Shunt flow and pulmonary hemodynamics during labor and delivery in the Eisenmenger syndrome

Exacerbation of underlying pulmonary disease in pregnancy

This article examines the management and outcomes of pregnant women with cystic fibrosis, primary pulmonary hypertension, and sarcoidosis. Pregnancy and the puerperium are associated with important cardiopulmonary changes that can adversely affect the clinical condition. Management of pregnant women with CF should be done with careful attention to complications of altered body weight, diabetes, and liver disease. Primary pulmonary hypertension is characterized by a progressive increase in pulmonary pressure and resistance in the absence of an identified cardiac or pulmonary cause. A multidisciplinary approach to the management of patients with primary pulmonary hypertension is of great importance for a successful maternal and fetal outcome. Good maternal and fetal outcomes are possible in women with restrictive lung disease in general and sarcoidosis in particular. The management of pregnancy, labor, and delivery are not altered by the presence of sarcoidosis.

Successful management of a pregnancy at high risk because of Eisenmenger reaction

Informed medical care, appropriate maternal and fetal monitoring, and cooperation among experienced obstetricians, anesthesists cardiologists, particularly during delivery and the early puerperium associated with psychological preparation of the mother, were the bases of the successful management of a pregnant 28-year-old woman at high risk because of the Eisenmenger reaction.

Management of labor in Eisenmenger syndrome with inhaled nitric oxide

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.

Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996

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.

Cyanotic congenital heart disease and pregnancy: natural selection, pulmonary hypertension, and anesthesia

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.

Eisenmenger's syndrome and pregnancy

Two cases of successfully managed Eisenmenger's syndrome during pregnancy are reported. A women suffering from Eisenmenger's syndrome who becomes pregnant should be advised to have her pregnancy terminated. On the basis of the available literature and our own experiences we suggest the following plan, if a woman, despite medical advice, chooses to continue her pregnancy: admission to hospital at approximately 25 weeks of gestation; bed rest during the remaining period of pregnancy; oxygen face-mask during episodes of dyspnoea; determination of serial blood gases to detect changes in the shunt flow. At the onset of labour, arterial and epidural catheters should be inserted, a fall in blood pressure should immediately be counteracted by the administration of norepinephrine and loss of blood by transfusion. The patient should remain in hospital for 7-14 days after delivery.

Congenital heart disease in pregnancy: short- and long-term implications

One hundred forty-four pregnancies that occurred in 74 patients with congenital heart disease at the Toronto General Hospital between 1975 and 1986 were reviewed. The patients were divided into two groups, those with acyanotic lesions and those with cyanotic lesions. Maternal and fetal outcomes in these two groups were compared. Patients with cyanotic lesions developed significantly more congestive heart failure and deteriorated more often in functional cardiac status than those with acyanotic lesions (p less than 0.005). Women with obstructive lesions had a higher incidence of pregnancy-induced hypertension than our general population (p less than 0.005). There was one maternal death in the puerperium in a woman with Eisenmenger's syndrome. Preterm births were more frequent in the cyanotic group (p less than 0.01) as were small for gestational age infants (p less than 0.005). In the cyanotic group the mean birth weight was 900 gm less than that in the acyanotic group (p less than 0.005). The major benefits of corrective cardiac surgery were in the cyanotic group and consisted of fewer spontaneous abortions (p less than 0.01) and small for gestational age infants (p less than 0.02) and more term births (p less than 0.01). Long-term follow-up revealed that 19.2% of women with acyanotic lesions had significant cardiac developments, compared with 90% in the cyanotic group (p less than 0.005). One of 87 infants (1.1%) had congenital heart disease and two had Marfan's syndrome.

Anaesthesia for a patient with Down's syndrome and Eisenmenger's complex

A patient with Down's syndrome and Eisenmenger's complex presented for orthopaedic surgery on the elbow under general anaesthesia. During pre-oxygenation, in order to prevent a subsequent fall in systemic vascular resistance, metaraminol 1 mg was administered intravenously. The patient immediately developed bradycardia, mild hypertension and became deeply cyanosed. His condition rapidly improved after atropine 0.6 mg was given intravenously. Following induction of anaesthesia with thiopentone and tracheal intubation facilitated by suxamethonium, anaesthesia was maintained by mechanical ventilation of the lungs with nitrous oxide and oxygen (40%) with intravenous increments of fentanyl for analgesia and pancuronium for muscle relaxation; residual neuromuscular blockade was reversed with neostigmine. The patient made an eventful recovery. Although general anaesthesia is tolerated by patients with Eisenmenger's complex, powerful vasoactive drugs should not be administered unless specifically indicated.

Clinical problems of postoperative pulmonary vascular disease

The younger the patient with a large left to right shunt at the time of operation, the greater the likelihood that pulmonary vascular resistance will fall to normal thereafter. In older patients, the degree to which the pulmonary vascular resistance is elevated before operation is a critical factor determining operability and prognosis. Patients at particularly high risk for the development of significant pulmonary vascular obstruction early in life are those with certain forms of cyanotic congenital heart disease, such as complete transposition of the great arteries with ventricular septal defect and patent ductus arteriosus, and truncus arteriosus. Other conditions in which pulmonary vascular obstruction appears to progress rapidly include large ventricular septal defect, complete atrioventricular canal defect and left to right shunt lesions in an environment of high altitude or associated with unilateral pulmonary arterial absence of the Down's syndrome. In this report the framework is reviewed for recognizing that important pre- and postnatal modifiers of the pulmonary vascular bed may be lesion-dependent. Thus, the growth and development of the pulmonary vascular bed during fetal and early postnatal life, as well as the morphologic alterations described in detail by Heath and Edwards, are likely to determine the ultimate intensity and magnitude of pulmonary vascular obstruction. Commentary is also provided concerning the management of patients with high pulmonary vascular resistance during pregnancy and delivery, their response to exercise, and the possibility of medical treatment designed to reduce pulmonary vascular resistance, and perhaps prolong life and enhance its quality.

Complications of pulmonary artery catheterization of obstetric patients

Twenty-one obstetric patients in whom pulmonary artery catheters had been inserted were studied. Complications were minor in nature and unassociated with adverse sequelae. They included transient premature ventricular contraction on insertion of the catheter in two cases and a ruptured balloon and a positive culture of the catheter tip in one case.

Invasive hemodynamic monitoring in critically ill pregnant patients: role of Swan-Ganz catheterization

Pulmonary artery flow-directed (Swan-Ganz [SG]) catheters are widely accepted as an integral part of the modern management of critically ill patients. Their use permits rational therapeutic decisions to be made on the basis of continuously evolving indices of ventricular function. The information which may be derived from these monitors and the complications associated with their use are outlined. The related reports in the obstetric literature and the authors' 3-year experience are discussed. It is concluded that SG catheterization can be of value in the hemodynamically unstable parturient patient.