IN LEFT LATERAL POSITION AT HEIGHT OF
EXPIRATION
ECG FINDINGS
1. BROAD NOTCHED “P” WAVES SIGNIFYING ATRIAL ENLARGEMENT.
2. ATRIAL FIBRILLATION (F- WAVES REPLACING P-WAVES)
3. RIGHT VENTRICULAR ENLARGEMENT
CXR
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
PULMONARY EDEMA, PULMONARY
VASCULAR CONGESTION.
5. KERLEY’S B LINES
6. DOUBLE CONTOUR OF THE RIGHT
BORDER OF HEART
CHEST X-RAY
Kerleyb lines
ECHOCARDIOGRAPHY
MANAGEMENT
MEDICAL
DIURETICS, β-
BLOCKERS
AF- DIGOXIN,
ANTI-COAGULANTS
SURGICAL
VALVULOPLASTY
VALVE
REPLACEMENT
OBSTETRICAL
VAGINAL
CAESAREAN
SECTION
MEDICAL MANAGEMENT
FIRST LINE OF TREATMENT IN SYMPTOMATICS
• BED REST
• OXYGEN THERAPY
• DIURETICS
• BETA-ADRENERGIC RECEPTOR BLOCKADE- USEFUL TO PREVENT TACHYCARDIA DURING PREGNANCY. PROPRANOLOL OR ATENOLOL DECREASES THE INCIDENCE OF MATERNAL PULMONARY OEDEMA WITHOUT ADVERSE EFFECTS ON THE FOETUS OR NEONATE.
• ANTIBIOTIC PROPHYLAXIS FOR ENDOCARDITIS IS RESERVED ONLY FOR PATIENTS WITH A PREVIOUS HISTORY OF ENDOCARDITIS OR PRESENCE OF ESTABLISHED INFECTION.
ASSOCIATED WITH ATRIAL FIBRILLATION
• DIGOXIN AND BETA BLOCKERS TO
REVERT IT TO SINUS RHYTHM.
• ANTICOAGULATION TO PREVENT
SYSTEMIC EMBOLIZATION.
• CARDIOVERSION SHOULD BE
PERFORMED IF PHARMACOLOGIC
THERAPY FAILS TO CONTROL THE
VENTRICULAR RESPONSE.
ANTICOAGULATION DURING PREGNANCY
• SC/IV HEPARIN FOR UP TO 12 WEEKS ANTEPARTUM (APTT 1.5–2.5-TIMES OF
NORMAL)
• WARFARIN FROM 12 TO 36 WEEKS (MAINTAIN INR 2.5– 3.0)
• SC/IV HEPARIN AFTER 36 WEEKS
• THERAPY WITH LOW-MOLECULAR WEIGHT HEPARIN (LMWH) INSTEAD OF
UNFRACTIONATED HEPARIN IS GAINING POPULARITY. ALTHOUGH AN “ANTI XA”
ACTIVITY IS USED TO MONITOR LMWH, NO ANTI-XA ACTIVITY-BASED
GUIDELINES HAVE BEEN ISSUED TILL DATE.
SURGICAL MANAGEMENT
II Trimester
Valvuloplasty
PERCUTANEOUS (success rate is
nearly 100%. It increases the valve area to
>1.5 cm2 without a substantial increase in
mitral regurgitation.)
OPEN (foetal loss is high in
open commissurotomy as
compared to percutaneous,
at a ratio of 1:8)
Valve Replacement
Reserved for severe cases
with calcified valve and in
mural thrombus.
OBSTETRIC MANAGEMENTVAGINAL DELIVERY
• Tachycardia, secondary to
labour pain, increases
flow across the mitral
valve, producing sudden
rises in left atrial
pressure, leading to acute
pulmonary oedema.
VAGINAL DELIVERY
• The second stage of delivery should be cut short byinstrumentation.
• Maintenance of left uterine displacement for good venousreturn.
• Supplemental oxygen administration with pulse oximetrymonitoring to minimize increases in pulmonary vascularresistance, fetal heart rate monitoring should be carried out.
• Invasive cardiac monitoring like radial artery cannulation andpulmonary catheter are beneficial in assessing the cardiacoutput, pulmonary artery pressure and for guiding fluid anddrug therapy, especially in NYHA III and IV patients.
• Sudden drops in systemic vascular resistance (SVR) in thepresence of a fixed cardiac output can be prevented by smallbolus doses of phenylephrine, with volume expansion whennecessary.
Good LABOUR ANALGESIA is must.
