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Safety of Regional Anesthesia in Eisenmengerʼs Syndrome. Reg Anesth Pain Med 2002. [DOI: 10.1097/00115550-200209000-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McMillan E, Martin WL, Waugh J, Rushton I, Lewis M, Clutton-Brock T, Townend JN, Kilby MD, Gordon C. Management of pregnancy in women with pulmonary hypertension secondary to SLE and anti-phospholipid syndrome. Lupus 2002; 11:392-8. [PMID: 12139379 DOI: 10.1191/0961203302lu216xx] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pulmonary hypertension is found in about 10% of patients with systemic lupus erythematosis (SLE). Pulmonary hypertension may be present at the time of diagnosis or may develop after the diagnosis of SLE or anti-phospholipid syndrome (APS). It often presents in the reproductive years and has a significant impact on pregnancy outcome, being a significant cause of indirect maternal deaths. In our observational case series of three patients there were two deaths (66%). In cases 1 and 2 the pulmonary hypertension developed during pregnancy and deteriorated rapidly with markedly abnormal mean pulmonary artery pressures of 80 and 70 mmHg respectively prior to death. Both patients died within 48 hours of delivery. In case 3 the pulmonary hypertension was milder and was diagnosed very early in pregnancy. The patient received multidisciplinary care from the first trimester and the management of the pregnancy, delivery and the early puerperium was planned. Careful epidural anaesthesia was used and the patient had invasive monitoring on the intensive therapy unit (ITU) for 72 hours. Women with pulmonary hypertension need to be aware of the high risk of maternal mortality associated with pregnancy but we believe that an improvement in outcome can be achieved by careful assessment and the use of a multidisciplinary approach from early in pregnancy.
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Affiliation(s)
- E McMillan
- Department of Fetal Medicine, Birmingham Women's Hospital, UK
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53
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Palmer CM, DiNardo JA, Hays RL, Van Maren GA. Use of transesophageal echocardiography for delivery of a parturient with severe pulmonary hypertension. Int J Obstet Anesth 2002; 11:48-51. [PMID: 15321576 DOI: 10.1054/ijoa.2001.0912] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The anesthetic management of a parturient with severe pulmonary hypertension during labor and subsequent cesarean delivery is presented. Transesophageal echocardiography was used intraoperatively to manage the patient's hemodynamics, while pulmonary artery pressure monitoring was of little use. The benefits of transesophageal echocardiography for management of these patients are discussed.
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Affiliation(s)
- C M Palmer
- Department of Anesthesiology, University of Arizona Health Sciences Center, Tucson, AZ 85724-5114, USA.
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Abstract
The pregnant state imposes a supraphysiologic strain on the pregnant woman's cardiac performance through complex biochemical, electric, and physiologic changes affecting the blood volume, myocardial contractility, and resistance of the vascular bed. In the presence of underlying heart disease, these changes can compromise the woman's hemodynamic balance, her life, and that of her unborn child. Cardiac pathology represents a heterogeneous group of disorders, each with its own hemodynamic, genetic, obstetric, and social implications. Physicians caring for these women should actively address the issue of reproduction. Ideally, pregnancy should be planned to occur after optimization of cardiac performance by medical or surgical means. Once pregnancy is achieved, the concerted effort of a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, nursing, social, and other services provides the best opportunity to carry the pregnancy to a successful outcome.
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Affiliation(s)
- A F Gei
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
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56
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Monnery L, Nanson J, Charlton G. Primary pulmonary hypertension in pregnancy; a role for novel vasodilators. Br J Anaesth 2001; 87:295-8. [PMID: 11493507 DOI: 10.1093/bja/87.2.295] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We describe the case of a 28-week pregnant woman presenting with severe primary pulmonary hypertension (PPH). She had an elective Caesarean section under general anaesthesia at 32 weeks gestation. Pulmonary artery pressures (PAP) measured from a pulmonary artery catheter before anaesthesia were in excess of 100 mm Hg. Intraoperative nitric oxide was used to reduce PAP. After the delivery of a healthy infant PAP was controlled with nebulized iloprost and a prostacyclin infusion. Seven days later she was discharged from intensive care taking an oral calcium antagonist and warfarin. She developed intractable right heart failure and died 14 days after delivery. Despite increasing experience in the use of drugs to reduce PAP, the clinical course of pregnancy complicated by severe PPH is usually fatal.
