Anesthesia in pregnancy with heart disease

Risk of Recurrent and Frequent Preterm Birth Among Women With Mitral Valve Prolapse: A Systematic Review and Meta-Analysis

Preterm delivery remains a prominent problem in obstetrics with significant adverse implications for both mothers and the offspring. The incidence of mitral valve prolapse (MVP) in women of childbearing age has raised concerns about pregnancy and pregnancy connotations. The objective of this systematic review and meta-analysis is to help in understanding the plausibility of the association between MVP and preterm birth in women with a history of frequent deliveries. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we searched the databases, including PubMed, Embase, Cochrane Library, Web of Science, and Scopus, for studies published in the period 1999 through 2024. Inclusion criteria consisted of studies such as cohort, cross-sectional, and case-control studies related to women diagnosed with MVP out of a total number of 1,029 articles found. Overall, a total of 19 studies were included in this review, with 3 of which were considered for further meta-analysis. It was revealed in the analysis that there was an association between MVP and preterm delivery when the severity of MVP was at Types II and III. The evidence also underscores the importance of both follow-up and preemptive measures among women suffering from MV prolapse for improved maternal and neonatal outcomes. The average Z-value (4.47) and p-value (0.00) for the test for overall effect size indicate the presence of a high correlation between MVP and premature delivery, suggesting satisfactory statistics on the association. The findings do indicate that MVP is a risk factor for preterm delivery (pooled ES = 0.24, 95% CI = 0.14 to 0.35, P <0.001).

Limb-girdle muscular dystrophy in pregnancy: a narrative review

Limb-girdle muscular dystrophy (LGMD) poses unique challenges for women during pregnancy, necessitating comprehensive care and tailored management strategies. The present narrative review aims to examine the unique challenges and management strategies required for women with LGMD during pregnancy. With over 30 genetic subtypes identified and the potential for additional discoveries through advanced diagnostic techniques, preconception counseling plays a crucial role in informing prospective parents about reproductive risks and available options. Baseline assessments, including cardiac and pulmonary evaluations, are essential to guide antenatal care, alongside genetic testing for precise diagnosis and counseling. Optimizing maternal health through respiratory exercises, cardiac monitoring, and individualized exercise and nutrition plans is paramount to avoid potential complications. During pregnancy, close monitoring of maternal and fetal well-being is important, with collaborative care between obstetricians and specialists. An individualized approach to delivery mode considering factors such as muscle strength, pelvic size, and fetal presentation is crucial. While vaginal delivery has been proven to be possible, the need for an emergency cesarean delivery should always be kept in mind. Regional anesthesia is preferred, with proactive planning for potential respiratory support. Bupivacaine has been shown to be effective with epidural catheters that may be used for prolonged relief with opioids like morphine and fentanyl, while also evaluating the patients' respiratory function. Postpartum considerations include pain management, mobility support, breastfeeding assistance, and emotional support. Early mobilization and tailored physiotherapy regimens may promote optimal recovery, while comprehensive breastfeeding guidance is needed to address challenges related to muscle weakness. Access to mental health resources and support networks is essential to helping individuals cope with the emotional demands of parenthood alongside managing LGMD. By addressing the unique needs of pregnant individuals with LGMD, healthcare providers can optimize maternal and fetal outcomes while supporting individuals in their journey to parenthood.

Challenges and Strategies in Administering Anesthesia to Pregnant Patients With Malaria: A Comprehensive Review