EpiduralCSE
OBSTETRIC MANAGEMENTCaesarean
section
Epidural/SpinalCombined Spinal
Epidural
General
Anaesthesia
Only for obstetric
reasons
Epidural anaesthesia might not be anideal technique as it requires slowinduction, delay in the onset of actionwhich may not be possible in anemergency situation. Moreover largevolume of local anesthetic is neededfor adequate blockade.
Subarachnoid causes rapid onset of extensive sympathetic blockade with intense vasodilatation, sudden hypotension and severe tachycardia.
Technique of choice. CSE offers rapid onset and
improved analgesia It offers ability to use low dose
spinal with room for post operative analgesia
OBSTETRIC MANAGEMENT
Category 1 - Immediate
threat to life of woman or
fetus (baby needs to be
removed in 30 min. of
making the decision to do
LSCS)
Category 2 - Maternal or
fetal compromise, not
immediately life
threatening(some time can
be spent for resuscitation)
Category 4- At a time to
suit the woman and
maternity team
Category 3 - Needing early
delivery but no maternal or
fetal compromise
GOALS FOR ANAESTHETIC MANAGEMENT
• MAINTENANCE OF AN ACCEPTABLE SLOW HEART RATE
• IMMEDIATE TREATMENT OF ACUTE ATRIAL FIBRILLATION AND REVERSION TO
SINUS RHYTHM
• AVOIDANCE OF AORTOCAVAL COMPRESSION
• MAINTENANCE OF ADEQUATE VENOUS RETURN
• MAINTENANCE OF ADEQUATE SVR
• PREVENTION OF PAIN, HYPOXAEMIA, HYPERCARBIA AND ACIDOSIS, WHICH MAY
INCREASE PULMONARY VASCULAR RESISTANCE.
EPIDURAL ANALGESIA• ONE OF THE MAJOR ADVANTAGES OF EPIDURAL ANALGESIA IS THAT IT CAN BE
ADMINISTERED IN INCREMENTAL DOSES AND THAT THE TOTAL DOSE COULD BE
TITRATED TO THE DESIRED SENSORY LEVEL.
• SLOWER ONSET OF ANAESTHESIA
• THE SEGMENTAL BLOCKADE SPARES THE LOWER EXTREMITY “MUSCLE PUMP,”
AIDING IN VENOUS RETURN, AND ALSO DECREASES THE INCIDENCE OF
THROMBOEMBOLIC EVENTS.
• INVASIVE HAEMODYNAMIC MONITORING, JUDICIOUS INTRAVENOUS
ADMINISTRATION OF CRYSTALLOID AND ADMINISTRATION OF SMALL BOLUS
DOSES OF PHENYLEPHRINE MAINTAIN MATERNAL HAEMODYNAMIC STABILITY.
• NEURAXIAL BLOCK IN AN ANTICOAGULATED PATIENT HAS THE RISK OF
EPIDURAL HAEMATOMA.
Allows the maternal cardiovascular system to compensate for the occurrence of
sympathetic blockade, resulting in a lower risk of hypotension and decreased
uteroplacental perfusion.
COMBINED SPINAL-EPIDURAL
PROCEDURE PER SE
• CSE IS PERFORMED IN LATERAL DECUBITUS POSITION UNDER STRICT ASEPTIC PRECAUTIONS
EPIDURAL SPACE IS IDENTIFIED WITH 18 G TUOHY NEEDLE USING LOR WITH SALINE. SPINAL
NEEDLE IS INTRODUCED THROUGH THE TUOHY NEEDLE AND SUBARACHNOID BLOCK IS
PERFORMED.20-30 ΜG OF FENTANYL ALONG WITH 2.5 -5MG OF 0.5% BUPIVACAINE IS GIVEN.
THIS IS FOLLOWED BY INSERTION OF EPIDURAL CATHETER THROUGH WHICH 3 ML OF 2%
XYLOCAINE WITH EPINEPHRINE IS GIVEN.
• POST OPERATIVE ANALGESIA IS MAINTAINED AS SHOWN IN THE TABLE BELOW
DRUG INITIAL INJECTION CONTINUOUS INFUSION
• BUPIVACAINE 10-15 ML OF A 0.25%-0.125% SOLUTION 0.0625%-0.125% SOLUTION AT 8-15
ML/HR
• ROPIVACAINE 10-15 ML OF A 0.1%-0.2% SOLUTION 0.5%-0.2% SOLUTION AT 8-15 ML/HR
• FENTANYL 50-100 MICROGRAM IN A 10-ML VOLUME 1-4
MICROGRAM/ML
MYTHS AND WORRIES ABOUT REGIONAL ANAESTHESIA
1. PRELOADING IS MANDATORY AND HAZARDOUS--CVP GUIDED FLUID
MANAGEMENT NEGATES OVERLOADING AND MAINTAINS ADEQUATE CARDIAC
OUTPUT
2. REGIONAL ANAESTHESIA IS ASSOCIATED WITH SUDDEN FALL IN BP. LOCAL
ANAESTHETIC WITH OPIOID COMBINATION INTRATHECALLY FOLLOWED BY
EPIDURAL TO TITRATE THE DESIRED LEVEL OF BLOCK DOES NOT PRODUCE RAPID
FALL IN BP.
