1
|
Sumarli A, Choi J, Wong V, Aluzri N, Pineda L, Reynoso E, Lodenkamp K, Kim U. Cesarean Section in a Group 1 Pulmonary Hypertension Parturient Patient: A Case Report. Cureus 2024; 16:e63390. [PMID: 39070444 PMCID: PMC11283848 DOI: 10.7759/cureus.63390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 07/30/2024] Open
Abstract
Severe pulmonary hypertension (PH) during pregnancy poses considerable challenges due to the physiological changes and increased cardiovascular demands. Close multidisciplinary management is essential throughout the peripartum period. The critical steps taken to provide anesthesia safely and successfully for a planned cesarian section are outlined, with special care for communication between the cardiothoracic surgery and obstetric team. A 31-year-old G3P1112 (three pregnancies, one term delivery, one pre-term delivery, one abortion, with two living children) patient with a history of systemic lupus erythematosus complicated by Group 1 PH presented to the operating room for a planned 34-week cesarean section. Pulmonary artery systolic pressure (PASP) was noted to be 68 mmHg at this time. Intravenous (IV) treprostinil at 8 ng/kg/min through a tunneled right subclavian line was initiated in her third trimester, and a day before her cesarean section, she was admitted for a lumbar epidural catheter placement. In the operating room, IV treprostinil was continued and a high-flow nasal cannula with inhaled nitric oxide at 20 ppm was initiated. A right internal jugular vein pulmonary artery catheter was placed for close monitoring of her pulmonary artery pressures, with a PASP reading of 64 mmHg at the start of the case. Femoral arterial and venous access was placed by the cardiothoracic surgery team for cardiopulmonary bypass standby. Intra-operative surgical analgesia was achieved by epidural lidocaine. A cesarean section was performed and was uncomplicated despite her post-delivery autotransfusion, where her PASP went as high as 89 mmHg. Uterine atony was managed with an oxytocin infusion. Epidural morphine was administered through the epidural catheter for post-operative analgesia. In the post-operative recovery room, her PASP was back down to baseline at 62 mmHg. The patient proceeded to have an uneventful postpartum hospital stay and was discharged home without any complications. While severe PH poses a challenge in the care of a parturient patient, safe and successful management may be achieved as outlined in this case report.
Collapse
Affiliation(s)
- Alexander Sumarli
- Anesthesiology, Loma Linda University School of Medicine, Loma Linda, USA
| | - Jeannie Choi
- Anesthesiology, Loma Linda University School of Medicine, Loma Linda, USA
| | - Vincent Wong
- Anesthesiology, Loma Linda University School of Medicine, Loma Linda, USA
| | - Nadia Aluzri
- Anesthesiology, Loma Linda University School of Medicine, Loma Linda, USA
| | - Lauren Pineda
- Anesthesiology, Loma Linda University School of Medicine, Loma Linda, USA
| | - Edgardo Reynoso
- Anesthesiology, Loma Linda University School of Medicine, Loma Linda, USA
| | - Kara Lodenkamp
- Anesthesiology, Loma Linda University School of Medicine, Loma Linda, USA
| | - Uoo Kim
- Anesthesiology and Perioperative Medicine, Loma Linda University Medical Center, Loma Linda, USA
| |
Collapse
|
2
|
Coursen J, Simpson CE, Mukherjee M, Vaught AJ, Kutty S, Al-Talib TK, Wood MJ, Scott NS, Mathai SC, Sharma G. Pregnancy Considerations in the Multidisciplinary Care of Patients with Pulmonary Arterial Hypertension. J Cardiovasc Dev Dis 2022; 9:jcdd9080260. [PMID: 36005424 PMCID: PMC9409449 DOI: 10.3390/jcdd9080260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/26/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a vasoconstrictive disease of the distal pulmonary vasculature resulting in adverse right heart remodeling. Pregnancy in PAH patients is associated with high maternal morbidity and mortality as well as neonatal and fetal complications. Pregnancy-associated changes in the cardiovascular, pulmonary, hormonal, and thrombotic systems challenge the complex PAH physiology. Due to the high risks, patients with PAH are currently counseled against pregnancy based on international consensus guidelines, but there are promising signs of improving outcomes, particularly for patients with mild disease. For patients who become pregnant, multidisciplinary care at a PAH specialist center is needed for peripartum monitoring, medication management, delivery, postpartum care, and complication management. Patients with PAH also require disease-specific counseling on contraception and breastfeeding. In this review, we detail the considerations for reproductive planning, pregnancy, and delivery for the multidisciplinary care of a patient with PAH.
