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Aryal SR, Moussa H, Sinkey R, Dhungana R, Tallaj JA, Pamboukian SV, Patarroyo-Aponte M, Acharya D, Bajaj NS, Bhattarai S, Lenneman A, Joly JM, Sibai BM, Rajapreyar IN. Management of reproductive health in patients with pulmonary hypertension. Am J Obstet Gynecol MFM 2020; 2:100087. [PMID: 33345958 DOI: 10.1016/j.ajogmf.2020.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 01/04/2020] [Accepted: 01/11/2020] [Indexed: 11/29/2022]
Abstract
Pulmonary hypertension is characterized by elevated pulmonary artery pressure caused by several clinical conditions that affect pulmonary vasculature. Morbidity and death in this condition are related to the development of right ventricular failure. Normal physiologic changes that occur in pregnancy to support the growing fetus can pose hemodynamic challenges to the pregnant patient with pulmonary hypertension that results in increased morbidity and mortality rates. Current guidelines recommend that patients with known pulmonary hypertension be counseled against pregnancy. This review aims to provide clinicians with guidelines for preconception counseling, medication management, and delivery planning.
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Affiliation(s)
- Sudeep R Aryal
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL.
| | - Hind Moussa
- Division of Maternal-Fetal medicine, The University of Cincinnati, Cincinnati, OH
| | - Rachel Sinkey
- Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL
| | - Rajat Dhungana
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Jose A Tallaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Salpy V Pamboukian
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Maria Patarroyo-Aponte
- Center for Advanced Heart Failure, University of Texas Health Science Center, Houston, TX
| | - Deepak Acharya
- Division of Cardiology, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Navkaranbir S Bajaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | | | - Andrew Lenneman
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Joanna M Joly
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Baha M Sibai
- Division of Maternal-Fetal Medicine, University of Texas, Houston, TX
| | - Indranee N Rajapreyar
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
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2
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Katsurahgi S, Kamiya C, Yamanaka K, Neki R, Miyoshi T, Iwanaga N, Horiuchi C, Tanaka H, Yoshimatsu J, Niwa K, Takagi Y, Ogo T, Nakanishi N, Ikeda T. Maternal and fetal outcomes in pregnancy complicated with Eisenmenger syndrome. Taiwan J Obstet Gynecol 2019; 58:183-187. [PMID: 30910135 DOI: 10.1016/j.tjog.2019.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The goal of the study was to clarify the risk factors for pregnancy complicated with Eisenmenger syndrome (ES). MATERIALS AND METHODS A retrospective study was performed in 15 patients with ES who were managed throughout pregnancy at one institution from 1982 to 2013. Cases associated with congenital heart diseases other than atrial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) were excluded. RESULTS The congenital heart diseases in ES included ASD (n = 3), VSD (n = 9), and PDA (n = 3). Ten women chose termination and 5 continued with their pregnancies. In the 5 continuation cases (PDA 1, VSD 4), worsening of cyanosis, exertional fatigue and dyspnea appeared between 25 and 30 weeks gestation and cesarean section was performed at 30 (28-33) weeks. LVEF, PaO2, and SpO2 decreased and heart rate increased significantly from before pregnancy to 25-30 weeks gestation. From before to during the pregnancy, there were no significant changes in mean PABP or pulmonary vascular resistance (PVR) in four cases with data (582-592, 885 to 868, 1280 to 1291, 1476-1522 dyn × s/cm2). PVR at conception had a negative relationship with delivery weeks. NYHA classes before, during and 1 year after pregnancy were II, III and II. In one recent case, epoprostenol and tadalafil were administered during pregnancy. CONCLUSIONS Pregnancy with ES has a high risk due to hypooxygenation, cyanosis, and cardiac failure, which can appear as common complications as early as the 2nd trimester. Early interventions with meticulous care are required for these complications during pregnancy and delivery.
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Affiliation(s)
- Shinji Katsurahgi
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Japan; Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan.
| | - Chizuko Kamiya
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Kaoru Yamanaka
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Reiko Neki
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Takekazu Miyoshi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Naoko Iwanaga
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Chinami Horiuchi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Hiroaki Tanaka
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Koichiro Niwa
- Department of Cardiology, St. Luke's International Hospital, Japan
| | - Yaemi Takagi
- Department of Cardiovascular Medicine, Pulmonary Circulation Group, National Cerebral and Cardiovascular Center, Japan
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, Pulmonary Circulation Group, National Cerebral and Cardiovascular Center, Japan
| | - Norifumi Nakanishi
- Department of Cardiovascular Medicine, Pulmonary Circulation Group, National Cerebral and Cardiovascular Center, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Japan
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3
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Duggan AB, Katz SG. Combined Spinal and Epidural Anaesthesia for Caesarean Section in a Parturient with Severe Primary Pulmonary Hypertension. Anaesth Intensive Care 2019; 31:565-9. [PMID: 14601281 DOI: 10.1177/0310057x0303100511] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We describe the management of a parturient with severe primary pulmonary hypertension who underwent caesarean section. A multi-disciplinary approach was used. She was admitted to the intensive care unit perioperatively for invasive monitoring and trial of inhaled nitric oxide. Anaesthesia was provided by combined spinal-epidural block. We discuss controversies about the management of obstetric patients with this rare and serious condition.