3. DELAY IN PERFORMING THE ACTUAL PROCEDURE: THIS DOESNT HAPPEN WITH
EXPERT HANDS
4. THE COMPLICATIONS OF CSE-LIKE TOTAL SPINAL, LA TOXICITY, EPIDURAL
HEMATOMA AND ABSCESS ARE NEGLIGIBLE WITH SENIOR ANESTHESIOLOGISTS.
REGIONAL ANAESTHESIA
CONTROVERSIES ABOUT CSE:
• RISK OF EPIDURAL CATHETER
THROUGH THE DURAL HOLE
• PERCEIVED INCREASE IN
NEUROTRAUMA
CONTRAINDICATIONS TO REGIONAL ANAESTHESIA
• ACTIVE HEAVY BLEEDING
• UNCORRECTED COAGULOPATHY (E.G. HELLP
SYNDROME (HEMOLYSIS, ELEVATED LIVER
ENZYMES, LOW PLATELETS) ASSOCIATED WITH
PRE-ECLAMPSIA)
• THROMBOCYTOPENIA
• SYSTEMIC SEPSIS
• LOCAL SEPSIS AT SITE OF INSERTION
• PATIENT REFUSAL
GUIDELINES FOR GENERAL
ANAESTHESIA
• ANAESTHETIC GOALS:
1. MAINTAIN THE HEART RATE AROUND 80-100
B/MIN .
2. MAINTAIN LEFT ATRIAL PRESSURE HIGH ENOUGH TO
TAKE ADVANTAGE OF THE INCREASED PRELOAD
RESERVE.
3. AVOID PULMONARY ARTERY HYPERTENSION BY
TREATING HYPERCARBIA, HYPOXEMIA, AND
ACIDEMIA.
4. AGGRESSIVELY TREAT PULMONARY ARTERY
HYPERTENSION WITH VASODILATOR THERAPY TO
AVOID RV FAILURE. IF RV FAILURE DOES OCCUR,
INOTROPIC SUPPORT OF THE RV AND PULMONARY
VASODILATION MAY BE NECESSARY. THE PRESENCE
OF PAH IS THE MAJOR FACTOR THAT INCREASE THE
MORTALITY.
GENERAL ANAESTHESIA
HAS THE ADVANTAGES
OF SPEED OF
INDUCTION, CONTROL
OF THE AIRWAY, AND
SUPERIOR
HEMODYNAMICS.
ANAESTHETIC GOALS
5. AVOID FACTORS WHICH DEPRESS THE MYOCARDIUM (INHALATION AGENTS AND DRUGS)
6. MAINTAIN AWARENESS OF POTENTIAL FOR LV RUPTURE.
7. AGGRESSIVE TREATMENT OF ARRHYTHMIAS IF THEY OCCUR
8. AVOID PROFOUND CHANGES IN SVR
9. ATTENUATE PRESSOR RESPONSE (INTUBATION, EXTUBATION, LIGHT PLANE OF ANESTHESIA)
10. ADEQUATE ANALGESIA AND ADEQUATE MUSCLE RELAXATION GUIDED BY NEURO MUSCULAR
MONITORING
11. ASPIRATION PROPHYLAXIS
12. BLOOD LOSS ASSESSMENT AND PROMPT REPLACEMENT
GENERAL ANAESTHESIA
• INDUCTION OF ANAESTHESIA
1. AVOID KETAMINE× – INCREASES HEART RATE, BLOOD PRESSURE
2. AVOID ATRACURIUM× – INCREASED HISTAMINE RELEASE CAUSES HYPOTENSION WHICH
MANIFESTS AS TACHYCARDIA.
• A BETA-ADRENERGIC RECEPTOR ANTAGONIST AND AN ADEQUATE DOSE OF OPIOID LIKE
FENTANYL SHOULD BE ADMINISTERED BEFORE OR DURING THE INDUCTION OF GENERAL
ANAESTHESIA.
