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Vinsard PA, Arendt KW, Sharpe EE. Care for the Obstetric Patient with Complex Cardiac Disease. Adv Anesth 2023; 41:53-69. [PMID: 38251622 DOI: 10.1016/j.aan.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.
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Affiliation(s)
- Patrice A Vinsard
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Albertini L, Spears DA. Management of arrhythmias during pregnancy. Heart Rhythm O2 2023; 4:597-598. [PMID: 37936664 PMCID: PMC10626184 DOI: 10.1016/j.hroo.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Affiliation(s)
- Lisa Albertini
- Toronto General Hospital, University Health Network Toronto, Ontario, Canada
| | - Danna A. Spears
- Toronto General Hospital, University Health Network Toronto, Ontario, Canada
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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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Pregnancy-Associated Myocardial Infarction: A Review of Current Practices and Guidelines. Curr Cardiol Rep 2021; 23:142. [PMID: 34410528 DOI: 10.1007/s11886-021-01579-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Pregnancy-associated myocardial infarction is a principal cause of cardiovascular disease with a steadily rising incidence of 4.98 AMI events/100,000 deliveries over the last four decades in the USA. It is also linked with significant maternal and fetal morbidity and mortality, with maternal case fatality rate ranging from 5.1 to 37%. The management of acute myocardial infarction can be challenging in pregnant patients since treatment modalities and medication use are limited by their safety during pregnancy. RECENT FINDINGS Limited guidelines exist regarding the management of pregnancy-associated myocardial infarction. Routinely used medications in myocardial infarction including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and statin therapy are contraindicated during pregnancy. Aspirin use is considered safe in pregnant women, but dual antiplatelet therapy and therapeutic anticoagulation can be associated with increased risk of maternal and fetal complications, and should only be used after a comprehensive benefit-to-risk assessment. The standard approach to revascularization requires additional caution in pregnant women. Percutaneous coronary intervention is generally considered safe but can be associated with high failure rates and poor outcomes depending on the etiology. Fibrinolytic therapy may have significant sequelae in pregnant patients, and hemodynamic management during surgery is complex and adds risk during pregnancy. Understanding the risks and benefits of the different treatment modalities available and their utility depending on the underlying etiology, encompassed with a multidisciplinary team approach, is vital to improve outcomes and minimize maternal and fetal complications.
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Schumer A, Contag S. Catecholaminergic polymorphic ventricular tachycardia in pregnancy: a case report. J Med Case Rep 2020; 14:238. [PMID: 33292493 PMCID: PMC7724802 DOI: 10.1186/s13256-020-02569-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/28/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a genetic disorder that can cause fatal tachyarrhythmias brought on by physical or emotional stress. There is little reported in the literature regarding management of CPVT in pregnancy much less during labor. Case presentation A gravida 2, para 1 presented to our high-risk clinic at 15 weeks gestation with known CPVT. The Caucasian female patient had been diagnosed after experiencing a cardiac arrest following a motor vehicle accident and found to have a pathogenic cardiac ryanodine receptor mutation. An implantable cardioverter defibrillator was placed at that time. Her pregnancy was uncomplicated, and she was medically managed with metoprolol, flecainide, and verapamil. Her labor course and successful vaginal delivery were uncomplicated and involved a multidisciplinary team comprising specialists in electrophysiology, maternal fetal medicine, anesthesiology, general obstetrics, lactation, and neonatology. Conclusions CPVT is likely underdiagnosed and, given that cardiovascular disease is a leading cause of death in pregnancy, it is important to bring further awareness to the diagnosis and management of this inherited arrhythmia syndrome in pregnancy.
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Affiliation(s)
- Amy Schumer
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
| | - Stephen Contag
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
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Abstract
Maternal heart disease has emerged as a major threat to safe motherhood and women's long-term cardiovascular health. In the United States, disease and dysfunction of the heart and vascular system as "cardiovascular disease" is now the leading cause of death in pregnant women and women in the postpartum period () accounting for 4.23 deaths per 100,000 live births, a rate almost twice that of the United Kingdom (). The most recent data indicate that cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths (). Of further concern are the disparities in cardiovascular disease outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women. Contributing factors include barriers to prepregnancy cardiovascular disease assessment, missed opportunities to identify cardiovascular disease risk factors during prenatal care, gaps in high-risk intrapartum care, and delays in recognition of cardiovascular disease symptoms during the puerperium. The purpose of this document is to 1) describe the prevalence and effect of heart disease among pregnant and postpartum women; 2) provide guidance for early antepartum and postpartum risk factor identification and modification; 3) outline common cardiovascular disorders that cause morbidity and mortality during pregnancy and the puerperium; 4) describe recommendations for care for pregnant and postpartum women with preexisting or new-onset acquired heart disease; and 5) present a comprehensive interpregnancy care plan for women with heart disease.
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Kumagai A, Makino S, Takeda J, Hirai C, Inoue R, Sumikura H, Itakura A, Takeda S. Characteristics of labor-onset hypertension persist after neuraxial labor analgesia. J Obstet Gynaecol Res 2019; 46:104-109. [PMID: 31621113 DOI: 10.1111/jog.14140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 09/25/2019] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to investigate the rate of labor-onset hypertension (LOH) under neuraxial labor analgesia and the effect of neuraxial labor analgesia on LOH. METHODS A retrospective study was conducted in a tertiary university hospital from 2015 to 2016. Patients who were admitted to the hospital for vaginal delivery under combined spinal and epidural anesthesia were selected. LOH was defined as the elevation of systolic blood pressure (BP) to ≥140 mmHg or diastolic BP to ≥90 mmHg for the first time after the onset of labor. Cases of LOH that persisted after neuraxial labor analgesia (prolonged LOH) were further analyzed to determine the hypertension severity and therapeutic intervention rate. RESULTS Among 775 patients, 213 (28.4%) developed LOH. Prolonged LOH was observed in 30 patients (3.9%). LOH severity and the likelihood of prolonged LOH were positively correlated. Therapeutic intervention was administered only to the patients with prolonged LOH, that is, to 100% of those with emergent hypertension, to 21.1% of those with severe hypertension during labor, and to 36.8% of those with severe hypertension, to 55.6% of those with mild hypertension in the post-partum period. CONCLUSION The rate of LOH was reduced significantly after neuraxial labor analgesia. Patients with prolonged LOH should be carefully followed up during labor and in the post-partum period because such patients often require antihypertensive therapy.
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Affiliation(s)
- Asako Kumagai
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo, Japan
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo, Japan
| | - Jun Takeda
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo, Japan
| | - Chihiro Hirai
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo, Japan
| | - Rie Inoue
- Department of Anesthesiology, Juntendo University, Tokyo, Japan
| | | | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo, Japan
| | - Satoru Takeda
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo, Japan
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Kendall MC. The importance of a standard obstetric analgesia regimen during labor. Taiwan J Obstet Gynecol 2018; 57:620. [PMID: 30122594 DOI: 10.1016/j.tjog.2018.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- Mark C Kendall
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, United States.
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