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MESH Headings
- Adrenergic Agonists/therapeutic use
- Adult
- Analgesics, Opioid/therapeutic use
- Anesthesia, Epidural
- Anesthesia, Obstetrical
- Anesthesia, Spinal
- Anesthetics, Combined/therapeutic use
- Anesthetics, Inhalation/therapeutic use
- Cesarean Section
- Dobutamine/therapeutic use
- Epinephrine/therapeutic use
- Female
- Fentanyl/therapeutic use
- Humans
- Hypertension, Pulmonary/drug therapy
- Hypertension, Pulmonary/physiopathology
- Morphine/therapeutic use
- Nitrous Oxide/therapeutic use
- Pregnancy
- Pregnancy Complications, Cardiovascular/drug therapy
- Pregnancy Complications, Cardiovascular/physiopathology
- Severity of Illness Index
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Affiliation(s)
- A B Duggan
- Division of Anaesthesia and Intensive Care, Prince of Wales Hospital, N.S.W
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4
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Zhang J, Lu J, Zhou X, Xu X, Ye Q, Ou Q, Li Y, Huang J. Perioperative Management of Pregnant Women With Idiopathic Pulmonary Arterial Hypertension: An Observational Case Series Study From China. J Cardiothorac Vasc Anesth 2018. [DOI: 10.1053/j.jvca.2018.01.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Rashidi F, Sate H. Pregnancy outcome in a pregnant patient with idiopathic Pulmonary Arterial Hypertension: a case report and review of the literature. J Med Case Rep 2018; 12:31. [PMID: 29433561 PMCID: PMC5810109 DOI: 10.1186/s13256-017-1547-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 12/18/2017] [Indexed: 12/20/2022] Open
Abstract
Background Idiopathic pulmonary arterial hypertension is a rare and progressive condition which is aggravated by the physiologic changes during pregnancy. Because of high mortality rate, most physicians recommend early termination of pregnancy in patients with idiopathic pulmonary arterial hypertension. Case presentation Here we describe a case of a 30-year-old primigravida Caucasian housewife with functional class 1 idiopathic pulmonary arterial hypertension and a positive vasoreactive response to adenosine who had a full-term non-complicated delivery. Right-sided heart catheterization before the pregnancy showed severe pulmonary hypertension with mean pulmonary arterial pressure of 60 mmHg, and pulmonary vascular resistance of 12.2 WU. Vasoreactivity was positive after infusion of 200 μg/kg per minute adenosine. During pregnancy, she did not receive medication other than prophylactic enoxaparin. She had an elective cesarean section under general anesthesia at 39 weeks of gestation without complication and delivered a healthy baby. After delivery, her hemodynamic status was stable. One month postpartum, she was in a stable clinical condition in functional class 1. Conclusions In pregnant patients with pulmonary arterial hypertension, decreased mortality has been observed over recent years particularly in patients with well-controlled pulmonary pressure and a positive vasoreactivity test.
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Affiliation(s)
- Farid Rashidi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Imam Reza General Hospital, 29 Bahaman St, Tabriz, Iran.
| | - Hossein Sate
- Department of Cardiology, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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6
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Monagle J, Manikappa S, Ingram B, Malkoutzis V. Pulmonary hypertension and pregnancy: the experience of a tertiary institution over 15 years. Ann Card Anaesth 2016; 18:153-60. [PMID: 25849682 PMCID: PMC4881648 DOI: 10.4103/0971-9784.154466] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: Pulmonary hypertension (PH) in pregnancy is associated with a high maternal mortality and morbidity and has been found to be as high as 30-56%. Aim: To review the management of such patients in a tertiary center over a 15 year period, as the current literature consists of a few case reports, a few small case series and 2 meta-analyses. Materials and Methods: A review of all patients admitted to our institution for management of PH in pregnancy between 1994 and February 2009 was undertaken. Cases were identified from the high-risk pregnancy database within the department of anesthesia and from the hospital medical records. Severity of PH, type of PH, NYHA functional status at presentation and delivery, mode of delivery, peripartum monitoring and APGAR scores were noted. Patients were reviewed by a multidisciplinary team and management planned accordingly. Results: 19 eligible patients were identified. Patients who were significantly sick due to their PH were aggressively managed during pregnancy. Overall there was an improvement in NYHA functional status at the time of delivery. Epidural analgesia and anesthesia for labor and operatively delivery seem to be the ideal choice. Conclusion: Multidisciplinary approach is a key to the successful management of these patients. Secondary PH results in higher morbidity and mortality, in particular, older the age higher the maternal morbidity and mortality.
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Affiliation(s)
| | - Shashikanth Manikappa
- Department of Anaesthesia and Perioperative Medicine, Monash Medical Centre, Clayton, Victoria 3168, Australia
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7
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Seyfarth HJ, Gille J, Sablotzki A, Gerlach S, Malcharek M, Gosse A, Gahr RH, Czeslick E. Perioperative management of patients with severe pulmonary hypertension in major orthopedic surgery: experience-based recommendations. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2015; 4:Doc03. [PMID: 26504732 PMCID: PMC4604756 DOI: 10.3205/iprs000062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: It is known that pulmonary hypertension is associated with worse outcome in both cardiac and non-cardiac surgery. The aims of our retrospective analysis were to evaluate the outcomes of our patients with pulmonary hypertension undergoing major orthopedic surgery and to give experience-based recommendations for the perioperative management. Material and methods: From 92 patients with pulmonary hypertension undergoing different kinds of surgical procedures from 2011–2014 in a tertiary academic hospital we evaluated 16 patients with major orthopedic surgery for perioperative morbidity and mortality. Results: Regarding the in-hospital morbidity and mortality, one patient died postoperatively due to pulmonary infection and right heart failure (6.25%) and 6 patients suffered significant postoperative complications (37.5%; bleeding = 1, infection = 1, wound healing deficits = 3; dysrhythmia = 1). Conclusion: Our data show that major orthopedic surgery is feasible with satisfactory outcome even in cases of severe pulmonary hypertension by an individualized, disease-adapted interdisciplinary treatment concept.
