Regional in Heart Disease

8/14/2019 Regional in Heart Disease

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Regional anaesthesia for a Caesarean section in women

with cardiac disease: a prospective study

E. LANGESTER, M. DRAGSUND and L. A. ROSSELANDDivision of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway

Background We conducted a prospective observationalsurvey of pregnant women with cardiac disease. The aimwas to analyse and present the mode of delivery, outcome,and haemodynamic changes during a caesarean sectionunder regional anaesthesia in women with cardiac disease.Methods All pregnant women with a cardiovascular diag-nosis, except hypertension, were included in the registry.Based on the cardiac diagnoses, and on the New YorkHeart Association classification, a multidisciplinary groupmade recommendations for each patient and decided onthe mode of delivery. The data from continuous, invasivehaemodynamic monitoring in intermediate- and high-riskpatients under regional anaesthesia for a caesarean sectionwere analysed and presented.Results The hospital had approximately 9000 deliveries inthe period from November 2003 to April 2008. A total of113 pregnancies in 107 women were included. Thirty-two(28.3%) pregnancies were classified into the high-riskcategory. Of 103 deliveries, caesarean sections were per-formed in 59 (52.2%) cases, with regional anaesthesia in 51

patients (18 emergencies), general anaesthesia in eightpatients (five emergencies), and a planned vaginal deliv-ery in 44 patients. There was no mortality among themothers or the babies during the hospital stay or 6 monthspostpartum. Pre-operative cardiovascular stability duringthe caesarean section was maintained by volume andphenylephrine infusion guided by invasive monitoring ofhaemodynamic variables.Conclusion Our study suggests that pregnant women withcardiac disease may safely deliver the baby by a caesareansection under regional anaesthesia. According to our find-ings, haemodynamic stability can be obtained by titratedregional anaesthesia, intravenous (i.v.) volume, pheny-lephrine infusion, and small repeated doses of i.v. oxytocinguided by invasive monitoring.

Accepted for publication 25 June 2009

r 2009 The Authors Journal compilationr 2009 The Acta Anaesthesiologica Scandinavica Foundation

THE number of pregnant women with heartdisease is increasing. Information regardingthe incidence and epidemiology is highlighted inthe UK registry of high-risk anaesthesia,1 and in theConfidential Enquiries into Maternal Deaths in theUnited Kingdom.2,3 Maternal mortality in womenwith cardiac disease has increased from 7.6 permillion pregnancies in 1980 to 22 per million in theperiod 20002002.4 Cardiac disease is now the most

common cause of indirect deaths as well as ofmaternal deaths overall.3 In general, vaginal deliv-ery has been recommended,5,6 but arguments have been put forward for a more frequent use of acaesarean section.7 There have been a number ofcase reports, but only a few studies on the anaes-thetic techniques, monitoring, and practical man-agement of these high-risk patients have beenconducted.4,8 No relevant randomized clinicaltrials have been published.

Rikshospitalet is a national centre for congenitalheart surgery in Norway and a tertiary centre forpregnancy disorders. The majority of women witha high-risk pregnancy due to heart disease aretransferred to our hospital from all other deliverydepartments in Norway.

We have conducted a prospective observationalsurvey of pregnant women with cardiac disease inour department from November 2003 to April 2008.

The aim of the study was to analyse and presentthe management, mode of delivery, haemodynamicchanges, and outcome during a caesarean sectionunder regional anaesthesia in women with cardiacdisease.

Materials and methods

The protocol for the study was approved by TheRegional Medical Research Ethics Committee for

46

Acta Anaesthesiol Scand 2010; 54: 4654Printed in Singapore. All rights reserved

r 2009 The Authors

Journal compilation r 2009 The Acta Anaesthesiologica Scandinavica Foundation

ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2009.02080.x


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Southern Norway, and the patients gave writteninformed consent. All pregnant women with acardiac diagnosis who delivered at Rikshospitaletfrom November 2003 to April 2008 were included.Parturients with only chronic hypertension orpregnancy-induced hypertension were not in-cluded. The database included information about

patient history, cardiac diagnosis and treatment,functional classification according to the New YorkHeart Association (NYHA), and echo cardiogra-phy.4,9,10 The patients were classified as high, inter-mediate, or low risk based on guidelines in thepublications by Siu and Colman,6 and Dob andYentis.11 The NYHA classification was based on astandardized exercise test. The women walked upa stairway, with continuous monitoring of heartrate and oxygen saturation, and stopped when theyfelt the need, due to dyspnoea. The exercise testwas repeated during the pregnancy in intermedi-