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Affiliation(s)
- L Monnery
- Department of Anaesthesia, Dorset County Hospital, Williams Avenue, Dorchester DT1 2JY, UK
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57
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Decoene C, Bourzoufi K, Moreau D, Narducci F, Crepin F, Krivosic-Horber R. Use of inhaled nitric oxide for emergency Cesarean section in a woman with unexpected primary pulmonary hypertension. Can J Anaesth 2001; 48:584-7. [PMID: 11444454 DOI: 10.1007/bf03016836] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Use of inhaled nitric oxide (iNO) could be of importance in emergency cases of primary pulmonary hypertension (PPH) in pregnant patients during labour and delivery. iNO acts as a selective pulmonary bed vasodilator avoiding systemic hemodynamic effects due to its ease of administration. Pulmonary bed vasodilation improves right ventricular function directly and left ventricular function indirectly. CLINICAL FEATURES We report the case of a pregnant patient with unexpected PPH in whom an emergency Cesarean section (CS) had to be performed. PPH was diagnosed on admission as she arrived in active labour at 34 weeks gestational age. An emergency CS was performed under epidural anesthesia for breech presentation . All along labour, delivery and the first 24 hr, iNO was administered via a noninvasive ventilation device. CS was uneventful. A severe pulmonary hypertensive crisis was observed 12 hr after delivery and resolved with an increase of iNO concentration and administration of isoprenalin. The patient and baby returned home on day ten. CONCLUSION The ease of administration of iNO allowed the optimal control of pulmonary arterial hypertension. No interaction with epidural anesthesia was observed. Use of iNO can improve the management of urgent CS in women with unexpected PPH.
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Affiliation(s)
- C Decoene
- Clinic of Anesthesiology and Reanimation in Cardiovascular Diseases, CHRU Lille, France.
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58
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Stewart R, Tuazon D, Olson G, Duarte AG. Pregnancy and primary pulmonary hypertension : successful outcome with epoprostenol therapy. Chest 2001; 119:973-5. [PMID: 11243988 DOI: 10.1378/chest.119.3.973] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Primary pulmonary hypertension (PPH) associated with pregnancy carries a high maternal mortality rate. Short-term epoprostenol infusion has been demonstrated to improve the hemodynamic profile in patients with PPH. We report a successful maternal-fetal outcome with epoprostenol therapy during pregnancy, cesarean section, and postpartum in a patient with PPH. Epoprostenol therapy did not produce any physical or developmental abnormalities in the fetus. A favorable maternal-fetal outcome may occur with a multidisciplinary approach.
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Affiliation(s)
- R Stewart
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Medical Branch, Galveston, TX, USA
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59
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Olofsson CH, Bremme K, Forssell G, Ohqvist G. Cesarean section under epidural ropivacaine 0.75% in a parturient with severe pulmonary hypertension. Acta Anaesthesiol Scand 2001. [DOI: 10.1034/j.1399-6576.2001.450220.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Smith M, Cooper GM, Clutton-Brock TH, Lewis M, Wilkey AD, Millns JP, Bowden MI. Five cases of severe cardiac disease in pregnancy: outcomes and costs. Int J Obstet Anesth 2001; 10:58-63. [PMID: 15321653 DOI: 10.1054/ijoa.2000.0748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The obstetric, medical and anaesthetic management of five pregnant patients with a variety of significant cardiac problems is briefly reviewed. The duration of hospitalisation, and the use of high dependency and intensive care are documented. Financial costs are estimated and their implications for the care of such patients during and following pregnancy are discussed.
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Affiliation(s)
- M Smith
- Birmingham Women's Hospital, UK
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61
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Buckland R, Pickett JA. Pregnancy and the univentricular heart: case report and literature review. Int J Obstet Anesth 2000; 9:55-63. [PMID: 15321109 DOI: 10.1054/ijoa.1999.0341] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The univentricular heart is a rare form of congenital cardiac disease. We report the successful management of a parturient with a single ventricle, transposition of the great arteries, pulmonary hypertension and thrombosis of the superior vena cava. The univentricular heart is discussed in detail and the outcome in other mothers with similar cardiac anomalies is reviewed.