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Affiliation(s)
- Hans-Jürgen Seyfarth
- Medical Clinic and Polyclinic I, Department of Pneumology, Universitätsklinikum Leipzig AöR, Leipzig, Germany
| | - Jochen Gille
- Clinic for Anesthesiology, Critical Care Medicine and Pain Therapy, St. Georg Hospital Leipzig, Germany
| | - Armin Sablotzki
- Clinic for Anesthesiology, Critical Care Medicine and Pain Therapy, St. Georg Hospital Leipzig, Germany
| | - Stefan Gerlach
- Clinic for Anesthesiology, Critical Care Medicine and Pain Therapy, St. Georg Hospital Leipzig, Germany
| | - Michael Malcharek
- Clinic for Anesthesiology, Critical Care Medicine and Pain Therapy, St. Georg Hospital Leipzig, Germany
| | - Andreas Gosse
- Clinic for Orthopedic and Reconstructive Surgery, St. Georg Hospital Leipzig, Germany
| | - Ralf H Gahr
- Clinic for Orthopedic and Reconstructive Surgery, St. Georg Hospital Leipzig, Germany
| | - Elke Czeslick
- Clinic for Anesthesiology and Critical Care Medicine, Martin-Luther-University of Halle-Wittenberg, Halle/Saale, Germany
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Goldsmith YB, Ivascu N, McGlothlin D, Heerdt PM, Horn EM. Perioperative Management of Pulmonary Hypertension. DIAGNOSIS AND MANAGEMENT OF PULMONARY HYPERTENSION 2015. [DOI: 10.1007/978-1-4939-2636-7_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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10
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Gupta SL, Satya Prakash MVS, Prabu G. Use of i-gel for caesarean section with kyphoscoliosis. BMJ Case Rep 2014; 2014:bcr2014203987. [PMID: 25012886 PMCID: PMC4112341 DOI: 10.1136/bcr-2014-203987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2014] [Indexed: 11/03/2022] Open
Abstract
We describe the anaesthetic management using i-gel for airway maintenance in a patient with kyphoscoliosis presenting for emergency caesarean section due to fetal distress and scar tenderness. The patient had a history of previous caesarean section under general anaesthesia, and presently her cardiorespiratory status is stable. We used i-gel, the new supraglottic airway device, for maintaining the airway under intravenous anaesthesia using propofol.
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Affiliation(s)
| | | | - Gunasekaran Prabu
- Department of Anaesthesiology and Critical Care, JIPMER, Pondicherry, India
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11
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12
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Albackr HB, Aldakhil LO, Ahamd A. Primary pulmonary hypertension during pregnancy: A case report. J Saudi Heart Assoc 2013; 25:219-23. [PMID: 24174863 DOI: 10.1016/j.jsha.2012.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 12/09/2012] [Accepted: 12/28/2012] [Indexed: 10/27/2022] Open
Abstract
We describe a case of a 25-year-old pregnant woman who presented with severe primary pulmonary hypertension (PPH). Her echocardiogram showed severe right ventricular hypertrophy with dilatation and Moderate right ventricular systolic dysfunction. Right ventricle systolic pressure (RVSP) was estimated to be 125 mmHg. She had an elective caesarean section under general anaesthesia at 32 weeks of gestation. Pulmonary artery pressures measured by a pulmonary artery catheter before anaesthesia were 102 mmHg and pulmonary vascular resistance was 429. Intraoperative nitric oxide was used to reduce pulmonary artery systolic pressure (PASP). After the delivery of a healthy infant, PASP was controlled with nebulized iloprost and silandifil. Five days later she was transferred from intensive care unit after she was started on silandifil 50 mg three times daily and a small dose of warfarin.
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Affiliation(s)
- Hanan B Albackr
- King Fahad Cardiac Center, King Khalid University Hospital College of Medicine, King Saud University, Saudi Arabia
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13
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Perioperative anesthesiological management of patients with pulmonary hypertension. Anesthesiol Res Pract 2012; 2012:356982. [PMID: 23097665 PMCID: PMC3477529 DOI: 10.1155/2012/356982] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 08/02/2012] [Accepted: 08/16/2012] [Indexed: 01/08/2023] Open
Abstract
Pulmonary hypertension is a major reason for elevated perioperative morbidity and mortality, even in noncardiac surgical procedures. Patients should be thoroughly prepared for the intervention and allowed plenty of time for consideration. All specialty units involved in treatment should play a role in these preparations. After selecting each of the suitable individual anesthetic and surgical procedures, intraoperative management should focus on avoiding all circumstances that could contribute to exacerbating pulmonary hypertension (hypoxemia, hypercapnia, acidosis, hypothermia, hypervolemia, and insufficient anesthesia and analgesia). Due to possible induction of hypotonic blood circulation, intravenous vasodilators (milrinone, dobutamine, prostacyclin, Na-nitroprusside, and nitroglycerine) should be administered with the greatest care. A method of treating elevations in pulmonary pressure with selective pulmonary vasodilation by inhalation should be available intraoperatively (iloprost, nitrogen monoxide, prostacyclin, and milrinone) in addition to invasive hemodynamic monitoring. During the postoperative phase, patients must be monitored continuously and receive sufficient analgesic therapy over an adequate period of time. All in all, perioperative management of patients with pulmonary hypertension presents an interdisciplinary challenge that requires the adequate involvement of anesthetists, surgeons, pulmonologists, and cardiologists alike.