Collapse
Affiliation(s)
- Julie Coursen
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Catherine E. Simpson
- Divisions of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Monica Mukherjee
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Arthur J. Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology Obstetrics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Shelby Kutty
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Tala K. Al-Talib
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Malissa J. Wood
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Nandita S. Scott
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Stephen C. Mathai
- Divisions of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
- Correspondence:
| |
Collapse
|
3
|
Abstract
Management of pregnant women with heart disease remains challenging due to the advancement of innovations in cardiac surgery and correction of complex cardiac anomalies, and more recently, with the successful performance of heart transplants, cardiac diseases are not only likely to coexist with pregnancy, but will also increase in frequency over the years to come. In developing countries with a higher prevalence of rheumatic fever, cardiac disease may complicate as many as 5.9% of pregnancies with a high incidence of maternal death. Since many of these deaths occur during or immediately following parturition, heart disease is of special importance to the anesthesiologist. This importance arises from the fact that drugs used for preventing or relieving pain during labor and delivery exert a major influence - for better or for worse - on the prognosis of the mother and newborn. Properly administered anesthesia and analgesia can contribute to the reduction of maternal and neonatal mortality and morbidity.
Collapse
Affiliation(s)
- Ankur Luthra
- Department of Anaesthesia and Intensive Care, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritika Bajaj
- Department of Obstetrics and Gynaecology, Jindal IVF and Sant Memorial Nursing Home, Sector 20, Chandigarh, India
| | - Anudeep Jafra
- Department of Anaesthesia and Intensive Care, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - VK Arya
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
4
|
Lata S, Prakash MVSS, Balachander H. Emergency cesarean section in peripartum cardiomyopathy. Anesth Essays Res 2015; 6:91-3. [PMID: 25885512 PMCID: PMC4173436 DOI: 10.4103/0259-1162.103386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is defined as onset of acute heart failure without demonstrable cause in last trimester of pregnancy or within the first 6 months after delivery. We report a case of PPCM with left ventricular ejection fraction less than 25% who had reported to us at 38 weeks of gestation for emergency caesarean section managed with graded epidural anaesthesia. PPCM is a form of dilated cadiomyopathy with left ventricular systolic dysfunction that results in signs and symptoms of heart failure.
Collapse
Affiliation(s)
- Suman Lata
- Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry, India
| | | | | |
Collapse
|
5
|
Celik M, Dostbil A, Alici HA, Sevimli S, Aksoy A, Erdem AF, Kürşad H. Anaesthetic management for caesarean section surgery in two pregnant women with severe pulmonary hypertension due to mitral valve stenosis. Balkan Med J 2013; 30:439-41. [PMID: 25207156 DOI: 10.5152/balkanmedj.2013.8416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 07/25/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Mitral stenosis is the most important and common cardiac complication seen during pregnancy. Conception is discouraged in cases where pulmonary hypertension develops during the course of mitral stenosis. Successful general and regional anaesthetic interventions have been reported in some cases of severe pulmonary hypertension. CASE REPORTS We present our experiences with anaesthetic management in two pregnant patients with pulmonary hypertension due to mitral valve stenosis. CONCLUSION We preferred to continue spinal anaesthesia because gradually increasing the local anaesthetic dose during the procedure may minimise probable undesirable haemodynamic changes, such as hypotension and tachycardia.