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Affiliation(s)
- R Buckland
- Department of Anaesthesia, Addenbrooke's NHS Trust, Cambridge, UK
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63
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Lust KM, Boots RJ, Dooris M, Wilson J. Management of labor in Eisenmenger syndrome with inhaled nitric oxide. Am J Obstet Gynecol 1999; 181:419-23. [PMID: 10454694 DOI: 10.1016/s0002-9378(99)70572-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Administration of nitric oxide by means of inhalation during the labor of a woman with Eisenmenger's syndrome caused by an atrial septal defect resulted in improved oxygenation and initial pulmonary arterial pressure. She gave birth to a live infant at 34 weeks' gestation but died of worsening pulmonary hypertension and heart failure 21 days post partum.
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Affiliation(s)
- K M Lust
- Royal Brisbane Hospital, Herston, Queensland, Australia
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64
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Tay SM, Ong BC, Tan SA. Cesarean section in a mother with uncorrected congenital coronary to pulmonary artery fistula. Can J Anaesth 1999; 46:368-71. [PMID: 10232722 DOI: 10.1007/bf03013230] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE We report a case of a 33 yr old woman with pulmonary hypertension secondary to uncorrected right coronary artery to pulmonary artery fistula who underwent two successful operative deliveries under general anesthesia. CLINICAL FEATURES This woman underwent an emergency Caesarean section at 32 wk gestation because she presented in NYHA Class IV, heart failure and premature labour. She did not have antenatal follow-up. For her second pregnancy, she was managed from the first trimester of pregnancy by the cardiologist, obstetrician and anesthesiologist. She received oral furosemide and digoxin from eight weeks gestation. Pregnancy was managed to term before she progressed to NYHA Class IV and cardiac failure at 37 wk gestation. She had a Caesarean section under general anesthesia. She received rapid sequence induction of anesthesia and tracheal intubation with 0.1 mg x kg(-1) etomidate, 2 mg x kg(-1) succinylcholine and maintenance with nitrous oxide 50% in oxygen, isoflurane 1% and 0.1 mg x kg(-1) vecuronium. Fentanyl, 2 microg x kg(-1) helped to obtund the hypertensive response to intubation. Analgesia was provided with 1 mg x kg(-1) morphine. Glyceryl trinitrate infusion, 10-30 microg x min(-1) was used in addition to the anti-heart failure therapy. End-tidal capnography, electrocardiogram, pulse oximetry, continuous arterial blood pressure and pulmonary arterial catheter provided hemodynamic monitoring. The lungs were mechanically ventilated for 24 hr postoperatively. She received anti-heart failure therapy which she continued after discharge. She was NYHA class II upon discharge. She defaulted from further follow-up. CONCLUSION Although the literature advocates, in this situation, controlled vaginal delivery utilising epidural analgesia, we describe the successful outcome for operative delivery under general anesthesia in a patient with secondary pulmonary hypertension and heart failure.
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Affiliation(s)
- S M Tay
- Department of Anesthesia & Surgical Intensive Care, Singapore General Hospital, Singapore.
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65
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Goodwin TM, Gherman RB, Hameed A, Elkayam U. Favorable response of Eisenmenger syndrome to inhaled nitric oxide during pregnancy. Am J Obstet Gynecol 1999; 180:64-7. [PMID: 9914580 DOI: 10.1016/s0002-9378(99)70151-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Our goal was to evaluate the effectiveness of therapy with a specific pulmonary vasodilator, nitric oxide, in a woman with Eisenmenger syndrome during pregnancy. STUDY DESIGN Eisenmenger syndrome consists of a congenital communication between the systemic and pulmonary circulation with secondary pulmonary hypertension causing reversal of flow through the shunt. Maternal morbidity is approximately 50% with the greatest risk of death being in the peripartum period. Pharmacologic therapy to relieve worsening pulmonary hypertension is confounded by the undesired effects of vasodilators on the systemic circulation. Therapy with a specific pulmonary vasodilator, nitric oxide, was attempted. RESULTS A 27-year-old woman with Eisenmenger syndrome at 36 weeks' gestation was treated with inhaled nitric oxide during the second stage of labor and the postpartum period when she experienced progressive refractory hypoxemia. Administration of nitric oxide was followed by improved oxygenation and lowering of pulmonary artery pressures. A brief episode of methemoglobinemia responded to lowering of the nitric oxide concentration and administration of intravenous methylene blue. Nitric oxide was discontinued after 48 hours. The patient died 2 days later despite continued vasodilator therapy including intra-pulmonary artery prostacyclin. CONCLUSION Inhaled nitric oxide can be used to correct the hypoxemia of Eisenmenger syndrome. Nitric oxide inhalation is easily performed, and pulmonary vasodilatory effects commence within minutes after administration.