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14
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Watanabe K, Hoshi T, Miyabe M, Tanaka M, Mizutani T. Volume manipulation by phlebotomy for cesarean section in a patient with pulmonary hypertension. J Anesth 2009; 23:449-52. [PMID: 19685134 DOI: 10.1007/s00540-009-0771-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 03/31/2009] [Indexed: 11/28/2022]
Abstract
Pulmonary hypertension in a parturient is known for its high perioperative mortality. We describe a successful case of cesarean section performed under general anesthesia in a parturient with pulmonary hypertension. A distinctive feature of our management was active blood volume manipulation by phlebotomy and reinfusion of the blood. Just after the baby was delivered, about 250 ml of blood was phlebotomized to counteract autotransfusion by the contracting uterus. We stopped phlebotomy at this volume because moderate systemic hypotension occurred. The blood was slowly infused, with transesophageal echocardiography used to evaluate right ventricle filling. The patient was hemodynamically stable during the operation and had an uneventful postpartum period. Her baby's perioperative course was also uneventful.
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Affiliation(s)
- Kazuhiro Watanabe
- Department of Anesthesiology and Critical Care Medicine, Doctoral Programs in Clinical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Japan
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15
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Krug S, Sablotzki A, Hammerschmidt S, Wirtz H, Seyfarth HJ. Inhaled iloprost for the control of pulmonary hypertension. Vasc Health Risk Manag 2009; 5:465-74. [PMID: 19475782 PMCID: PMC2686263 DOI: 10.2147/vhrm.s3223] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening disease characterized by an elevated pulmonary arterial pressure and vascular resistance with a poor prognosis. Various pulmonary and extrapulmonary causes are now recognized to exist separately from the idiopathic form of pulmonary hypertension. An imbalance in the presence of vasoconstrictors and vasodilators plays an important role in the pathophysiology of the disease, one example being the lack of prostacyclin. Prostacyclin and its analogues are potent vasodilators with antithrombotic, antiproliferative and anti-inflammatory qualities, all of which are important factors in the pathogenesis of precapillary pulmonary hypertension. Iloprost is a stable prostacyclin analogue available for intravenous and aerosolized application. Due to the severe side effects of intravenous administration, the use of inhaled iloprost has become a mainstay in PAH therapy. However, owing to the necessity for 6 to 9 inhalations a day, oral treatment is often preferred as a first-line therapy. Numerous studies proving the efficacy and safety of inhaled iloprost have been performed. It is therefore available for a first-line therapy for PAH. The combination with endothelin-receptor antagonists or sildenafil has shown encouraging effects. Further studies with larger patient populations will have to demonstrate the use of combination therapy for long-term treatment of pulmonary hypertension.
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Affiliation(s)
- Sabine Krug
- Department of Respiratory Medicine, University of Leipzig, Leipzig, Germany.
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16
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Perioperative management including new pharmacological vistas for patients with pulmonary hypertension for noncardiac surgery. Curr Opin Anaesthesiol 2008; 21:467-72. [DOI: 10.1097/aco.0b013e3283007eb4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Olofsson CH, Bremme K, Forssell G, Öhqvist G. Cesarean section under epidural ropivacaine 0.75% in a parturient with severe pulmonary hypertension. Acta Anaesthesiol Scand 2008. [DOI: 10.1111/j.1399-6576.2001.450220.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Sudden and unexpected natural deaths and nonnatural deaths may result from various pulmonary conditions. Additionally, several nonpulmonary conditions of forensic significance may be complicated by the development of respiratory lesions. Certain situations with pulmonary pathology are particularly likely to be critically scrutinized and may form the basis of allegations of medical negligence, other personal injury liability, or wrongful death.1
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Abstract
In summary, the major physiologic changes that occur in pregnancy are the increased minute ventilation, which is caused by increased respiratory center sensitivity and drive; a compensated respiratory alkalosis; and a low expiratory reserve volume. The vital capacity and measures of forced expiration are well preserved. Patients who have many lung diseases tolerate pregnancy well, with the exception of those who have pulmonary hypertension or chronic respiratory insufficiency from parenchymal or neuromuscular disease.
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Affiliation(s)
- Robert A Wise
- Department of Medicine (Pulmonary and Critical Care Medicine), Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Baltimore, MD 21224, USA.