• ESMOLOL HAS A RAPID ONSET AND SHORT DURATION OF ACTION, IT IS A BETTER CHOICE IN
CONTROLLING TACHYCARDIA. SINCE FOETAL BRADYCARDIA HAS BEEN REPORTED AFTER
ESMOLOL, FOETAL HEART RATE SHOULD BE MONITORED.
GENERAL ANAESTHESIA• MAINTENANCE OF ANAESTHESIA
1. DRUGS SHOULD HAVE MINIMAL EFFECTS ON HEMODYNAMIC PATTERN
2. BALANCED ANAESTHESIA WITH N2O/ NARCOTIC/ VOLATILE ANAESTHETIC
3. N2O CAUSES INSIGNIFICANT PULMONARY VASOCONSTRICTION. IT IS SIGNIFICANT ONLY IF
PULMONARY HYPERTENSION EXISTS. SO, ONE NEEDS TO TREAT PULMONARY HYPERTENSION
PREOPERATIVELY.
4. CARDIAC STABLE MUSCLE RELAXANTS ARE TO BE USED. (PREFERABLY AVOID PANCURONIUM
×)
5. AVOID LIGHTER PLANES OF ANAESTHESIA (TO AVOID TACHYCARDIA)
6. FLUID MANAGEMENT:
• AVOID HYPERVOLEMIA - -> WORSENS PULMONARY EDEMA
• AVOID HYPOVOLEMIA - -> SACRIFICES ALREADY DECREASED LEFT VENTRICULAR
FILLING, WHICH FURTHER DECREASES CARDIAC OUTPUT. HYPOVOLEMIA
SECONDARY TO BLOOD LOSS AND VASODILATORY EFFECTS OF ANAESTHESIA OUGHT TO BE
GENERAL ANAESTHESIA
• AFTER DELIVERY OF THE FOETUS, OXYTOCIN 10–20 U IN 1,000 ML OF CRYSTALLOID
SHOULD BE ADMINISTERED AT A RATE OF 40– 80 MU/MIN. AN INFUSION OF
OXYTOCIN CAN LOWER THE SVR AS WELL AS ELEVATE THE PULMONARY VASCULAR
RESISTANCE, RESULTING IN A DROP IN CARDIAC OUTPUT. CARE MUST BE TAKEN
DURING ITS ADMINISTRATION.
• METHYLERGOMETRINE, OR 15-METHYLPROSTAGLANDIN F2, PRODUCES SEVERE
HYPERTENSION, TACHYCARDIA AND INCREASED PULMONARY VASCULAR
RESISTANCE.
• POST-OPERATIVELY
AVOID PAIN AS PAIN BEGETS HYPOVENTILATION WHICH LEADS TO RESPIRATORY
ACIDOSIS, HYPOXEMIA WHICH MANIFESTS AS RAISED HEART RATE AND PULMONARY
VASCULAR RESISTANCE.
ADVANTAGES OF GA
1. RAPIDLY ESTABLISHED
2. BETTER HEMODYNAMIC STABILITY
3. PREVENTION OF ASPIRATION AS THE
AIRWAY IS ISOLATED
4. HIGH FIO2 -WHICH WILL REDUCE PVR
5. VENTILATION CONTROLLED TO AVOID
HYPERCARBIA-WHICH WILL INCREASE PVR
6. FRC IS INCREASED BY CONTROLLED
VENTILATION
7. VENTILATION OF ATELECTATIC AREAS –
BETTER V/Q
8. SINUS RHYTHM CAN BE MAINTAINED. IN
CASE OF SVT AND VENTRICULAR ARRHYTHMIAS
PROMPTLY REVERTED BY CARDIOVERSION
9. PEAK AIRWAY PRESSURE CAN BE KEPT <20
CMS H2O
10. ELECTIVE POST OPERATIVE VENTILATION TO
TIDE OVER THE CCF THAT MAY BE POSSIBLE
AFTER PARTURITION
11. EFFECTIVE MANAGEMENT OF PULMONARY
OEDEMA - IPPV WITH PEEP, LIBERAL USE OF
HIGH DOSE MORPHINE
COMPLICATIONS OF GA
1. FAILED INTUBATION
2. ASPIRATION( MORE COMMON IN
UNPREPARED CASE)
