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REVIEW ARTICLE Table of Contents   
Year : 2010  |  Volume : 13  |  Issue : 2  |  Page : 102-109
Pregnancy and non-valvular heart disease - Anesthetic considerations


1 Consultant Anaesthesiologist, Department of Anesthesiology, Apollo Gleneagles Hospital, Kolkata, India
2 Hon. Consultant Anesthesiologist, Department of Anesthesiology, Apollo Gleneagles Hospital, Kolkata, India
3 PG student in Anesthesiology, Department of Anesthesiology, Apollo Gleneagles Hospital, Kolkata, India

Click here for correspondence address and email

Date of Submission14-Jul-2009
Date of Acceptance27-Nov-2009
Date of Web Publication3-May-2010
 

   Abstract 

Non-valvular heart disease is an important cause of cardiac disease in pregnancy and presents a unique challenge to the anesthesiologist during labor and delivery. A keen understanding of the underlying pathophysiology, in addition to the altered physiology of pregnancy, is the key to managing such patients. Disease-specific goals of management may help preserve the hemodynamic and ventilatory parameters within an acceptable limit and a successful conduct of labor and postpartum period

Keywords: Pregnancy, non-valvular heart disease, anesthesia, labor

How to cite this article:
Maitra G, Sengupta S, Rudra A, Debnath S. Pregnancy and non-valvular heart disease - Anesthetic considerations. Ann Card Anaesth 2010;13:102-9

How to cite this URL:
Maitra G, Sengupta S, Rudra A, Debnath S. Pregnancy and non-valvular heart disease - Anesthetic considerations. Ann Card Anaesth [serial online] 2010 [cited 2018 Dec 11];13:102-9. Available from: http://www.annals.in/text.asp?2010/13/2/102/62933



   Introduction Top


The prevalence of cardiac disease in pregnancy has remained relatively constant over the past decades and ranges from 0.4-4.1%. [1],[2],[3] In the developed world, congenital heart disease has supplanted rheumatic heart disease as the major cause of cardiac disease in pregnancy because, with the improvement in outcome in surgery for congenital heart anomalies, patients are increasingly likely to survive up to the child-bearing age. [4] Counseling of women with cardiac diseases is best performed prior to conception. This will allow for a thorough history taking and evaluation that includes invasive procedures like cardiac catheterization with fluoroscopy, if needed. These procedures are better performed during non-pregnant state to avoid potential fetal risks. However, majority of the cardiac diseases, whether acquired or congenital, can now be evaluated non-invasively by transthoracic echocardiography; cardiac catheterization is reserved for a few patients in whom corrective intracardiac repair is planned and adequate information could not be obtained by echocardiographic imaging. In addition, patients with surgically correctable lesions should undergo repair before pregnancy to improve both maternal and fetal outcome. [5] This article deals with only the non-valvular heart disease in pregnancy and anesthetic considerations in the peri-partum period.


   Physiological and General Considerations Top


There are five physiological changes which occur during pregnancy and they represent unique problems with anesthetic implications in patients with cardiac diseases:

  1. Fifty per cent increase in intravascular volume that peaks by early to mid third trimester
  2. Progressive decrease in systemic vascular resistance throughout pregnancy such that the mean arterial pressure is preserved at normal values despite 30-40 % increase in cardiac output. There is 15 % increase in heart rate.
  3. Marked fluctuations in cardiac output during labor with tachycardia and about 500 ml of blood added to the circulation during each uterine contraction.
  4. Hyper coagulability associated with pregnancy.
  5. Reduced functional residual capacity [6]
The most common causes of maternal death-embolism and hemorrhage, have remained unchanged over the past decades, but there has been an increase in maternal mortality from cardiac causes. [7] Due to reduced cardiopulmonary reserve in pregnancy, women with cardiovascular disease have an increased rate of abortion and a higher incidence of small for gestation age children. [8]

Predictors for cardiovascular complications during pregnancy include:

  • Earlier cardiovascular events or arrhythmias (cardiac decompensation, stroke, transient ischemic attack)
  • Heart failure with New York Heart Association (NYHA) classification of more than 2 or cyanosis
  • Ejection fraction less than 40% [9]

   Grown up with Congenital Heart Disease (GUCH) Top


Congenital heart disease is now the major cause of cardiac disease in pregnant women in the United States, accounting for 60-80 % of all cases. In some cases, successful surgery during infancy and childhood results in complete repair and normal cardiovascular function. Such patients often require no special treatment apart from two considerations. First, antibiotic prophylaxis may be warranted as per the current recommendations. Second, the presence of neonatologist at delivery is desirable as there is 0.7-1 % incidence of congenital cardiac lesions in the offspring of these women. On the other hand, some women may present during pregnancy with uncorrected lesion or partially corrected lesion, which becomes an anesthetic challenge during the conduct of labor. [10] Sometimes, parturients, especially in the non urban areas land up in less than ideal hospitals for management of labor and delivery. Therefore obtaining a detailed history and conducting a meticulous exam of the patient is vital. Patients detected with such cardiac disease should be referred to higher centers with adequate monitoring facilities and trained personnel for peripartum and perinatal care. Both maternal and fetal monitoring is essential throughout the peripartum period.

i) Left to Right shunts - Either small atrial septal defects (ASD) or ventricular septal defects (VSD) or patent ductus arteriosus (PDA) with modest left to right shunt is often well tolerated during pregnancy. During the peri-operative period, care should be taken to avoid accidental intravenous infusion of air bubbles. During epidural space localization loss of resistance to saline rather than air is preferable as identification of the epidural space with air might result in systemic air embolization. Even small amount of air can result in systemic embolization due to transient reversal of pressures in left or right side of heart during the cardiac cycle. Early epidural analgesia is desirable to avoid pain and resulting increase in systemic vascular resistance (SVR) and therefore potential left to right shunt. Intrapartum monitoring of mother with trans-esophageal echocardiography is beneficial. Slow onset epidural anesthesia is preferred as rapid decrease in SVR could possibly result in reversal of shunt flow and hypoxemia. And finally, the patient may benefit from supplemental inspired oxygen which may decrease the chance of patient developing hypoxia caused by reversal of shunt due to elevation of pulmonary vascular resistance. [11]

Anesthetic goals

  • avoid accidental injection of air intravenously
  • avoid decrease in SVR
  • prevent hypoxia, hypercapnia, acidosis
ii) Coarctation of Aorta - Coarctation of aorta is characterized by narrowing of the aorta at or near the insertion of ductus arteriosus. Maternal hypertension, particularly of the upper body is the principal concern. [12],[13] An arm to leg systolic blood pressure gradient of less than 20 mm Hg is associated with a good outcome during pregnancy. [14] Pregnant women with uncorrected coarctation or a residual decrease in aorta diameter are at high risk for left ventricular failure, aortic rupture or dissection. In such pregnancies, fetal mortality rate may reach up to 20 % because of decreased uterine perfusion distal to the aorta lesion. [15] Controlling maternal hypertension is important to diminish the chances of aortic dissection and rupture and beta blockers are indicated to achieve these. Although administration of beta blockers during pregnancy may increase the chance of fetal growth retardation, maternal safety takes precedence. The anesthetic management is aimed towards maintaining normal (or slightly elevated) SVR and heart rate, while taking care to keep the intravascular volume adequate. For caesarean section, general anesthesia is preferred though slow onset ("graded") epidural anesthesia has also been used.

