Anesthesia Management

for Maternal with Heart

Diseases

Purwoko

Dept. of Anesthesiology and Intensive Therapy Dr. Moewardi General Hospital / Sebelas Maret Univ

Surakarta2014

Latest management for maternal with heart

disease requiring surgery.

Techniques of regional anesthesia in patients

with heart disease need little adjustment.

Monitoring of fluid and several heart function.

Introduction

The prevalence of heart disease in pregnancy is 0.4 - 1%

High risk maternal requires an understanding of the impact of pregnancy and heart lesions on hemodynamic response

Objective : To discuss anesthesia management for maternal with common heart lesions which requires non cardiac surgery.

Physiological changes in pregnancy

• Stroke volume ↑↑, Heart rate ↑↑.

• Cardiac output ↑↑

• Sistemic vascular resistance ↓ ± 20%

• Blood flow to uterus ↑↑ 700-900 ml / hour (increasing heart load)

• - Healthy heart no problem

- Abnormal heart problem

1. Congenital Heart Disease

Patent ductus arteriosus (PDA), Atrial

Septal Defect (ASD) and Ventricular Septal

Defect (VSD) are common congenital heart

diseases

Increased cardiovascular volume during pregnancy →increasing atrial volume that leads to enlargement of both atria and susceptibility of supraventriculare dysrhythmias

Actions performed on the CHD patients :

1. Prevention of air bubbles into the intravenous access.

2. Epidural anesthesia is better using NaCl, slow onset of epidural analgesia

3. Oxygen supplementation

4. Antibiotic prophylaxis is recommended.

Tetralogy of Fallot (TOF)

Minimizing hemodynamic changes that

leads to increased R to L shunt.

It is important to prevent decreased in SVR,

venous return or myocardial depression

Both GA or RA techniques can be used.

• For GA, induction agents chosen are those that cause the most minimal hemodynamic changes, for examples narcotics and etomidate.

• Regional anesthesia techniques can be used with special attention.

• Single Shot spinal anesthesia should be avoided.

• Slow induction of epidural anesthesia is recommended

Eisenmenger Syndrome

Abnormalities : pulmonary hypertension,

right-to-left shunting produces arterial

hypoxemia.

Clinical manifestations include dyspnoea,

clubbing, polycythemia, peripheral edema

and cyanosis.

Avoid decreased of SVR.

RA or GA may be used if only there are no contraindications . RA can be done using epidural dose titration.

Oxygen should be given

Blood loss should be replaced with colloid, crystalloid or blood components.

Invasive Monitoring should be done such as arterial Line and CVP

Ampycillin and Gentamicin should be given as prophylaxis drugs against infective endocarditis and repeated every 8 hours after the initial dose.

Valvular Heart Diseases

1. Mitral stenosis

Maintain heart rate, venous return and SVR remained low (slow)

Avoid aorto caval compression, aggressive treatment of atrial fibrillation, maintaining sinus rhythm.

prevent pain, hypoxemia, hypercarbia and acidosis ↑↑ SVR.

Both RA or GA can be used.

Epidural anesthesia is an option

Vasopressors: low dose of phenylephrine.

GA also provide stable hemodynamics,

Etomidate is best used as an induction agent.

Beta blockers such as esmolol and moderate dose of opioids should be administered before induction

2. Mitral regurgitation• Pregnancy will induce a state of hyper

coagulation and systemic embolism.

• Epidural anesthesia can prevent an increase in SVR, and prevent pulmonary congestion.

• Invasive blood pressure monitoring

• Antibiotics profilaxis is recommended• GA : Ketamin and Pancuronium

• The main consideration is maintaining

slight increase in heart rate to prevent an

increase in SVR and central blood volume.

• Prevent hypoxemia, hypercarbia, acidosis

that will lead to an increase in PVR.

• Avoiding Aortocaval compression and

myocardial depression.

3. Aorta Stenosis

In aorta stenosis, transvascular gradient will progressively increased during pregnancy, this is due to an increase in blood volume and decrease in SVR.

Avoid tachycardia and bradycardia, maintain intravascular volume and "venous return", avoid aortocaval compression and myocardial depression, maintain heart rate as the normal condition because decrease in heart rate will decrease cardiac output

GA: combination of etomidate and mid-dose opioids with succinylcholine for "Rapid Sequence intubation".

Myocardial depression due to volatile anesthetic agents should be avoided

Pulmonary artery catheter monitoring is controversial, CVP monitoring is needed and must be maintained at high normal level

4. Aorta Insufficiency

Pathophysiology that occurs due to the "volume overload" on

the LV, with hypertrophy and dilatation and increased LVEDV,

decreased ejection fraction (EF) and signs and symptoms of

edema pumonal.

Minimalizing pain is an attempt to prevent release of

catecholamines , which may increase SVR

Avoid bradycardia because it can lead to an increase in

regurgitant flow.

• Epidural anesthesia is

preferable/recommended

• Induction agent using etomidate,

endotracheal intubation using

suxamethonium

• Remifentanyl for analgesia

5. Prosthetic Valves

The high risk of fetal and maternal complications

The use of anticoagulant therapy is contra indication for regional anesthesia.

GA: the use of an additional monitoring tool such as CVP, PA catheter and A-Line

Peripartum Cardiomyopathy (PPCM)

Heart failure can occurs in the 3rd trimester, EF less than 45% and diastolic dimensions greater than 2.72cm / m2

Avoiding myocardial depression and attention to fluid management with the use of diuretics and vasodilators, as well as keeping the heart rate within the normal range with sinus rhythm.

Titration slowly CSA / CEA

GA: monitoring invasive, PA Line, A Line

Narcotics for the induction and maintenance of anesthesia

Maternal arrhythmias during pregnancy

Cathecolamine Sensitive Ventricular Tachycardia (VT)

Often due to the VT re-entry (ca)

Patients with a history of VT are required to continue the anti-arrhythmia medication during pregnancy.

CSE drug delivery slowly (slow incremental)

Congenital Heart Block and Bradyarrhytmia

The use of pacemaker; QT interval lengthening or if there is enlargement of the left atrium.

Access CVC and "trans Venous Pacing wires should be prepared in addition to the patient during the surgery

Epidural analgesia is recommended for surgery and postoperative pain.

Maternal postoperative period in heart disease

Patients with less - severe cardiac dysfunction that undergo

surgery should be monitored in Intensive Care Unit (ICU)

The first 24-72 hours of fluid displacement will appear

significantly.

Adequate postoperative analgesia should be provided in the

form of "continuous epidural analgesia" or "patient controlled

IV analgesia”.

Provision of early ambulation to minimize the occurrence of

"deep vein thrombosis and paradoxical emboli"

"Outcome" of fetal and maternal heart disease

requiring surgery

• Mortality that is less than 1% have been

reported in patients with NYHA Class I and

II, whereas in NYHA Class III and IV are

about 5-15%.

Conclusions

Cardiologist, obstetrician and anestesiologist should cooperate to each other

The advantage of regional anesthesia is patients can communicate if symptoms occur

If palpitations, chest pain and shortness of breath happened, immediate action should be performed

RA should be given using lower dose of local anesthetics opioids and slow induction

GA : standard technique “rapid sequence induction”

THANK YOU