Low dose combined spinal-epidural anaesthesia for caesarean section in a patient with peripartum cardiomyopathy

Low-dose spinal block combined with epidural volume extension in a high-risk cardiac patient: A case-based systematic literature review

Background:

Anesthetic management of patients with severe cardiac disease can be challenging during prolonged surgical procedures. Thus, alternative neuraxial anesthetic techniques have been described to avoid general anesthesia in these patients.

Methods:

A case-based systematic literature review on low-dose spinal block combined with different methods of epidural block extension in high-risk cardiac patients was performed.

Results:

We describe the successful management of a patient with poor left ventricular function who underwent excision arthroplasty of an infected hip prosthesis under low-dose spinal block with levobupivacaine 5 mg and fentanyl 15 μg combined with saline epidural volume extension (EVE). Epidural ropivacaine 0.75% was administered as a bolus of 5 ml followed by an infusion at 5 ml/h later during the course of surgery.

Conclusions:

Although continuous spinal anesthesia (CSA) or epidural anesthesia may limit hemodynamic instability, the possibility of devastating central nervous system infection may prevent CSA use, and epidural block alone may be less reliable than CSA. Epidural block alone may require large volumes of concentrated local anesthetic to obtain sacral block, which may produce hemodynamic instability. The EVE, particularly using saline EVE, has rarely been described in high-risk cardiac patients as an alternative to CSA or epidural block alone, with the intention to avoid general anesthesia, but it has demonstrated efficacy and a low rate of complications. Hemodynamic stability was maintained in most cases.

Anesthetic management of peripartum cardiomyopathy

INTRODUCTION

Peripartum cardiomyopathy (PPCM) is a rare idiopathic cardiomyopathy frequently presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery. Within the published literature, there are case reports extolling the safety of both regional and general anesthetic interventions in PPCM. However, there is an absence of high-quality evidence to define a suitable paradigm for peri-operative care. In the absence of a large prospective case series or clinical trials, the synthesis of clinical data from published case reports provides an opportunity to distil published clinical data and explore the effect of clinical interventions.

EVIDENCE ACQUISITION

A systematic search of English articles English language case reports published between 1986 and 2020 within multiple databases. Clinical data was extracted and aggregated into a database for analysis.

EVIDENCE SYNTHESIS

Gestational hypertension and pre-eclampsia were pre-partum risk factors. 403 case reports provided 466 individual cases from 48 countries. Neither regional nor general anesthetic interventions in the peripartum period have a discernible impact on the outcome of patients with PPCM. Rapid unpredictable deterioration in the peripartum period, requiring mechanical cardiac support or heart transplantation is described. The mortality of PPCM is 5-6%.

CONCLUSIONS

Patients with PPCM are at risk of rapid unpredictable decline. Management within specialist centers should be considered. Although the data is unsuitable to provide a comprehensive paradigm for the anesthetic and critical care management of PPCM, the observations provide a direction for future clinical audits and trials.

Emergency cesarean section in peripartum cardiomyopathy

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.

The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs

Since 2006, the Canadian Cardiovascular Society heart failure (HF) guidelines have published annual focused updates for cardiovascular care providers. The 2010 Canadian Cardiovascular Society HF guidelines update focuses on an increasing issue in the western world - HF in ethnic minorities - and in an uncommon but important setting - the pregnant patient. Additionally, due to increasing attention recently given to the assessment of how care is delivered and measured, two critically important topics - disease management programs in HF and quality assurance - have been included. Both of these topics were written from a clinical perspective. It is hoped that the present update will become a useful tool for health care providers and planners in the ongoing evolution of care for HF patients in Canada.

[Anesthetic management for a pregnant woman with Chagas cardiomyopathy]

Chagas disease, or American trypanosomiasis, is a parasitic disease caused by the protozoan Trypanosoma cruzi, which is native to the Americas. We report the case of a 35-year-old woman in her 37th week of pregnancy who required a cesarean section after being diagnosed with chronic-stage Chagas disease involving the heart and the digestive system. We discuss the anesthetic technique used, the principal pathophysiologic features of the cardiomyopathy and megaesophagus seen in this disease, and their implications for anesthetic management. We review the different clinical stages of the disease, its diagnosis and treatment, and the main routes of transmission, with special emphasis on the transfusion route in nonendemic areas.