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20
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Pearl RG. Perioperative Management of PH: Covering All Aspects From Risk Assessment to Postoperative Considerations. ACTA ACUST UNITED AC 2005. [DOI: 10.21693/1933-088x-4.4.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Ronald G. Pearl
- Professor and Chair, Department of Anesthesia, Stanford University School of Medicine, Stanford, California
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Abstract
OBJECTIVE The presence of underlying pulmonary disease in women of childbearing potential can present a significant challenge during pregnancy and the postpartum period. Management of the underlying disease, recognizing and preventing disease progression, and, most important, managing and minimizing toxic side effects of various therapies require the expertise of an interdisciplinary team. This team must involve close collaboration between intensive care physicians, pulmonary physicians, and high-risk obstetricians familiar with these disease states in an effort to minimize fetal and maternal morbidity and mortality. We will review the impact of the pregnant state in lung transplant recipients, patients with pulmonary arterial hypertension, and patients with underlying cystic fibrosis. DESIGN Review of the literature in regards to pregnancy outcomes and issues for patients with cystic fibrosis, pulmonary hypertension, and lung transplants. METHODS A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and outcomes for pregnant patients with underlying pulmonary diseases. CONCLUSIONS Safety of pregnancy in the female lung transplant recipient concerns three outcomes: maternal outcome, fetal outcome, and transplanted graft outcome.
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Affiliation(s)
- Marie M Budev
- Lung Transplantation Program, Department of Allergy, Pulmonary, and Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland, OH, USA
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Hamlyn EL, Douglass CA, Plaat F, Crowhurst JA, Stocks GM. Low-dose sequential combined spinal-epidural: an anaesthetic technique for caesarean section in patients with significant cardiac disease. Int J Obstet Anesth 2005; 14:355-61. [PMID: 16139497 DOI: 10.1016/j.ijoa.2005.01.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2004] [Revised: 12/01/2004] [Accepted: 01/01/2005] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- E L Hamlyn
- Department of Anaesthesia, Queen Charlotte's & Chelsea Hospital, London, UK
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23
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Shen CC, Hsu TY, Roan CJ, Chang SY. Peripartum Heart Failure due to Primary Pulmonary Hypertension: Two Case Reports. Taiwan J Obstet Gynecol 2004. [DOI: 10.1016/s1028-4559(09)60074-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Van de Velde M, Teunkens A, Kuypers M, Dewinter T, Vandermeersch E. General anaesthesia with target controlled infusion of propofol for planned caesarean section: maternal and neonatal effects of a remifentanil-based technique. Int J Obstet Anesth 2004; 13:153-8. [PMID: 15321393 DOI: 10.1016/j.ijoa.2004.01.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/01/2004] [Indexed: 11/29/2022]
Abstract
The present case series evaluated maternal and neonatal effects of remifentanil, combined with propofol, during general anaesthesia for caesarean delivery. Following written informed consent, ten patients scheduled for semi-elective caesarean section were recruited to this prospective, unblinded trial. All patients with non-reassuring fetal status were excluded. A 0.50-micrograms/kg bolus of remifentanil was given intravenously, followed by a continuous infusion of 0.20 micrograms.kg(-1)min(-1). Anaesthesia was induced using propofol target controlled infusion set at a blood concentration of 5 micrograms/mL, 45 s after the remifentanil bolus. Following tracheal intubation the propofol target was reduced to 2.5 micrograms/mL and remifentanil maintained at 0.20 micrograms.kg(-1)min(-1). Mean arterial pressure remained stable throughout anaesthesia. Two patients experienced episodes of hypotension (mean arterial pressure decrease >20%). Although neonatal depression occurred in six babies and assisted mask ventilation was required briefly, recovery was rapid without the need for naloxone or tracheal intubation. Umbilical artery pH was >7.20 in all infants. We conclude that the results of the present case series using a remifentanil/propofol-based technique of general anaesthesia for caesarean section provide a basis to study the safety of this technique in a larger population. Under the conditions of the present trial, this anaesthetic technique seems safe for mother and infant, provided adequate precautions are taken to manage brief, self-limiting infant respiratory depression. At the moment we cannot advise the routine use of this technique, especially since it has not been studied in situations of fetal compromise.
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Affiliation(s)
- M Van de Velde
- Department of Anesthesiology, University Hospitals Gasthuisberg, Katholieke Universiteit, Leuven, Belgium.
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Kuczkowski KM. Labor analgesia for the parturient with cardiac disease: what does an obstetrician need to know? Acta Obstet Gynecol Scand 2004; 83:223-33. [PMID: 14995916 DOI: 10.1111/j.0001-6349.2004.0430.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Maternal heart disease complicates 0.2-3% of pregnancies. The optimal management of the pregnant patient with cardiac disease depends on the cooperative efforts of the obstetrician, the cardiologist and the anesthesiologist involved in peripartum care. A comprehensive understanding of physiology of pregnancy and pathophysiology of underlying cardiac disease is of primary importance in provision of obstetric analgesia or anesthesia for this high-risk group of patients. This article will review the current guidelines and standards pertinent to management of obstetric analgesia and anesthesia in parturients with cardiac disease.
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Al-Mobeireek AF, Almutawa J, Alsatli RA. The nineteenth pregnancy in a patient with cor pulmonale and severe pulmonary hypertension: a management challenge. Acta Obstet Gynecol Scand 2003; 82:676-8. [PMID: 12790853 DOI: 10.1034/j.1600-0412.2003.00202.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Fischer LG, Aken HV, Bürkle H. Management of pulmonary hypertension: physiological and pharmacological considerations for anesthesiologists. Anesth Analg 2003; 96:1603-1616. [PMID: 12760982 DOI: 10.1213/01.ane.0000062523.67426.0b] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lars G Fischer
- Department of Anesthesiology and Intensive Care, Universita[Combining Diaeresis]tsklinikum Mu[Combining Diaeresis]nster, Mu[Combining Diaeresis]nster, Germany
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Vial F, Bayoumeu F, Marçon F, Dupays R, Chillet-Mion M, Laxenaire MC. [General anaesthesia for Caesarean section in a patient with pulmonary atresia and an intact intraventricular septum]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2003; 22:548-52. [PMID: 12893383 DOI: 10.1016/s0750-7658(03)00140-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We report the case of a 22-year-old primigravida patient presenting pulmonary atresia with intact ventricular septum, a rare congenital heart disease. Caesarean delivery was performed at 32 weeks of gestation because of moderate maternal function deterioration and foetal growth restriction. General anaesthesia was used because of the presence of lumbar Harrington rods. The administration of etomidate, celocurine and a continuous perfusion of remifentanil right from induction ensured haemodynamic stability and a rapid emergence and recovery.