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Affiliation(s)
- T M Goodwin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles 90033, USA
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66
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67
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Weiss BM, Zemp L, Seifert B, Hess OM. Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996. J Am Coll Cardiol 1998; 31:1650-7. [PMID: 9626847 DOI: 10.1016/s0735-1097(98)00162-4] [Citation(s) in RCA: 339] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Published reports were reviewed to evaluate the characteristics of peripartal management and the late pregnancy outcome in women with pulmonary vascular disease (PVD). BACKGROUND Pulmonary hypertension poses one of the highest risks for maternal mortality, but actual data on the maternal and neonatal prognosis in this group are lacking. METHODS Reports published from 1978 through 1996 of Eisenmenger's syndrome (n = 73), primary pulmonary hypertension (PPH) (n = 27) and secondary vascular pulmonary hypertension (SVPH) (n = 25) complicating late pregnancy were included and analyzed using logistic regression analysis. RESULTS Maternal mortality was 36% in Eisenmenger's syndrome, 30% in PPH and 56% (p < 0.08 vs. other two groups) in SVPH. Except for three prepartal deaths due to Eisenmenger's syndrome, all fatalities occurred within 35 days after delivery. Neonatal survival ranging from 87% to 89% was similar in the three groups. Previous pregnancies, timing of the diagnosis and hospital admission, operative delivery and diastolic pulmonary artery pressure were significant univariate (p < 0.05) maternal risk factors. Late diagnosis (p = 0.002, odds ratio 5.4) and late hospital admission (p = 0.01, odds ratio 1.1 per week of pregnancy) were independent predictive risk factors of maternal mortality. CONCLUSIONS In the last two decades maternal mortality was comparable in patients with Eisenmenger's syndrome and PPH; however, it was relevantly higher in SVPH. Maternal prognosis depends on the early diagnosis of PVD, early hospital admission, individually tailored treatment during pregnancy and medical therapy and care focused on the postpartal period.
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Affiliation(s)
- B M Weiss
- Department of Anesthesiology, University Hospital, Zurich, Switzerland
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68
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VanHelder T, Smedstad KG. Combined spinal epidural anaesthesia in a primigravida with valvular heart disease. Can J Anaesth 1998; 45:488-90. [PMID: 9598266 DOI: 10.1007/bf03012587] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE This is the first report describing combined spinal epidural anaesthesia for labour and unexpected Caesarean section in a patient with mitral and aortic stenosis and insufficiency. CLINICAL FEATURES The patient was a 30-yr-old GIPO with a history of rheumatic fever. She had moderate stenosis and insufficiency of the mitral and aortic valves. Combined spinal epidural anaesthesia was used throughout labour and subsequent Caesarean section. The patient remained haemodynamically stable throughout the procedure. CONCLUSION Carefully planned regional anaesthesia was safely used for labour and operative delivery in this parturient with mitral and aortic valvular disease.