ate- and high-risk patients.In the beginning, in November 2003, there was noorganized multidisciplinary group, but this devel-oped during the survey period. From 2005, a multi-disciplinary team of cardiologists, obstetricians,obstetric anaesthetists, and a cardiac anaesthetisthave had regular meetings to discuss all pregnantwomen with a cardiac diagnosis planned for deliv-ery in our hospital. This group decided on theindividual recommendations for each patient in-cluding whether the woman should have a plannedcaesarean section or a vaginal delivery. This decision

was based on an individual assessment of the riskgroup. Central in the evaluation of the recom-mended method of delivery was the functionalclassification according to NYHA. Our routine strat-egy in most high-risk patients was to deliver by anelective caesarean section with regional anaesthesia,unless there were contraindications such as antic-oagulation. Patients with a previous uncomplicatedvaginal delivery were considered for vaginal deliv-ery, even in the high-risk group.

Standard routine monitoring for an elective cae-sarean section was an arterial line in all high- and

intermediate-risk patients. In addition to invasiveblood pressure, we measured haemodynamic vari-ables using LiDCOPlus (LiDCO Ltd, Cambridge,UK), which is a monitor that provides continuoushaemodynamic measurements. This new mini-mally invasive technique is based on two methods:a continuous arterial waveform analysis system(PulseCO) coupled to a single-point lithium indi-cator dilution calibration system (LiDCO). For thecalibration to measure the actual cardiac output

(CO), lithium chloride 0.3 mmol is injected througha peripheral line and the lithium is detected by alithium ion-sensitive external electrode connectedto a peripheral arterial line. The lithium dose hasno pharmacological effect on the woman or thefoetus.12 The LiDCOPlus gives continuous bloodpressure and a beat-to-beat measurement of CO,

stroke volume (SV), and systemic vascular resis-tance (SVR).13 We started to use this monitor in ouranaesthetic department in 2005. The CO monitorhas been validated in other patient groups,14 and inthe last year there have been publications on its usein pregnant women.1517

A prophylactic low-dose phenylephrine infusionand cohydration with crystalloids was part of astandard protocol for preventing haemodynamicinstability during a caesarean section, based ondata from healthy women.17 Haemodynamic in-stability was defined as a decrease in CO to levels

below 70% of the baseline, and systolic blood pres-sure (SBP)o90 mmHg, until delivery of the baby.Oxytocin (Syntocinon

s

, Novartis, Copenhagen,Denmark) used to be given as boluses of 5 U, whichwas the standard dose in our department in 2003.The use of oxytocin changed during the studyperiod. We reduced the dose to repeated bolusesof 0.5 U in the beginning of the study. Based on thetwo studies by Carvalho and colleagues18,19, andour own experience, we reduced the dose further to0.1 U, repeated until there was an adequate effecton uterine contractions.

We registered the mode of delivery and anaes-thetic technique during a caesarean section, use ofphenylephrine, use of oxytocin, bleeding, haemo-globin concentration pre- and post-delivery, needfor transfusion, and the maternal outcome in allpatients 6 months postpartum. The Apgar scoreand umbilical venous and arterial pH were re-corded for all the babies.

The haemodynamic data were stored in the LiD-COPlus-monitor and downloaded as csv files (textfiles) for each patient. Construction of the data setwas performed using MATLAB version R2007a (The

MathWorks, Natick, MA). Outliers were removed,and the beat-to-beat data set was constructed using acentred moving average of 30 observations.

Results

PatientsOur obstetric department at Rikshospitalet hadapproximately 9000 deliveries from November

Caesarean section in women with cardiac disease

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2003 to April 2008. We included 113 pregnancies in107 women with heart disease in this period.Patients who were transferred from other hospitalsafter delivery, because of cardiac disease, were notincluded. There were 32 high-risk patients, 31patients with an intermediate risk, and 50 patientsin the low-risk group. Table 1 shows descriptive

data on the 103 parturients (the 10 abortions are notincluded). The characteristics of the newborn areshown in Table 2. Diagnoses and risk groups areshown in Table 3.