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Affiliation(s)
- F Vial
- Service d'anesthésie-réanimation, maternité régionale de Nancy, 10, rue du Docteur-Heydenreich, 54042 Nancy cedex, France.
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Kuczkowski KM. Anesthesia for the parturient with cardiovascular disease. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2003. [DOI: 10.1080/22201173.2003.10873001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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30
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Gandhimathi K, Atkinson S, Gibson FM. Pulmonary hypertension complicating twin pregnancy: continuous spinal anaesthesia for caesarean section. Int J Obstet Anesth 2002; 11:301-5. [PMID: 15321534 DOI: 10.1054/ijoa.2002.0975] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A case of secondary pulmonary hypertension complicating twin pregnancy and necessitating caesarean section is presented. A planned team approach involving senior consultants in obstetrics, cardiology, neonatology and cardiac and obstetric anaesthesia resulted in successful perioperative management. Continuous spinal anaesthesia was the chosen technique to give adequate operating conditions with least haemodynamic disturbance. This is the first report of continuous spinal anaesthesia in such a condition.
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Affiliation(s)
- K Gandhimathi
- Department of Anaesthetics, Royal Group of Hospitals, Belfast, UK.
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31
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Palmer CM, DiNardo JA, Hays RL, Van Maren GA. Use of transesophageal echocardiography for delivery of a parturient with severe pulmonary hypertension. Int J Obstet Anesth 2002; 11:48-51. [PMID: 15321576 DOI: 10.1054/ijoa.2001.0912] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The anesthetic management of a parturient with severe pulmonary hypertension during labor and subsequent cesarean delivery is presented. Transesophageal echocardiography was used intraoperatively to manage the patient's hemodynamics, while pulmonary artery pressure monitoring was of little use. The benefits of transesophageal echocardiography for management of these patients are discussed.
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Affiliation(s)
- C M Palmer
- Department of Anesthesiology, University of Arizona Health Sciences Center, Tucson, AZ 85724-5114, USA.
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32
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Monnery L, Nanson J, Charlton G. Primary pulmonary hypertension in pregnancy; a role for novel vasodilators. Br J Anaesth 2001; 87:295-8. [PMID: 11493507 DOI: 10.1093/bja/87.2.295] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We describe the case of a 28-week pregnant woman presenting with severe primary pulmonary hypertension (PPH). She had an elective Caesarean section under general anaesthesia at 32 weeks gestation. Pulmonary artery pressures (PAP) measured from a pulmonary artery catheter before anaesthesia were in excess of 100 mm Hg. Intraoperative nitric oxide was used to reduce PAP. After the delivery of a healthy infant PAP was controlled with nebulized iloprost and a prostacyclin infusion. Seven days later she was discharged from intensive care taking an oral calcium antagonist and warfarin. She developed intractable right heart failure and died 14 days after delivery. Despite increasing experience in the use of drugs to reduce PAP, the clinical course of pregnancy complicated by severe PPH is usually fatal.
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Affiliation(s)
- L Monnery
- Department of Anaesthesia, Dorset County Hospital, Williams Avenue, Dorchester DT1 2JY, UK
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Abstract
Anaesthetic and analgesic techniques in the critically ill are determined largely by the nature of the presenting illness. The commonest conditions likely to present as life-threatening emergencies are pre-eclampsia, obstetric haemorrhage, cardiac disease and severe sepsis. Issues dictating choice of anaesthetic technique are the patient's ability to maintain her airway, coagulation status, intravascular volume and haemodynamic dependence upon sympathetic drive, and requirements for ventilatory support and intensive care. Fetal well-being is an issue in the antepartum period, uteroplacental blood flow should be maintained and hypotension avoided. Maternal survival takes priority, however, and occasionally general anaesthetic techniques must be used which lead to neonatal respiratory depression and requirement for ventilatory support. Anaesthesia itself is associated with known hazards. The risks of each technique must be balanced against possible benefits in the context of the presenting illness.