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Affiliation(s)
- T VanHelder
- Department of Anaesthesia, McMaster University, Ontario, Canada
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69
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Abstract
With changes in the demographics of human immunodeficiency virus (HIV) infection, women and children are becoming the fastest growing group of newly infected patients. With longer survival after HIV infection, more women infected with HIV are becoming pregnant. Pulmonary disease is one of the most common presenting conditions in an AIDS-defining illness. Pneumocystis carini pneumonia and tuberculosis are the most common disorders that herald the onset of AIDS. They are also the most frequently encountered HIV-related pulmonary complications during pregnancy. Others have been rarely reported during pregnancy and include fungal infections (Cryptococcus neoformans, Histoplasma capsulatum, and Coccidioides immitus), bacterial infections (Haemophilus influenzae and Streptococcus pneumoniae along with Pseudomona aeruginosa), viral infections (CMV), opportunistic neoplasms (Kaposi's sarcoma, lymphoma) and miscellaneous conditions peculiar to HIV-infected individuals (nonspecific interstitial pneumonitis, lymphoid interstitial pneumonitis, isolated pulmonary hypertension, and pulmonary edema secondary to cardiac disease or drug abuse). Most of the data regarding the pulmonary complications of HIV infection come from studies in nonpregnant patients. The extent to which pregnancy affects the course of respiratory disease in HIV infection and vice versa is not well documented. Clinical presentation is usually not altered by pregnancy. Except for minor modifications mainly related to potential fetal effects, the diagnostic work-up and management are similar to those in the nonpregnant patient. The most important effect of pregnancy on these conditions remains the delay in diagnosis and treatment. A high index of suspicion should, therefore, be maintained. In addition, most prophylactic measures recommended in nonpregnant HIV-infected individuals also apply to pregnant women.
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Affiliation(s)
- G R Saade
- Division of Maternal-Fetal Medicine, The University of Texas Medical Branch, Galveston 77555-1062, USA
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70
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Jonmarker C. Patients with congenital heart malformations for noncardiac surgery. ACTA ANAESTHESIOLOGICA SCANDINAVICA. SUPPLEMENTUM 1997; 110:104-5. [PMID: 9248552 DOI: 10.1111/j.1399-6576.1997.tb05520.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Most patients with CHD can be safely anesthetized with regular techniques. Preoperative consultation with appropriate specialists and a well planned anesthetic management is important.
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Affiliation(s)
- C Jonmarker
- Department of Anesthesia and Intensive Care, Lund University Hospital, Sweden
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71
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Khan MJ, Bhatt SB, Kryc JJ. Anesthetic considerations for parturients with primary pulmonary hypertension: review of the literature and clinical presentation. Int J Obstet Anesth 1996; 5:36-42. [PMID: 15321380 DOI: 10.1016/s0959-289x(96)80072-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Primary pulmonary hypertension, though uncommon, is found relatively frequently in women of childbearing age and carries a high peripartum mortality. We present a patient with severe primary pulmonary hypertension who underwent two cesarean sections 3 and 6 years after the diagnosis of primary pulmonary hypertension was made. Epidural anesthesia was provided on both occasions and resulted in a good maternal and fetal outcome. We have reviewed the literature as it relates to the choice of anesthetic technique and maternal outcome in patients with primary pulmonary hypertension.
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Affiliation(s)
- M J Khan
- Department of Anesthesiology, Maricopa Medical Center, Phoenix, AZ 85010, USA
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72
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Groves ER, Groves JB. Epidural analgesia for labour in a patient with Ebstein's anomaly. Can J Anaesth 1995; 42:77-9. [PMID: 7889589 DOI: 10.1007/bf03010576] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Ebstein's anomaly is an uncommon congenital cardiac defect which is associated with cyanosis and arrhythmias. There have been very few previous reported cases of successful outcome in pregnancy in women with this disorder. We describe the successful analgesic management of an obstetric patient who had been known to have Ebstein's anomaly since childhood. Her first pregnancy was uneventful and analgesia during labour was provided by an epidural. During her second pregnancy she presented to our hospital as her condition had deteriorated. Symptomatic control was achieved with digoxin. Despite this, several episodes of hospitalization were needed pre-partum for rest and oxygen therapy. After the onset of spontaneous labour, analgesia was managed by an epidural using bupivacaine. Invasive monitoring was not deemed appropriate due to increased risk and questionable usefulness. Vaginal delivery was managed with elective lift-out forceps to minimize the stress of pushing. When reviewed two months post-partum she still required digoxin although her symptoms had improved considerably. The successful management of Ebstein's anomaly in pregnancy should include team management from early in pregnancy.
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Affiliation(s)
- E R Groves
- Department of Anaesthetics, Northern General Hospital, Sheffield, UK
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