Ten patients had an abortion. Four high-riskpatients were advised to terminate the pregnancy.Two patients with Eisenmenger syndrome and onepatient with hypertrophic obstructive cardiomyo-pathy (HOCM) had a surgical abortion with a low-dose spinal anaesthesia. One patient with severemyocarditis had a medical abortion using miso-prostol.

Following the multidisciplinary assessment, 48patients were scheduled for an elective caesareansection and 55 patients were planned for a vaginaldelivery. Eleven of the planned vaginal deliveriesended as an emergency caesarean section, and 12 ofthe planned caesarean section had to be conductedearlier than planned due to obstetric indications. Inseveral high-risk patients, there were no changes inthe findings on repeated echocardiography,although the patients functional capacity wor-sened during the pregnancy judged by the exercisetests.

Regional anaesthesia was administered in 51patients (18 emergencies), and general anaesthesiain eight patients (five emergencies) of a total of 59caesarean sections (57.3% of the deliveries) (seeTable 4). Twenty of the 23 emergency caesareansections were for an obstetric indication. In thehigh-risk group, 82.1% had a caesarean section.

Table 1

Patient characteristics.*

Age 30.5 (20.042.5)GA 37.6 (24.942.5)Weight (kg) 77.6 (40.0130.0)Height (cm) 167 (150179)BMI (kg/m2) 27.9 (17.842.4)

Data are presented as mean (range).*Ten women having an abortion, were not included.GA, gestational age; BMI, body mass index.

Table 2

Characteristics of the newborn.

Apgar 1 9 (210)Apgar 2 9 (610)Umbilical vein pH 7.34 (6.987.46)Umbilical artery pH 7.27 (6.977.39)Birth weight (g) 3084 (13004590)

Data are presented as median (range) for Apgar score or mean(range) for pH and birth weight. Apgar 1: Apgar score after 1min; Apgar 2: Apgar score after 5 mins.

Table 3

Cardiac diagnosis and risk classification.

Diagnosis High risk Medium risk Low risk Total

CardiomyopathyDilated 10 0 1 11HOCM 2 2 1 5HCM 0 0 4 4

AS/AI/AVR 1 6 2 9

MS/MI/MVR 1 5 12 18PI/PS 2 2 5 9PHT 4 1 0 5Eisenmenger 3 0 0 3Heart; tx 0 1 1 2ASD 1 0 3 4VSD 0 0 3 3CoA 2 1 0 3TGA, mustard 3 4 0 7Fallots tetrade 0 6 4 10Arrhythmias

LQTS 0 0 6 6VT/WPW/AF 0 0 9 9

Myocarditis 1 0 0 1TAA 0 1 0 1Coronary disease 1 0 0 1Ebstein anomaly 0 1 0 1Double-chamber RV 0 1 0 1Total N 32 31 50 113

HOCM, hypertrophic obstructive cardiomyopathy; HCM, hyper-trophic cardiomyopathy; AS/AI/AVR, aortic stenosis/aortic in-sufficiency/aortic valve replacement; MI/MS, mitral insufficiency/stenosis; MVR, mitral valve replacement; PI/PS, pulmonaryinsufficiency/stenosis; PHT, pulmonary hypertension; ASD/VSD, atrial/ventricular septal defect; TAA, thoracic aortic anuer-ism; CoA, aortic coarctation; TGA, transposition of the greatarteries; LQTS, long QT syndrome; VT, ventricular tachycardia;WPW, WolffParkinsonWhite syndrome; double-chamber RV,double-chamber right ventricle.

Table 4

Delivery and anaesthesia (emergency C-section in bracket).

Total: 113 High risk Intermediaterisk

Low risk

(n532) (n531) (n550)

Mode of deliveryC-section (n559) 23 (8) 16 (7) 20 (8)Vaginal delivery (n544) 5 11 28Abortion (n510) 4 4 2

AnaesthesiaGeneral anaesthesia 5 (4) 2 (1) 1

Regional anaesthesia 18 (4) 14 (6) 19 (8)

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Anaesthetic techniqueAll elective caesarean sections were performedwith regional anaesthesia apart from three caseson anticoagulation therapy. Standard doses ofspinal anaesthesia with bupivacaine plain 810 mg and sufentanil 5mg or fentanyl 20mg wereadministered using spinal or a combined spinal

epidural (CSE) technique in 49 cases. One patienthad an epidural top-up for an emergency caesareansection, and one patient with severe peripartumcardiomyopathy had a spinal catheter for contin-uous spinal anaesthesia. Eight patients had generalanaesthesia with Pentothal and Suxamethonium aspart of a rapid sequence induction.20 None of thepatients receiving regional anaesthesia needed con-version to general anaesthesia. One patient withCSE had a local anaesthetic skin infiltration andfentanyl intravenous (i.v.) while waiting for theepidural top-up to have effect.

