Perioperative noninvasive cardiac output monitoring in parturients with singleton and twin pregnancies undergoing cesarean section under spinal anesthesia with prophylactic phenylephrine drip: a prospective observational cohort study

Obstetric anesthesia management of dilated cardiomyopathies and heart failure: a narrative review

Pregnancy in patients with dilated cardiomyopathy carries a significantly increased risk of maternal mortality or severe morbidity, and pregnancy is typically considered contraindicated for patients with severely reduced ventricular function. Nonetheless, anesthesiologists will still encounter patients with cardiomyopathy requiring delivery or termination care. This review describes how NT-ProBNP testing and echocardiography can help with early recognition of heart failure in pregnancy, and describes a suggested approach to anesthetic management of patients with cardiomyopathies or acute heart failure, including hemodynamic goals, use of vasoactive medications and mechanical support. Vaginal delivery, with effective neuraxial anesthesia is the preferred mode of delivery in most patients with cardiomyopathy, with cesarean delivery reserved for maternal or fetal indications. The Pregnancy Heart Team is vital in coordinating the multidisciplinary care necessary to safely support these patients through pregnancy.

Blood pressure and cardiac output during caesarean delivery under spinal anaesthesia: a prospective cohort study

OBJECTIVES

We have previously established a method to measure transfer of nutrients between mother, placenta and fetus in vivo. The method includes measurements of maternal and fetal blood flow by Doppler ultrasound prior to spinal anaesthesia. Spinal anaesthesia affects maternal blood pressure and cardiac output. We aimed to determine the effect of spinal anaesthesia in mothers undergoing an elective caesarean section on blood pressure, heart rate and cardiac output, and whether cardiac output levels were comparable before induction of spinal anaesthesia and before delivery.

DESIGN

Prospective cohort study.

SETTING

Tertiary hospital in Norway.

PARTICIPANTS

76 healthy women with uneventful pregnancies undergoing an elective caesarean section.

INTERVENTIONS

We induced spinal anaesthesia with a standard prevention of hypotension including intravenous fluid coloading and phenylephrine infusion.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measure was maternal cardiac output, and secondary outcome measures were invasive systolic blood pressure and heart rate. We measured heart rate and blood pressure by continuous invasive monitoring with a cannula in the radial artery. Cardiac output was estimated based on continuous arterial waveform. We compared maternal parameters 30 s before induction of spinal anaesthesia to 30 s before delivery.

RESULTS

Median age at delivery was 34.5 (range 21-43) years and 17 of 76 women were nulliparous. The most prevalent indications were previous caesarean section and maternal request. Among 76 included women, 71 had sufficient data for analysis of endpoints. Median cardiac output was 6.51 (IQR (5.56-7.54) L/min before spinal anaesthesia and 6.40 (5.83-7.56) L/min before delivery (p=0.40)). Median invasive systolic blood pressure increased from 128.5 (120.1-142.7) mm Hg to 134.1 (124.0-146.6) mm Hg (p=0.014), and mean heart rate decreased from 86.0 (SD 13.9) to 75.2 (14.2) (p<0.001).

CONCLUSIONS

Maternal cardiac output at the time of caesarean delivery is comparable to levels before induction of spinal anaesthesia.

TRIAL REGISTRATION NUMBER

NCT00977769.