Cardiomyopathy in pregnancy and caesarean section: Four case reports

We present the clinical details of four women with cardiomyopathy who required caesarean section. Two women had peripartum cardiomyopathy and two had hypertrophic obstructive cardiomyopathy, one of whom has had two caesarean sections. Those with peripartum cardiomyopathy were more compromised than those with hypertrophic obstructive cardiomyopathy. Co-operation between obstetric and cardiac anaesthetists ensured optimum experience was available. An incremental combined spinal-epidural technique with invasive monitoring was used for three women and one received general anaesthesia. The risks and benefits of different anaesthetic techniques are discussed.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare cardiac disorder associated with high rates of mortality that occurs during the peripartum period. PPCM is recognized as a distinct entity, separate from preexisting cardiomyopathies that are worsened by the stressors of pregnancy. To date, its etiology is unknown, although several theories are under investigation in an effort to provide more information regarding available treatment options. A multidisciplinary review of PPCM held by the National Heart, Lung, and Blood Institute, in conjunction with the Office of Rare Disease of the National Institutes of Health, in April 1997 reviewed the current knowledge and developed recommendations for areas of further research and education about PPCM. Since then, there have been some promising research testing hypotheses regarding the etiology of PPCM and advancements in possible treatment options. However, despite these efforts, knowledge and treatment recommendations about PPCM are still generally unchanged, whereas mortality rates remain high. This article attempts to provide an updated, comprehensive review about PPCM and draw attention to areas in need of further research.

Low-dose sequential combined spinal-epidural: an anaesthetic technique for caesarean section in patients with significant cardiac disease

In the United Kingdom, cardiac disease is the second most common cause of all maternal deaths. The best anaesthetic technique for caesarean section in these patients has yet to be established. We describe a low-dose combined spinal-epidural technique in four high-risk obstetric patients who presented to this unit. Invasive monitoring was used in each case, and drugs with significant cardiovascular effects were avoided or used with extreme caution. Multidisciplinary team involvement, including serial echocardiography in the antenatal period, is strongly recommended.

UK registry of high-risk obstetric anaesthesia: report on cardiorespiratory disease

Forms were sent to members of the Obstetric Anaesthetists' Association requesting information on cardiorespiratory disease in pregnancy. Reports of 274 pregnancies in 259 women were received over four years (1997-2000). There were 83 valve lesions, 52 complex congenital heart disease, 112 miscellaneous heart disease and 27 respiratory disease. Half the mothers were classified as New York Heart Association grade I, 29% grade II, 14% grade III, 5% grade IV and six unknown. Thirty-nine mothers were seen by an anaesthetist only just before delivery. Regional analgesia for labour was more likely to be planned for severe (82%) than for mild symptoms (55%; P=0.039), but severity of symptoms did not affect choice of anaesthesia for caesarean section. Eighty-one women were delivered by elective caesarean section, 59 by emergency caesarean section, 82 had spontaneous and 49 assisted vaginal delivery. Three women suffered miscarriages. Regional analgesia was used in 73% of vaginal deliveries, Entonox or pethidine in 15% and no analgesia in 12%. Spinal anaesthesia was used in 21% of caesarean sections, an incremental regional technique (incremental epidural or combined spinal-epidural) in 40% and general anaesthesia in 39%. Forty-three women were admitted to intensive care units electively and 10 unplanned. Ninety-five per cent survived pregnancy in the same state as antepartum, 2% deteriorated and seven died. Ninety-four per cent of babies (258 babies) were delivered in good condition, nine in poor condition and seven died. Despite lack of denominator data and potential biases among the reported cases, the Registry provides a valuable snapshot of current practice in the UK.

Anaesthesia in parturients with heart disease: a five year review in an Australian tertiary hospital

At the Royal Women's Hospital, Queensland, between 1993 and 1997 there were 56 vaginal and 22 caesarean deliveries involving 68 women with heart disease. Over half of those women required anaesthetic input, in particular, the women who had the most serious cardiac compromise. There were two maternal deaths, four unbooked and five booked admissions to intensive or coronary care unit.

Peripartum cardiomyopathy and thromboembolism; anesthetic management and clinical course of an obese, diabetic patient

PURPOSE

To describe the anesthetic management and clinical course of a patient with peripartum cardiomyopathy. We highlight the frequent occurrence of thromboembolic morbidity in this group of parturients, emphasizing the need for early consideration of prophylactic anticoagulation.

CLINICAL FEATURES

A 38-yr-old, diabetic, obese parturient was admitted with pulmonary edema and severe orthopnea at 31 weeks gestation. The respiratory rate was 44 breaths x min(-1), blood pressure 110/70 mmHg, pulse 120 beats x min(-1) and rales were heard in both lung fields. The diagnosis of peripartum cardiomyopathy was made based on sinus tachycardia with no evidence of ischemia on the electrocardiogram, and global left ventricular hypokinesis with an ejection fraction of 40-45% noted on transthoracic echocardiography. Cesarean delivery was planned to improve maternal respiratory status and hemodynamics. General anesthesia with invasive monitoring was planned, and surgery and anesthesia proceeded uneventfully. Less than 24 hr postoperatively, she sustained a thrombotic cerebral infarct leaving her hemiparetic and dysarthric. Subsequent investigations revealed a thrombophilic state due to elevated anticardiolipin antibody.

CONCLUSION

General anesthesia is an acceptable option in parturients with heart failure secondary to cardiomyopathy. Thromboembolic complications are common, and early consideration should be given to prophylactic anticoagulation.