Invasive haemodynamic monitoringArterial line monitoring of blood pressure wasused in 49 patients during a caesarean section, infour vaginal deliveries, and in six abortions. Thir-teen patients for a caesarean section had a centralvenous catheter inserted. Six patients had a pul-monary artery catheter. We used the LiDCOplus in33 patients during a caesarean section. Hypoten-sion was prevented and treated with an i.v. crystal-

loid solution and phenylephrine infusion. Themedian requirement of phenylephrine in all cae-sarean section patients peri-operatively was 140 mg(01960mg). Twenty of the 59 patients for a caesar-ean section had no phenylephrine. The haemody-namic changes during regional anaesthesia in 24intermediate- and high-risk patients are shown inFig. 1. Two patients (patients 6 and 14) had an SBPbelow 90 mmHg for a short period. Three patients(patients 14, 20, and 24) had a decrease in CObelow 70% of the baseline. In patient 2, the changesin CO and SBP at 18 min were due to an artefact

caused by temporary technical problems with thearterial line. Seven low-risk patients, one inter-mediate-risk patient with general anaesthesia, andone intermediate-risk patient with technical pro-blems with the arterial line are not displayed. Thehaemodynamic changes in CO and SBP are pre-sented after the start of regional anaesthesia whenthe patient was positioned in the left lateral tilt anduntil delivery of the baby, including the effects ofoxytocin. All patients tolerated the haemodynamic

changes induced by regional anaesthesia withoutany clinical deterioration.

Use of oxytocinOxytocin decreases SVR and increases CO.21 In thisheterogenic patient group the haemodynamic ef-

fects of small doses of oxytocin will differ frompatient to patient, but given in small titrated doses,the haemodynamic changes were minor and tran-sient without aggravating any symptoms. Only onepatient (Fig 1; patient 3) had a short period ofdyspnoea after oxytocin 0.1 U. The haemodynamiceffects of oxytocin in 24 high- and intermediate-riskpatients are shown in Fig. 1. These patients wereadministered boluses from 0.05 to 0.5 U oxytocin i.v.

Outcome

There was no maternal or child mortality after 6months. The Apgar scores were 2 and 6 at 1 and 5min, respectively, in one baby whose mother hadan HOCM and pulmonary hypertension. She hadan emergency caesarean section due to circulatorycollapse in the operation theatre while inserting acentral venous catheter, during the preparation forregional anaesthesia, and before inserting an arter-ial line. Probably, the combination of anxiety, over-night fasting, and inferior vena cava compressionresulted in bradycardia and unconsciousness. Shewas dependent on a high heart rate of 120/min

with a low SV due to severe hypertrophic myocar-dium (septum 43 cm). An emergency caesareansection was performed under general anaesthesiaand both the mother and the baby survived. Asecond patient with a subvalvular aortic stenosiswas haemodynamically stable during a caesareansection with CSE anaesthesia (see Figs 13). Shedied 7 months postpartum after a cardiac re-opera-tion when she suffered a post-operative coronaryinfarction with heart failure. A third patient, with asevere heart failure due to peripartum cardiomyo-pathy (ejection fraction 1520%, left ventricle 9 cm,

heart rate 150/min), was haemodynamically stableduring a caesarean section using continuous spinalanaesthesia (see Figs 1 and 2). This patient had,prophylactically, an introducer for an intra-aorticballoon pump (IABP), and an introducer for pul-monary catheter. A pulmonary catheter was in-serted post-operatively. On the first post-operativeday, she deteriorated and required treatment withIABP and an i.v. infusion of nitroprusside. Acoronary angiography on the second day showed


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a dissection of the proximal left descending cor-onary artery, which was stented. After 71 days shehad a successful heart transplantation and theIABP was removed. Throughout this period she

did not need invasive respiratory support.Eight patients needed a blood transfusion. The

mean preoperative and post-operative haemoglo-bin concentrations were 11.9 (SD 1.4) and 10.8 (SD1.3), respectively, in the caesarean section patients.The mean estimated blood loss was 500 ml (1502500) in the caesarean section group and 410 ml(1502500) in the vaginal delivery group. Onepatient had a post-operative wound infection aftera caesarean section.