Collapse
Affiliation(s)
- Mine Celik
- Department of Anesthesiology and Reanimation, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Ayşenur Dostbil
- Department of Anesthesiology and Reanimation, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Hacı Ahmet Alici
- Department of Anesthesiology and Reanimation, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Serdar Sevimli
- Department of Cardiology, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Ayşenur Aksoy
- Department of Obstetric and Gynecology, Nenehatun Hospital, Erzurum, Turkey
| | - Ali Fuat Erdem
- Department of Anesthesiology and Reanimation, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Hüsnü Kürşad
- Department of Anesthesiology and Reanimation, Atatürk University Faculty of Medicine, Erzurum, Turkey
| |
Collapse
|
6
|
Elgebaly AS, Elhawary T. General anaesthesia versus combined spinal epidural anaesthesia in the presence of mild to moderate pericardial effusion: A study of volunteers undergoing caesarean section. EGYPTIAN JOURNAL OF ANAESTHESIA 2013. [DOI: 10.1016/j.egja.2012.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Ahmed S. Elgebaly
- Department of Anesthesia and SICUD, Faculty of Medicine , Tanta University , Egypt
| | - Tark Elhawary
- Department of Obstetrics and Gynecology, Faculty of Medicine , Tanta University , Egypt
| |
Collapse
|
7
|
Curry RA, Fletcher C, Gelson E, Gatzoulis MA, Woolnough M, Richards N, Swan L, Steer PJ, Johnson MR. Pulmonary hypertension and pregnancy-a review of 12 pregnancies in nine women. BJOG 2012; 119:752-61. [DOI: 10.1111/j.1471-0528.2012.03295.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
8
|
[Management of cardiac high risk pregnancy. Caesarean section in a primagravida with cyanotic cardiac defect]. Anaesthesist 2010; 60:57-62. [PMID: 20552151 DOI: 10.1007/s00101-010-1741-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A 37-year-old gravida I with cyanotic heart disease presented for caesarean section in the 31st week of gestation. Caesarean section was performed uneventfully with the patient under epidural anaesthesia accompanied by invasive monitoring. Postoperative echocardiography showed no change in the shunt fraction, volumes or the ventricular function. Every patient with complex comorbidities has to be managed according to individual prerequisites and the experiences and preferences of the team. For such high risk pregnancies regional anaesthesia seems to be a possible option although no clear evidence can be found in the literature.
Collapse
|
9
|
Lata I, Gupta R, Sahu S, Singh H. Emergency management of decompensated peripartum cardiomyopathy. J Emerg Trauma Shock 2009; 2:124-8. [PMID: 19561973 PMCID: PMC2700591 DOI: 10.4103/0974-2700.50748] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 11/22/2008] [Indexed: 12/16/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a rare life-threatening cardiomyopathy of unknown cause that occurs in the peripartum period in previously healthy women.[1] the symptomatic patients should receive standard therapy for heart failure, managed by a multidisciplinary team. The diagnosis of PPCM rests on the echocardiographic identification of new left ventricular systolic dysfunction during a limited period surrounding parturition. Diagnostic criteria include an ejection fraction of less than 45%, fractional shortening of less than 30%, or both, and end-diastolic dimension of greater than 2.7 cm/m(2) body surface-area. This entity presents a diagnostic challenge because many women in the last month of a normal pregnancy experience dyspnea, fatigue, and pedal edema, symptoms identical to early congestive heart failure. There are no specific criteria for differentiating subtle symptoms of heart failure from normal late pregnancy. Therefore, it is important that a high index of suspicion be maintained to identify the rare case of PPCM as general examination showing symptoms of heart failure with pulmonary edema. PPCM remains a diagnosis of exclusion. No additional specific criteria have been identified to allow distinction between a peripartum patient with new onset heart failure and left ventricular systolic dysfunction as PPCM and another form of dilated cardiomyopathy. Therefore, all other causes of dilated cardiomyopathy with heart failure must be systematically excluded before accepting the designation of PPCM. Recent observations from Haiti[2] suggest that a latent form of PPCM without clinical symptoms might exist. The investigators identified four clinically normal postpartum women with asymptomatic systolic dysfunction on echocardiography, who subsequently either developed clinically detectable dilated cardiomyopathy or improved and completely recovered heart function.