3. HYPERTENSIVE CRISIS
4. ARRHYTHMIA-HYPOXIA,
HYPERCARBIA, INHALATIONAL
AGENTS, DRUGS
5. USE OF POLY PHARMACY AND
ANAPHYLAXIS
6. AWARENESS
7. UTERINE ATONY WITH INHALATION
AGENTS
8. NEED FOR ADEQUATE POST OP.
ANALGESIA
9. NEONATAL DEPRESSION
10. DELAYED RECOVERY
11. ANAESTHETIC DRUG INTERACTIONS
12. INCREASED INCIDENCE OF PONV
13. PROLONGED STAY ICU
OUTLINES OF MANAGEMENT1. PRE-CONCEPTUAL COUNSELING- NYHA III AND IV ARE ADVISED CORRECTIVE
CARDIAC BEFORE PREGNANCY. IT IS ADVISABLE FOR CERTAIN CARDIAC DISEASES WHERE PREGNANCY IS TO BE AVOIDED
• THEY HAVE TO BE REGISTERED, INTERVIEWED REGARDING FUNCTIONAL DIFFICULTIES, REGULARFOLLOW UPS STARTING FROM EARLY PREGNANCY. IT IS ADVISABLE TO MANAGE THEM IN HIGHERCENTERS WHERE MULTIDISCIPLINARY SUPPORT IS AVAILABLE(MULTIDISCIPLINARY APPROACH:MANAGEMENT BY A TEAM OF SPECIALISTS APART FROM OBSTETRICIANS THAT INCLUDES THECARDIOLOGIST(FAILURE PREVENTION, ARRHYTHMIA MANAGEMENT), CT SURGEON(EMERGENTCARDIAC SURGERY), NEONATOLOGIST(PRETERM BABY) ANESTHESIOLOGIST(PAIN RELIEF-EPIDURAL,MECHANICAL VENTILATION IF NECESSARY)
2. CORRECT FACTORS WHICH WILL BURDEN THE CARDIAC LESION LIKE ANEMIA, OBESITY, HYPERTENSION, ARRHYTHMIA
3. PREVENTION OF INFECTION
OUTLINES OF MANAGEMENT
4. OPTIMIZATION OF HEART RATE WITH PHARMACOLOGICAL AGENTS
5. PREGNANCY IS A HYPERCOAGULABLE STATE, WHICH INCREASES THE RISK OF THROMBOEMBOLIC EVENTS, ESPECIALLY IN THE CARDIAC PATIENT WITH A PROSTHETIC HEART VALVE, VALVULAR HEART DISEASE, OR HEART FAILURE. ANTICOAGULANT THERAPY SHOULD BE CONSIDERED IN THESE HIGH-RISK PATIENTS TO PREVENT THROMBOEMBOLISM OR THROMBUS FORMATION.
6. IE PROPHYLAXIS -(AS PER THE ACOG GUIDELINES- SOME OF THE DRUGS RECOMMENDED BY ACC/AHA ARE NOT RECOMMENDED FOR PREGNANT PATIENTS)
7. MONITORS- OTHER THAN THE ASA STANDARDS RECOMMENDATION- ADVANCED MONITORS LIKE INVASIVE ARTERIAL PRESSURE, CVP -, PCWP AND TEE ARE RECOMMENDED. THEY SHOULD BE CONTINUED IN THE POST PARTUM PERIOD UPTO 72 HRS AT LEAST
OUTLINES OF MANAGEMENT
8. PLANNING THE MODE OF DELIVERY-VAGINAL DELIVERY IS BETTER TOLERATED(LESS BLOOD LOSS, LESS CATECHOLAMINE), PAIN RELIEF DURING LABOR - RECOMMENDED, SHORTENING THE SECOND STAGE- OUTLET FORCEPS, EPISIOTOMY.
9. LARGE BOLUSES OF OXYTOCICS SHOULD BE AVOIDED AS THEY CAUSE PROFOUND HYPOTENSION. ERGOMETRINE BETTER AVOIDED. PGF2 ALPHA AND MESOPROSTOL ARE USED CAUTIOUSLY.
10. IF PLANNED FOR CESAREAN SECTION CHOICE OF ANESTHETIC SHOULD BE DIRECTED TO KEEP THE HAEMODYNAMIC STABLE (AS NEAR NORMAL SYSTEMIC VASCULAR RESISTANCE, PRELOAD, AFTERLOAD AS POSSIBLE)ADEQUATE REPLACEMENT OF BLOOD LOSS.
11. ALL PATIENTS WITH CARDIAC DISEASE SHOULD BE KEPT IN HIGH DEPENDENCY UNIT AND MONITORED AFTER THE DELIVERY FOR A MINIMUM PERIOD OF 72HRS
12. PLAN AND ADVISE CARDIAC SURGERY IN THE SECOND TRIMESTER IF IS WARRANTED IN THE INTEREST OF THE MOTHER'S WELL BEING.
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