Discussion

Vasodilatation, a reduction in blood pressure, andthe risk of right to left shunting have been given as

reasons for not using regional anaesthesia in preg-nant women with cardiac disease. In our opinion,the arguments against regional anaesthesia are notvalid, and several case reports demonstrate a fa-vourable outcome.22,23 The reduction in SVR afterinduction of spinal anaesthesia can be counteracted by giving smaller doses of spinal anaesthetic,cohydration with crystalloids, and a concurrentinfusion of phenylephrine.17 Phenylephrine is re-garded as safe for the baby and is the vasopressor

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Fig. 1. This figure shows the changes in cardiac output (CO) and systolic blood pressure (SBP) during regional anaesthesia in 24 high- (112) and intermediate- (1324) risk patients during a caesarean section. The curves start at induction of anaesthesia. Time is shown on thex-axis with a 2-min interval. Baseline for CO is marked on the left y-axis. Baseline for SBP is marked on the right y-axis. The arrow on the

x-axis marks the administration of oxytocin. PPCM, peripartum cardiomyopathy; Subvalv AS, subvalvular aortic stenosis; PI, pulmonaryinsufficiency; TGA, transposition of the great arteries; AS/AI, aortic stenosis/aortic insufficiency; PHT, pulmonary hypertension; ASD,atrial septal defect; MI, mitral insufficiency; PE, preeclampsia; STEMI, ST-elevation myocardial infarction; CoA, aortic coarctation; AVR,aortic valve replacement; Heart tx, heart transplantation; Fallot, Tetralogy of Fallot; and TAA, thoracic aortic aneurism.

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of choice during a caesarean section under aneuraxial blockade in uncomplicated pregnan-cies.24,25 Animal studies have shown that the useof phenylephrine may not be as well tolerated inthe compromised foetus.26 The impact of this inclinical obstetric anaesthesia is questionable. Phe-nylephrine has a negative effect on maternal CO,and the use of a vasopressor in haemodynamicallycompromised pregnant women should be guidedwith CO monitoring, as blood pressure alone oftengives a poor indication of tissue blood flow. Mon-

itoring of CO is recommended in other patientgroups with circulatory derangements, and obste-tric patients should be no exception.27

A recent publication showed that a titratedspinal anaesthesia using a spinal catheter in preg-nant patients with mild to moderate signs ofcardiac failure induced a symptomatic transienthypotension in 18%.28 Their patients were moni-tored with continuous invasive blood pressure. Themean dose of phenylephrine used in this study was

550mg compared with 140mg in our study. Thelower dose of phenylephrine used in our study,mainly using a single shot spinal and CSE techni-que, could be explained by the use of continuousCO monitoring in our study to guide haemody-namic stability and the need for a vasopressor.

From the start of this study, with no systematicroutines, we now have regular multidisciplinarygroup meetings to decide how to manage parturi-ents with cardiac disease. The major limitation ofthis study is that the impact of different anaesthetic

methods on patient outcome cannot be analysed.During the study period, we have gained experi-ence in invasive monitoring and how this can beimplemented in the treatment protocols in order toreduce haemodynamic instability during a caesar-ean section under regional anaesthesia.

Compared with a recently published article fromthe United Kingdom29 with only 5% high-riskpatients in pregnant women with congenital heartdisease, nearly 30% of our patients were high-risk

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patients. This high proportion of severe cases mayreflect that our hospital is a tertiary centre forcomplicated pregnancies, and a national centrefor congenital heart disease.

International recommendations state that, withfew exceptions, these women should be plannedfor a vaginal delivery.4,6,11 Our practice differs from

this with 82% C-sections in the high-risk group.The arguments against a caesarean delivery are thehigher risk of infection, bleeding, and anaestheticcomplications. However, a vaginal delivery mayincrease the cardiovascular stress, even when opti-mal pain relief is offered.30 There is sparse litera-ture concerning the haemodynamic changesduring vaginal delivery, especially during the sec-ond stage, and this concern has not been a mainfocus in previous papers discussing the mode ofdelivery in these high-risk patients.