Collapse
Affiliation(s)
- Indu Lata
- Department of Obstetrics and Gynaecology V.M.M.C and Safdarjung Hospital, N. Delhi, India
| | - Renu Gupta
- Department of Obstetrics and Gynaecology, G.S.V.M. Medical College, Kanpur, India
| | - Sandeep Sahu
- Department of Anaesthesiology, G.S.V.M. Medical College, Kanpur, India
| | - Harpreet Singh
- Department of Anaesthesiology, G.S.V.M. Medical College, Kanpur, India
| |
Collapse
|
10
|
Olofsson CH, Bremme K, Forssell G, Öhqvist G. Cesarean section under epidural ropivacaine 0.75% in a parturient with severe pulmonary hypertension. Acta Anaesthesiol Scand 2008. [DOI: 10.1111/j.1399-6576.2001.450220.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
11
|
Abstract
Cardiac disorders complicate less than 1% of all pregnancies. Physiologic changes in pregnancy may mimic heart disease. In order to differentiate these adaptations from pathologic conditions, an in-depth knowledge of cardiovascular physiology is mandatory. A comprehensive history, physical examination, electrocardiogram, chest radiograph, and echocardiogram are sufficient in most cases to confirm the diagnosis. Care of women with cardiac disease begins with preconception counseling. Severe lesions should be taken care of prior to contemplating pregnancy. Management principles for pregnant women are similar to those for the non-pregnant state. A team approach comprised of a maternal fetal medicine specialist, cardiologist, neonatologist, and anesthesiologist is essential to assure optimal outcome for both the mother and the fetus. Although fetal heart disease complicates only a small percentage of pregnancies, congenital heart disease causes more neonatal morbidity and mortality than any other congenital malformation. Unfortunately, screening approaches for fetal heart disease continue to miss a large percentage of cases. This weakness in fetal screening has important clinical implications, because the prenatal detection and diagnosis of congenital heart disease may improve the outcome for many of these fetal patients. In fact, simply the detection of major heart disease prenatally can improve neonatal outcome by avoiding discharge to home of neonates with ductal-dependent congenital heart disease. Fortunately, recent advances in screening techniques, an increased ability to change the prenatal natural history of many forms of fetal heart disease, and an increasing recognition of the importance of a multidisciplinary, team approach to the management of pregnancies complicated with fetal heart disease, together promise to improve the outcome of the fetus with congenital heart disease.
Collapse
Affiliation(s)
- Afshan B Hameed
- Maternal Fetal Medicine and Cardiology, University of California, Irvine, USA
| | | |
Collapse
|
12
|
Vial F, Bayoumeu F, Marçon F, Dupays R, Chillet-Mion M, Laxenaire MC. [General anaesthesia for Caesarean section in a patient with pulmonary atresia and an intact intraventricular septum]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2003; 22:548-52. [PMID: 12893383 DOI: 10.1016/s0750-7658(03)00140-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We report the case of a 22-year-old primigravida patient presenting pulmonary atresia with intact ventricular septum, a rare congenital heart disease. Caesarean delivery was performed at 32 weeks of gestation because of moderate maternal function deterioration and foetal growth restriction. General anaesthesia was used because of the presence of lumbar Harrington rods. The administration of etomidate, celocurine and a continuous perfusion of remifentanil right from induction ensured haemodynamic stability and a rapid emergence and recovery.