Malaria remains a significant global health challenge, particularly in sub-Saharan Africa, where its impact on pregnant women and their fetuses is profound. The disease's complex interaction with pregnancy introduces unique challenges in anesthesia management, necessitating a thorough understanding of both malaria and its implications for anesthetic care. This review aims to explore the multifaceted issues associated with anesthesia for pregnant patients with malaria, examining the impact of the disease on pregnancy and the specific considerations required for effective anesthetic management. A comprehensive review of the current literature was conducted, focusing on the physiological effects of malaria on pregnancy, its complications, and the related anesthetic challenges. The review synthesizes findings from clinical studies, case reports, and expert guidelines to provide an overview of best practices and strategies. Malaria in pregnant women can lead to severe complications such as maternal anemia, placental insufficiency, and preterm labor, all of which complicate anesthetic management. The review identifies key considerations for anesthesia, including the choice of anesthetic techniques, drug interactions, and fluid management. Specific challenges include managing anemia, ensuring adequate hemodynamic stability, and mitigating potential risks associated with malaria medications. Effective anesthesia management in pregnant patients with malaria requires a nuanced approach that addresses both the disease's effects and the physiological changes of pregnancy. This review underscores the need for tailored anesthetic strategies and highlights areas for further research to enhance patient safety and outcomes. Recommendations are provided to guide clinicians in optimizing care for this vulnerable population.

Friedreich's Ataxia and Cesarean Delivery: A Case Report of Epidural Anesthesia With Ropivacaine

Friedreich's ataxia (FRDA), a rare inherited neurodegenerative disease, presents distinctive complexities in obstetrical anesthesia. Available research about FRDA in obstetrics is extremely limited. In this report, the anesthetic management of a 40-year-old primigravida with FRDA undergoing cesarean delivery is presented. An uneventful cesarean delivery with effective epidural anesthesia with ropivacaine at the L2-L3 intervertebral space was performed in our case. Neither hypotension nor bradycardia was observed, and vital signs remained stable, with no need for administration of vasoactive drugs. After discharge, the parturient reported no change in her neurologic symptoms. Conclusive recommendations are contingent upon more extensive studies. Overall management and the choice to proceed with neuraxial anesthesia in a woman with FRDA should be based on comprehensive consultations in both cardio-obstetrics and pre-anesthetic evaluations.

Application effect of gastrointestinal bundle nursing on the protection of gastrointestinal function in patients with gastric cancer

Evidence-based nursing practice was used to formulate the enhanced recovery surgery bundle nursing strategy and apply it to patients with gastric cancer, to explore its safety, effectiveness and feasibility in perioperative gastrointestinal function protection in patients with gastric cancer. Selected the clinical medical records of 100 gastric cancer patients treated in our hospital from June 2019 to June 2021 as the research objects, and divided them into the control group and the observation group with 50 cases in each group according to the random number table. Among them, the control group was given routine nursing measures for nursing intervention, and the observation group was given gastrointestinal enhanced recovery surgery cluster nursing on the basis of the control group. The differences in stress response, gastrointestinal function protection, negative emotions and pain scores of gastric cancer patients before and after nursing were compared between the 2 groups. The postoperative bowel sounds recovery time, first anal exhaust, and first defecation time in the observation group were lower than those in the control group, and the differences were statistically significant (P < .05). Before nursing, there was no significant difference in the scores of stress response changes between the 2 groups (P > .05). After nursing, heart rate (HR), mean arterial pressure (MAP), norepinephrine (NE), and epinephrine (E2) in the observation group were lower than those in the control group, and the difference was statistically significant (P < .05). The pain scores of the 2 groups were significantly improved at different time points, and the observation group was significantly less than the control group, and the difference was statistically significant (P < .05). Gastrointestinal enhanced recovery surgery bundle nursing can effectively improve the gastrointestinal function of patients with gastric cancer, improve the emotional response and stress response of patients, and has certain reference value for the nursing of patients with gastric cancer.

Cesarean section of a patient with combined severe mitral and aortic stenosis: a case report

Cardiovascular diseases during pregnancy are rare but account for complications that pose risks to the mother as well as the child. In patients with fixed cardiac output due to stenotic valvular lesion(s), the physiological changes during pregnancy carry high risk of morbidity and mortality.

Case Presentation

Our patient was diagnosed with severe mitral and aortic stenosis at her first antenatal visit at 24 weeks of gestation. She was also diagnosed with intrauterine growth restriction and was therefore planned to be operated on at a gestational age of 34 weeks. After careful selection of monitoring and anesthetic regime, the patient was managed without any intraoperative or postoperative complications.