A planned caesarean section has, in our view,

many advantages in high-risk parturients, espe-cially if the patient has not given birth before. Onecan decide on a definite date during the daytimewith experienced staff, with sufficient time foradequate monitoring, and for administering regio-nal anaesthesia. The relative risk (RR) for mortalityin a vaginal delivery vs. an elective caesareansection is 2.3. When a vaginal delivery is comparedwith an instrumental vaginal delivery, the RRincreases to 3.6, and to 12 in case of an emergencycaesarean section.31 In the UK registry of high-riskobstetric patients,32 only 50 out of 274 had a

spontaneously vaginal delivery. An emergencycaesarean section under general anaesthesia mayalso carry a risk of intubation failure. It is oftenperformed by less experienced staff, at an incon-venient time, and with less monitoring. A previouspublication shows that a high number of pregnan-cies in high-risk cardiac patients attempting vagi-nal deliveries ended up in an emergency caesareansection.1,33 Deaths due to intubation failure arerare, but the confidential enquiry 200020022 re-ported six deaths due to general anaesthesia inwomen with no cardiac disease. General anaesthe-

sia may also induce autonomic responses withhypo- or hypertension and tachycardia, whichmay be less controllable. Positive pressure ventila-tion may be an important additional concern insome patients. Unless a patient has a bleedingdisorder or is treated with high doses of antic-oagulation drugs, we would recommend regionalanaesthesia for an elective caesarean section. In ourview, general anaesthesia should only be chosenwhen there are contraindications to regional anaes-

thesia or in case of an emergency caesarean sectionwith no time for regional anaesthesia.

Blood loss during a caesarean section may be anoverestimated risk factor in the debate concerningdelivery. In this population, the median change inpre-and post-operative haemoglobin was 1.1 g/dl.In two trials where the patients were randomized

to a caesarean section or a vaginal delivery, therewere no statistically significant differences inbleeding between the two groups.34,35

The use of oxytocin is controversial. Someauthors avoid i.v. oxytocin in pregnant womenwith cardiac disease,36 and others administer oxy-tocin as an infusion.11,36,37 However, the risk ofbleeding caused by uterine atony is also a majorconcern. In this series we administered small in-cremental doses of oxytocin until uterine tonus wassufficient. We do not practice administering oxyto-cin as an infusion, as recommended by others,11

because this may lead to an unnecessary volumeload after the delivery of the baby.38,39 For somepatients this may aggravate congestive heart fail-ure. In addition, a prophylactic B-lynch suture toprevent uterine atony and post-operative bleedingmay be indicated in some patients.

Carvalho and colleagues have shown in twostudies that the ED95% of oxytocin was 0.35 U inan elective caesarean section, and 3.0 U if thepatient was in labour with oxytocin stimulationbefore an emergency caesarean section.18,19

We find that the implementation of a minimally

invasive technique for haemodynamic monitoringperi-operatively is useful, and suitable for high-riskpregnant women. In contrast to blood pressurealone, monitoring CO and SVR provides importantinformation to guide therapy (volume, vasoactivemedication). Continuing the monitoring post-opera-tively, the individual patient can be given optimaltreatment, and complications may be prevented.Even though our observational study is small, ourfindings suggest that the haemodynamic changesinduced by regional anaesthesia are well toleratedin intermediate- and high-risk patients. We find CO

monitoring useful in the high-risk patients bothduring a caesarean section and post-operatively toguide treatment. Further studies are needed toverify the usefulness of this minimally invasivetechnique in obstetric patients.

Conclusion

Our study suggests that pregnant women with ahigh-risk cardiac disease may safely deliver the

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baby by a planned caesarean section under regionalanaesthesia. There is no evidence of an increasedrisk of bleeding compared with a vaginal delivery.Oxytocin i.v. administered as small repeated dosescan be used with minimal haemodynamic effects.Haemodynamic stability can be obtained by titratedregional anaesthesia, i.v. volume, and phenylephr-

ine infusion guided by invasive monitoring.

Acknowledgements

The authors thank Tor H. Hauge (MSc, Oslo, Norway) for datahandling in MatLab, and Mike S. Dodgson (MB ChB FRCA,Consultant Anaesthetist, Division of Anaesthesia and IntensiveCare Medicine, Rikshospitalet, Oslo, Norway) for linguisticadvice.

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Address:Eldrid LangesterDivision of Anaesthesia and Intensive Care MedicineOslo University HospitalRikshospitaletN-0027 OsloNorwaye-mail: [email protected]

E. Langester et al.

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