Collapse
Affiliation(s)
- F Vial
- Service d'anesthésie-réanimation, maternité régionale de Nancy, 10, rue du Docteur-Heydenreich, 54042 Nancy cedex, France.
| | | | | | | | | | | |
Collapse
|
13
|
Gandhimathi K, Atkinson S, Gibson FM. Pulmonary hypertension complicating twin pregnancy: continuous spinal anaesthesia for caesarean section. Int J Obstet Anesth 2002; 11:301-5. [PMID: 15321534 DOI: 10.1054/ijoa.2002.0975] [Citation(s) in RCA: 8] [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
A case of secondary pulmonary hypertension complicating twin pregnancy and necessitating caesarean section is presented. A planned team approach involving senior consultants in obstetrics, cardiology, neonatology and cardiac and obstetric anaesthesia resulted in successful perioperative management. Continuous spinal anaesthesia was the chosen technique to give adequate operating conditions with least haemodynamic disturbance. This is the first report of continuous spinal anaesthesia in such a condition.
Collapse
Affiliation(s)
- K Gandhimathi
- Department of Anaesthetics, Royal Group of Hospitals, Belfast, UK.
| | | | | |
Collapse
|
14
|
Lepoivre T, Legendre E, Pinaud M. [Anesthesia for cesarean section in a patient with McArdle disease and hereditary dilated cardiomyopathy]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:517-20. [PMID: 12134596 DOI: 10.1016/s0750-7658(02)00645-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A caesarean section was indicated in a 29-year-old parturient affected by a muscular deficit in myophosphorylase responsible for a type V glycogen storage disease (McArdle disease). This metabolic myopathy had been diagnosed two years previously, whereas the patient already suffered from a hereditary form of dilated cardiomyopathy. The muscular disease was invalidating on the functional level with exercise intolerance. The cardiopathy was little symptomatic but the dysfunction of the left ventricle worsened during the pregnancy with an ejection fraction calculated to 43%. In this case, we report the realization of a general anaesthesia in a patient who had epidural anaesthesia for a previous caesarean section.
Collapse
Affiliation(s)
- T Lepoivre
- Service d'anesthésie-réanimation chirurgicale, Hôtel-Dieu, 44093 Nantes, France.
| | | | | |
Collapse
|
15
|
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.
Collapse
Affiliation(s)
- C M Palmer
- Department of Anesthesiology, University of Arizona Health Sciences Center, Tucson, AZ 85724-5114, USA.
| | | | | | | |
Collapse
|
16
|
Shnaider R, Ezri T, Szmuk P, Larson S, Warters RD, Katz J. Combined spinal-epidural anesthesia for Cesarean section in a patient with peripartum dilated cardiomyopathy. Can J Anaesth 2001; 48:681-3. [PMID: 11495876 DOI: 10.1007/bf03016203] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To report a case of peripartum dilated cardiomyopathy associated with morbid obesity and possible difficult airway presenting for elective Cesarean section, which was successfully managed with combined spinal-epidural anesthesia. CLINICAL FEATURES A morbidly obese parturient with a potentially difficult airway, suffering from idiopathic peripartum cardiomyopathy (ejection fraction 20%), was scheduled for an elective Cesarean section. A combined spinal epidural anesthesia was performed and 6 mg of bupivacaine were injected into the subarachnoid space. This was supplemented after 60 min with 25 mg of bupivacaine injected epidurally. The patient's hemodynamic status was monitored with direct intra-arterial blood pressure and central venous pressure measurements. The patient's perioperative course was uneventful. CONCLUSION In patients suffering from peripartum cardiomyopathy, undergoing Cesarean section, combined spinal-epidural anesthesia may be an acceptable anesthetic alternative.
Collapse
Affiliation(s)
- R Shnaider
- Department of Anesthesiology University of Texas Medical School at Houston, Houston, Texas 77030, USA
| | | | | | | | | | | |
Collapse
|
17
|
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]
|
18
|
Affiliation(s)
- R M Rodriguez
- Department of Anesthesia, Stanford University Medical Center, California 94305-5117, USA
| | | |
Collapse
|
19
|
|
20
|
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.
