Anesthetic management of the parturient with cardiac and diabetic diseases

Cardiac disease in pregnancy

Cardiac disease complicates approximately 1% to 3% of pregnancies and is responsible for 10% to 15% of maternal mortality. The number of women of childbearing age with congenital disease is increasing as advances in diagnosis and treatment improve survival rates and overall health, allowing successful pregnancy. Pregnant women with severe cardiac disease or women who experience a cardiac event during pregnancy will require admission and stabilization in an adult critical care unit. This group of patients can prove challenging for the obstetrical staff and the critical care staff because they require blending of the knowledge and skills of 2 highly specialized areas of healthcare. The key component to a comprehensive and organized approach to management that ensures the best possible outcome for the woman is a multidisciplinary team that devises a plan on the basis of the most current information, communicates with each other and the patient effectively, and assumes responsibility for implementation of the plan. The purpose of this article is to review management of the woman with cardiac disease throughout pregnancy.

Neuroaxial anaesthesia in obstetrical patients with cardiac disease

PURPOSE OF REVIEW

Pregnancy and the peripartum period represent a physiological burden for the cardiac patient that can worsen even moderate degrees of cardiac disease. Valvular stenotic diseases, congenital cardiac disease, and coronary insufficiency are relatively frequent in pregnant patients. Since considerable variability exists in the cardiovascular changes and responses to labour among different cardiac diseases and their functional status, recommendations for anaesthetic management are based on reported clinical experience and pathophysiological concepts.

RECENT FINDINGS

Neuroaxial blockade reduces or even abolishes the cardiovascular stress response to pain, mitigates Valsalva effects by decreasing the pushing reflex, and allows the adaptation of analgesia or anaesthesia to labour stage and delivery. Sympathetic blockade caused by standard neuroaxial techniques, however, reduces systemic vascular resistance and cardiac preload followed by reflex tachycardia. Recent development of neuroaxial techniques with spinal opiates for the first stage of labour, carefully titrated segmental epidural analgesia with opiates combined with low concentrations of local anaesthetic for the second stage, and even low spinal anaesthesia for vaginal instrumental delivery, have all been used with good results in patients with severe cardiac disease.

SUMMARY

Only Tetralogy of Fallot, primary pulmonary hypertension, idiopathic hypertrophic subaortic stenosis, and anticoagulation are considered relative or absolute contraindications for neuroaxial techniques, though slow segmental blockade of dermatomes may offer an alternative. For Caesarean section, single shot spinal anaesthesia is not recommended in moderate or severe heart disease. Adequate cardiovascular invasive monitoring is essential and should be administered and maintained in the postpartum period with the same criteria that reduce morbidity and mortality in cardiac patients undergoing general surgery.

What’s new and novel in obstetric anesthesia? Contributions from the 2003 scientific literature

THE PREGNANT PATIENT: Age; maternal disease; prophylactic antibiotics; gastroesophageal reflux; obesity; starvation; genotyping; coagulopathy; infection; substance abuse; altered drug responses in pregnancy; physiological changes of pregnancy. THE FETUS: Fetal monitoring; intrauterine surgery. THE NEWBORN: Breastfeeding; maternal infection, fever, and neonatal sepsis evaluation. OBSTETRIC COMPLICATIONS: Embolic phenomena; hemorrhage; preeclampsia; preterm delivery. OBSTETRIC MANAGEMENT: External cephalic version and cervical cerclage; elective cesarean delivery; fetal malpresentation; vaginal birth after cesarean delivery; termination of pregnancy. OBSTETRIC ANESTHESIA: Analgesia for labor and delivery; anesthesia for cesarean delivery; anesthesia for short obstetric operations; complications of anesthesia. MISCELLANEOUS: Consent; ethics; history; labor support; websites/books/leaflets/journal announcements.