Clinical Discussion

This case reports how the anesthetists, obstetricians, and cardiac surgeons devised a well-designed plan to operate on a patient with a relatively rare disease manifestation. Our patient had coexisting severe stenotic lesions of both mitral and aortic valves and posed a clinical dilemma regarding the choice of anesthesia and perioperative management. Regardless of the anesthetic technique, goals for a patient with the combined valvular disease include maintenance of adequate preload, systemic vascular resistance, cardiac contractility, sinus rhythm and avoidance of tachycardia, bradycardia, aortocaval compression, and anesthetic or surgery-induced hemodynamic changes.

Conclusion

The course of management would give clinicians an idea of how to manage a patient with combined stenotic valvular lesions for cesarean section, ensuring a smooth course and a safe postoperative period.

Neurosurgical Emergency in an Adult With Single Ventricle Physiology: A Case Report

The anesthetic management of a patient with uncorrected congenital heart disease presenting for noncardiac surgery is quite challenging. When this becomes a neurosurgical emergency, the need to balance cerebral and complex circulatory physiologies tests the anesthesiologist's preparedness. The principal clinical challenges we faced were preventing increases in intracranial pressure while maintaining the circulatory physiology using the "cardiac grid" approach to hemodynamic management in a case of acyanotic double outlet right ventricle with a posterior fossa space-occupying lesion. Point of care preoperative echocardiography enabled us to understand the altered circulatory physiology and successfully manage this patient.

Critical Care Management of the Parturient with Cardiac Disease

Parturient with heart disease forms a challenging group of patients and requires specialized critical care support in the peripartum period. Maternal heart disease may remain undiagnosed till the second trimester of pregnancy, presenting frequently after 20 weeks of gestation, due to increased demands imposed on the cardiovascular system and pose a serious risk to the life of mother and fetus. Management of critically ill parturient with heart disease must be tailored according to individual assessment of the patient and requires a strategic, multidisciplinary, and protocol-based approach. A dedicated obstetric intensive care unit (ICU) and team effort are the need of the hour.

HOW TO CITE THIS ARTICLE

Garg R, Hariharan UR, Malik I. Critical Care Management of the Parturient with Cardiac Disease. Indian J Crit Care Med 2021;25(Suppl 3):S230-S240.

Pregnancy Management in a Patient With Congenital Heart Disease and Severe Right Ventricle to Pulmonary Artery Conduit Stenosis

Background: Pregnancy causes multiple hemodynamic changes that place significant stress on the cardiovascular system. With advancements in medical care, individuals with complex congenital heart disease are living into their childbearing years. Much remains to be understood about the effects and management of pregnancy in individuals with complex congenital heart disease. Case Report: We describe the management and delivery of a 29-year-old pregnant female with repaired tetralogy of Fallot or ventricular septal defect with pulmonary atresia. The patient presented at 21 weeks' gestation with New York Heart Association class II symptoms and pulmonary conduit stenosis, with a mean gradient of 52 mmHg. At 36.5 weeks' gestation, she developed severe pulmonary conduit stenosis with a mean gradient of >75 mmHg. The patient was admitted at 37 weeks' gestation for planned delivery. After a successful cesarean section and bilateral tubal ligation, the patient had an uncomplicated postoperative course. She was scheduled for follow-up for severe conduit stenosis at 6 weeks postpartum to discuss management options. Conclusion: Management of a pregnant patient with adult congenital heart disease should involve risk stratification for complications (commonly congestive heart failure exacerbation and arrhythmias) using tools such as the modified World Health Organization pregnancy risk classification. Based on the risk category, decisions must be made about frequency of follow-up, anesthesia, and mode of delivery. Patients in moderate to high-risk stratification should be managed by a multidisciplinary team at a specialty center, and all patients should undergo an anesthesia consultation prior to delivery. The decision for vaginal or cesarean delivery should be made on a case-by-case basis with consideration given to patient preference. Patients with asymptomatic moderate to severe pulmonic stenosis can be managed conservatively with appropriate follow-up and cardiac imaging, allowing intervention to be completed after delivery.