Collapse
Affiliation(s)
- B M Weiss
- Department of Anesthesiology, University Hospital, Zurich, Switzerland
| | | | | | | |
Collapse
|
21
|
Abstract
We present a 36-year-old multiparous woman who developed intractable hypotension and cardiac arrest during spinal anaesthesia for elective caesarean section. Cardiopulmonary resuscitation was successful and both mother and baby made a good recovery. Postoperative investigation revealed a dilated cardiomyopathy related to pregnancy. This case highlights the importance of expediting delivery of the neonate during maternal cardiopulmonary resuscitation, the prompt use of adrenaline as inotropic support, and preoperative assessment in apparently healthy parturients.
Collapse
Affiliation(s)
- L Hawthorne
- Department of Anaesthesia, St James's University Hospital, Leeds, UK
| | | |
Collapse
|
22
|
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.
Collapse
Affiliation(s)
- M J Khan
- Department of Anesthesiology, Maricopa Medical Center, Phoenix, AZ 85010, USA
| | | | | |
Collapse
|
23
|
Abstract
OBJECTIVE To ascertain the significance of coexisting pulmonary hypertension in cardiac disease in pregnancy. METHODS Over a 3-year period a group of pregnant women with cardiac disease was followed until 6 weeks postpartum. Twenty women with pulmonary hypertension were compared with 20 controls without pulmonary hypertension with particular reference to maternal and fetal outcome. Analysis of data was carried out using Fisher's exact test and Student's t-test. RESULTS Except for Eisenmenger's syndrome, there were no differences in maternal morbidity and mortality between the two groups. There were more low birth weight babies but no significant differences in premature delivery rate, mode of delivery or perinatal mortality. CONCLUSION Except for Eisenmenger's syndrome, coexisting pulmonary hypertension complicating cardiac disease in pregnancy generally has a favorable outcome for both mother and fetus.
Collapse
Affiliation(s)
- H Tahir
- Department of Obstetrics and Gynaecology, Medical Faculty, Universiti Kebangsaan Malaysia, Kuala Lumpur
| |
Collapse
|
24
|
Smedstad KG, Cramb R, Morison DH. Pulmonary hypertension and pregnancy: a series of eight cases. Can J Anaesth 1994; 41:502-12. [PMID: 8069991 DOI: 10.1007/bf03011545] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
This is the report of a series of eight patients with pulmonary hypertension (primary and secondary) who delivered at the McMaster University Medical Centre between 1978 and 1987. Seven of the eight patients delivered vaginally and had a successful outcome. The eighth patient was admitted as an emergency and died shortly after Caesarean section under general anaesthesia, performed to save the infant. The other seven patients were all managed by a team, including anaesthetists, cardiologists and obstetricians, from about 25 wk. The patients were hospitalized pre-partum and received oxygen therapy and anticoagulation with heparin. Analgesia in labour was managed, once anticoagulation was reversed, by low concentrations of epidural bupivacaine (0.125%-0.375%) and fentanyl. The patients were monitored during labour and delivery with oximetry and arterial and central venous pressure lines. Pulmonary arterial lines were not used because of increased risk and questionable usefulness. Vaginal delivery was managed with vacuum extraction or forceps lift-out to minimize the stress of pushing. After delivery, all patients were monitored in an intensive care unit for several days, anticoagulation was restarted, and all patients were discharged home taking oral anticoagulant therapy. The successful management of pulmonary hypertension in pregnancy should include team management started early in pregnancy and controlled vaginal delivery utilizing epidural analgesia.