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Affiliation(s)
- C C Rout
- Department of Anaesthetics, School of Clinical Sciences, Nelson R Mandela Medical School, University of Natal, 719 Umbilo Road, Durban, Congella 4013, South Africa
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RESPIRATORY PHYSIOLOGIC CHANGES IN PREGNANCY. Radiol Clin North Am 2000. [DOI: 10.1016/s0033-8389(22)00119-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Bédard JM, Richardson MG, Wissler RN. General anesthesia with remifentanil for Cesarean section in a parturient with an acoustic neuroma. Can J Anaesth 1999; 46:576-80. [PMID: 10391607 DOI: 10.1007/bf03013550] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To describe the anesthetic management of a parturient with a large acoustic neuroma undergoing general anesthesia with remifentanil for Cesarean section. CLINICAL FEATURES A near-term parturient presented with a large intracranial mass. Cesarean section under general anesthesia was elected one week prior to craniotomy for tumour resection. Remifentanil infusion, 0.2-1.0 microg x kg(-1) x min(-1), was used from induction to emergence of general anesthesia. The neonate was born seven minutes after the remifentanil infusion was started. She had normal umbilical cord pH and her Apgar scores were 7 and 8, at one and five minutes respectively. Although the neonate received supplemental oxygen, she did not require naloxone. Both mother and neonate made an uneventful recovery. CONCLUSION Remifentanil was effective in producing stable hemodynamic conditions, without severe neonatal respiratory depression, during induction and maintenance of general anesthesia for a Cesarean delivery in a parturient with a large intracranial tumour.
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Affiliation(s)
- J M Bédard
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Strong Memorial Hospital, NY 14642, USA.
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38
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Tay SM, Ong BC, Tan SA. Cesarean section in a mother with uncorrected congenital coronary to pulmonary artery fistula. Can J Anaesth 1999; 46:368-71. [PMID: 10232722 DOI: 10.1007/bf03013230] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE We report a case of a 33 yr old woman with pulmonary hypertension secondary to uncorrected right coronary artery to pulmonary artery fistula who underwent two successful operative deliveries under general anesthesia. CLINICAL FEATURES This woman underwent an emergency Caesarean section at 32 wk gestation because she presented in NYHA Class IV, heart failure and premature labour. She did not have antenatal follow-up. For her second pregnancy, she was managed from the first trimester of pregnancy by the cardiologist, obstetrician and anesthesiologist. She received oral furosemide and digoxin from eight weeks gestation. Pregnancy was managed to term before she progressed to NYHA Class IV and cardiac failure at 37 wk gestation. She had a Caesarean section under general anesthesia. She received rapid sequence induction of anesthesia and tracheal intubation with 0.1 mg x kg(-1) etomidate, 2 mg x kg(-1) succinylcholine and maintenance with nitrous oxide 50% in oxygen, isoflurane 1% and 0.1 mg x kg(-1) vecuronium. Fentanyl, 2 microg x kg(-1) helped to obtund the hypertensive response to intubation. Analgesia was provided with 1 mg x kg(-1) morphine. Glyceryl trinitrate infusion, 10-30 microg x min(-1) was used in addition to the anti-heart failure therapy. End-tidal capnography, electrocardiogram, pulse oximetry, continuous arterial blood pressure and pulmonary arterial catheter provided hemodynamic monitoring. The lungs were mechanically ventilated for 24 hr postoperatively. She received anti-heart failure therapy which she continued after discharge. She was NYHA class II upon discharge. She defaulted from further follow-up. CONCLUSION Although the literature advocates, in this situation, controlled vaginal delivery utilising epidural analgesia, we describe the successful outcome for operative delivery under general anesthesia in a patient with secondary pulmonary hypertension and heart failure.
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Affiliation(s)
- S M Tay
- Department of Anesthesia & Surgical Intensive Care, Singapore General Hospital, Singapore.
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39
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Keck C, Wilhelm C, Wellens E, Korinthenberg R, Breckwoldt M. Fetal cerebral AV-malformation and cardiomegaly, diagnostic and therapeutic problems. J Perinat Med 1998; 26:225-30. [PMID: 9773384 DOI: 10.1515/jpme.1998.26.3.225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intracerebral aneurysms are rare. However they are potentially life-threatening. Today by means of ultrasound investigations these malformations can occasionally be identified prenatally. In these cases questions of intrauterine therapy, mode and time of delivery and postnatal treatment have to be discussed with the parents. We describe two cases with prenatal diagnosis of intracerebral arteriovenous malformations, diagnostic workup, therapeutic options and fetal outcome.
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Affiliation(s)
- C Keck
- Dep. of Obstetrics and Gynecology, The University Freiburg, Germany.
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40
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Affiliation(s)
- R M Rodriguez
- Department of Anesthesia, Stanford University Medical Center, California 94305-5117, USA
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41
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42
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43
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Weiss BM, Zemp L, Seifert B, Hess OM. Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996. J Am Coll Cardiol 1998; 31:1650-7. [PMID: 9626847 DOI: 10.1016/s0735-1097(98)00162-4] [Citation(s) in RCA: 339] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- B M Weiss
- Department of Anesthesiology, University Hospital, Zurich, Switzerland
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44
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Khan MJ, Bhatt SB, Kryc JJ. Anesthetic considerations for parturients with primary pulmonary hypertension: review of the literature and clinical presentation. Int J Obstet Anesth 1996; 5:36-42. [PMID: 15321380 DOI: 10.1016/s0959-289x(96)80072-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Primary pulmonary hypertension, though uncommon, is found relatively frequently in women of childbearing age and carries a high peripartum mortality. We present a patient with severe primary pulmonary hypertension who underwent two cesarean sections 3 and 6 years after the diagnosis of primary pulmonary hypertension was made. Epidural anesthesia was provided on both occasions and resulted in a good maternal and fetal outcome. We have reviewed the literature as it relates to the choice of anesthetic technique and maternal outcome in patients with primary pulmonary hypertension.