Collapse
MESH Headings
- Adult
- Anesthesia, Epidural
- Anesthesia, Obstetrical
- Delivery, Obstetric
- Ductus Arteriosus, Patent/physiopathology
- Eisenmenger Complex/physiopathology
- Female
- Heart Septal Defects, Atrial/physiopathology
- Heart Septal Defects, Ventricular/physiopathology
- Heart Valve Diseases/physiopathology
- Heparin/therapeutic use
- Humans
- Hypertension, Pulmonary/physiopathology
- Hypertension, Pulmonary/prevention & control
- Mitral Valve
- Monitoring, Physiologic
- Obstetric Labor Complications/prevention & control
- Pregnancy
- Pregnancy Complications, Cardiovascular/prevention & control
- Pregnancy Outcome
- Warfarin/therapeutic use
Collapse
Affiliation(s)
- K G Smedstad
- Department of Anaesthesia, McMaster University, Hamilton, Ontario
| | | | | |
Collapse
|
25
|
Weiss BM, Atanassoff PG. Cyanotic congenital heart disease and pregnancy: natural selection, pulmonary hypertension, and anesthesia. J Clin Anesth 1993; 5:332-41. [PMID: 8373615 DOI: 10.1016/0952-8180(93)90130-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Pregnancy carries substantial maternal and fetal risks in patients with uncorrected or palliatively corrected cyanotic congenital heart disease (CHD). In tricuspid valve Ebstein's anomaly, pregnancy is well tolerated. Maternal mortality in tetralogy of Fallot seems to be less than 10%, but it exceeds 50% in Eisenmenger's syndrome and primary pulmonary hypertension (PPH). Maternal hematocrit greater than 60%, arterial oxygen saturation lower than 80%, right ventricular hypertension, and syncopal episodes are poor prognostic signs. Maternal risk could be reduced by vaginal delivery. Continuous monitoring of arterial and central venous pressure, electrocardiography, and pulse oximetry are recommended for every anesthetic procedure. The use of a pulmonary artery catheter is controversial and probably should be avoided in parturients with cyanotic CHD or PPH. The choice of anesthetic technique and drugs per se is of secondary importance and should be governed by individual preferences. Titration of anesthetic drugs, general anesthesia with controlled ventilation, or, preferably, regional anesthesia with spontaneous breathing should be used cautiously to avoid worsening of the preexisting condition. Prevention of excessive erythrocytosis, volume and blood loss substitution, cardiocirculatory pharmacologic support, prophylaxis of infective endocarditis, and judicious use of anticoagulant drugs should be applied as indicated by the type and presentation of CHD. Poor outcome of pregnancy in PPH requires an early consideration of heart-lung or lung transplantation. Multidisciplinary team effort and prolonged monitoring in the intensive care unit are mandatory to ensure a favorable outcome for cyanotic CHD and PPH parturients.
Collapse
Affiliation(s)
- B M Weiss
- Institute of Anesthesiology, University Hospital Zurich, Switzerland
| | | |
Collapse
|
26
|
Affiliation(s)
- M Nootens
- Department of Medicine, University of Illinois College of Medicine, Chicago 60680
| | | |
Collapse
|
27
|
Lenoir B, Freiermuth C, Bonnet A, Marty J. [Cesarean section, mitral valve disease and pulmonary hypertension. Implications of hemodynamic monitoring on anesthetic management]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1993; 12:582-6. [PMID: 8017674 DOI: 10.1016/s0750-7658(05)80626-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We present the case of a 25-year-old woman with mitral valve disease and severe pulmonary hypertension scheduled for Caesarean section under general anaesthesia. General anaesthesia for such cardiac patients requires usually high doses of fentanyl prior to intubation, which favours maternal inhalation and neonatal ventilatory depression. Invasive haemodynamic monitoring allowed a rapid sequence induction, with an optimal drug titration and an early recovery.
Collapse
Affiliation(s)
- B Lenoir
- Service d'Anesthésie-Réanimation, Hôpital Beaujon, Clichy
| | | | | | | |
Collapse
|