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Affiliation(s)
- M J Khan
- Department of Anesthesiology, Maricopa Medical Center, Phoenix, AZ 85010, USA
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45
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Abstract
OBJECTIVE To ascertain the significance of coexisting pulmonary hypertension in cardiac disease in pregnancy. METHODS Over a 3-year period a group of pregnant women with cardiac disease was followed until 6 weeks postpartum. Twenty women with pulmonary hypertension were compared with 20 controls without pulmonary hypertension with particular reference to maternal and fetal outcome. Analysis of data was carried out using Fisher's exact test and Student's t-test. RESULTS Except for Eisenmenger's syndrome, there were no differences in maternal morbidity and mortality between the two groups. There were more low birth weight babies but no significant differences in premature delivery rate, mode of delivery or perinatal mortality. CONCLUSION Except for Eisenmenger's syndrome, coexisting pulmonary hypertension complicating cardiac disease in pregnancy generally has a favorable outcome for both mother and fetus.
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Affiliation(s)
- H Tahir
- Department of Obstetrics and Gynaecology, Medical Faculty, Universiti Kebangsaan Malaysia, Kuala Lumpur
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46
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Kiss H, Egarter C, Asseryanis E, Putz D, Kneussl M. Primary pulmonary hypertension in pregnancy: a case report. Am J Obstet Gynecol 1995; 172:1052-4. [PMID: 7892851 DOI: 10.1016/0002-9378(95)90047-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Primary pulmonary hypertension is a rare, incurable, and progressive disease. When it is associated with pregnancy, the mortality rises to > 50%. We report a patient who was diagnosed with severe pulmonary hypertension of unknown cause in the twenty-second week of gestation. She was treated with an oral calcium-channel blocker and low-molecular-weight heparin and underwent delivery by cesarean section with good maternal and fetal outcome. Patients with severe pulmonary hypertension should, however, avoid pregnancy because of the high mortality, although cases have been reported with positive outcome.
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Affiliation(s)
- H Kiss
- Department of Obstetrics and Gynecology, University of Vienna, Austria
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47
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Myles PS, Hall JL, Berry CB, Esmore DS. Primary pulmonary hypertension: prolonged cardiac arrest and successful resuscitation following induction of anesthesia for heart-lung transplantation. J Cardiothorac Vasc Anesth 1994; 8:678-81. [PMID: 7881000 DOI: 10.1016/1053-0770(94)90203-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- P S Myles
- Department of Anaesthesia, Alfred Hospital, Victoria, Australia
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48
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Myles PS. Anaesthetic management for laparoscopic sterilisation and termination of pregnancy in a patient with severe primary pulmonary hypertension. Anaesth Intensive Care 1994; 22:465-9. [PMID: 7978215 DOI: 10.1177/0310057x9402200426] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- P S Myles
- Department of Anaesthesia, Alfred Hospital, Melbourne, Victoria
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49
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Smedstad KG, Cramb R, Morison DH. Pulmonary hypertension and pregnancy: a series of eight cases. Can J Anaesth 1994; 41:502-12. [PMID: 8069991 DOI: 10.1007/bf03011545] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
This is the report of a series of eight patients with pulmonary hypertension (primary and secondary) who delivered at the McMaster University Medical Centre between 1978 and 1987. Seven of the eight patients delivered vaginally and had a successful outcome. The eighth patient was admitted as an emergency and died shortly after Caesarean section under general anaesthesia, performed to save the infant. The other seven patients were all managed by a team, including anaesthetists, cardiologists and obstetricians, from about 25 wk. The patients were hospitalized pre-partum and received oxygen therapy and anticoagulation with heparin. Analgesia in labour was managed, once anticoagulation was reversed, by low concentrations of epidural bupivacaine (0.125%-0.375%) and fentanyl. The patients were monitored during labour and delivery with oximetry and arterial and central venous pressure lines. Pulmonary arterial lines were not used because of increased risk and questionable usefulness. Vaginal delivery was managed with vacuum extraction or forceps lift-out to minimize the stress of pushing. After delivery, all patients were monitored in an intensive care unit for several days, anticoagulation was restarted, and all patients were discharged home taking oral anticoagulant therapy. The successful management of pulmonary hypertension in pregnancy should include team management started early in pregnancy and controlled vaginal delivery utilizing epidural analgesia.
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MESH Headings
- Adult
- Anesthesia, Epidural
- Anesthesia, Obstetrical
- Delivery, Obstetric
- Ductus Arteriosus, Patent/physiopathology
- Eisenmenger Complex/physiopathology
- Female
- Heart Septal Defects, Atrial/physiopathology
- Heart Septal Defects, Ventricular/physiopathology
- Heart Valve Diseases/physiopathology
- Heparin/therapeutic use
- Humans
- Hypertension, Pulmonary/physiopathology
- Hypertension, Pulmonary/prevention & control
- Mitral Valve
- Monitoring, Physiologic
- Obstetric Labor Complications/prevention & control
- Pregnancy
- Pregnancy Complications, Cardiovascular/prevention & control
- Pregnancy Outcome
- Warfarin/therapeutic use
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Affiliation(s)
- K G Smedstad
- Department of Anaesthesia, McMaster University, Hamilton, Ontario
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50
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Weiss BM, Atanassoff PG. Cyanotic congenital heart disease and pregnancy: natural selection, pulmonary hypertension, and anesthesia. J Clin Anesth 1993; 5:332-41. [PMID: 8373615 DOI: 10.1016/0952-8180(93)90130-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- B M Weiss
- Institute of Anesthesiology, University Hospital Zurich, Switzerland
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