Physiologically, an uncorrected coarctation of aorta represents a fixed obstruction to aortic outflow with distal hypoperfusion. The use of regional block in the presence of a fixed cardiac output state is controversial, because of the potential risk of excessive fall in SVR and reduction in venous return. Maintaining a maternal lower limb systolic blood pressure at more than100 mmHg is advisable, in order to avoid compromising the placental blood flow. Continuous fetal heart rate monitoring should be maintained during anesthesia to detect any compromise in placental circulation. As per current recommendations antibiotic prophylaxis for endocarditis and endoarteritis is recommended. [12] Invasive hemodynamic monitoring can help guide the administration of intravenous fluids. Uterine perfusion is reflected by using a post-ductal intra-arterial catheter instead of a pre-ductal catheter. Fetal bradycardia can also indicate placental hypo perfusion but only after a time lag. Ephedrine and dopamine are vasopressors of choice for their mild positive chronotropic effect. [11]

Anesthetic goals

  • maintain normal to slightly elevated SVR
  • maintain normal to slightly elevated heart rate
  • maintain adequate intravascular volume and venous return
  • invasive hemodynamic monitoring
iii ) Tetralogy of Fallot - Accounts for 5 % of cases of congenital heart disease in pregnancy. Includes four components -

  • A ventricular septal defect (VSD)
  • Infundibular or right ventricular outflow tract obstruction
  • Overriding of aorta sitting over the VSD
  • Right ventricular hypertrophy
It is the commonest congenital heart disease with right to left shunt. Patients present with cyanosis. Pregnant women with tetralogy usually have had corrective surgery in childhood - closure of VSD and widening of pulmonary outflow tract. In some, a small residual VSD may be present or progressive hypertrophy of pulmonary outflow tract may occur slowly over decades.

In these patients the physiological stress and compromised cardiopulmonary function of the pregnant state combined with the effect of residual cardiovascular lesions after corrective surgery is of concern because of -

  • Progressive right ventricular dysfunction
  • Atrial and ventricular dysrhythmia
  • Thromboembolic phenomena
  • Progressive aortic root dilatation
  • Intrauterine growth retardation
  • Endocarditis [16]
Patients with corrected tetralogy, even if asymptomatic for many years, should undergo echocardiography before and during early pregnancy. These patients may manifest atrial and ventricular arrhythmias due to surgical injury to cardiac conduction system. A 12 lead electrocardiogram (ECG) and ECG monitoring during labor is desirable. Meticulous attention should be given to avoid any intravenous air bubble infusion as it may lead to systemic embolization.

In uncorrected TOF or corrected TOF with residual disease, anesthetic management revolves around avoiding decrease in SVR, which increases right to left shunt. It is important to maintain intravascular volume and venous return. Trans-esophageal echocardiographic monitoring is helpful. Administration of epidural block recommended in early labor to avoid pain and consequent right ventricular outflow tract spasm and increase in right to left shunt. For caesarean section onset of regional block should be slow so single shot spinal is a poor choice as abrupt decrease in SVR may cause increase in right to left shunt. [11]

Antibiotic prophylaxis against endocarditis is essential.

Anesthetic goals

  • Avoid decrease in SVR
  • Maintain adequate intravascular volume and venous return
  • Epidural analgesia early in labor
Eisenmenger's Syndrome - This is a consequence of chronic uncorrected left to right shunt producing right ventricular hypertrophy, elevated pulmonary artery pressure and right ventricular dysfunction. Primary lesion may either be ASD, VSD or PDA. A reversal of shunt occurs when pulmonary arterial pressure exceeds systemic pressure and ultimately irreversible pulmonary hypertension occurs, at which point correction of primary lesion is not helpful. It presents with arterial hypoxemia and right ventricular failure. Pregnancy-associated decrease in SVR increases severity of right to left shunt with decreased pulmonary perfusion. Decrease in functional residual capacity further predisposes to hypoxemia. [11] In the presence of fixed pulmonary hypertension, reduction in right ventricular filling pressure due to hypotension from any cause may lead to sudden profound hypoxemia and death. Maternal hypoxemia results in decreased oxygen delivery to fetus and thus high incidence of intra-uterine growth retardation (IUGR) and fetal demise. [17] Maternal mortality is as high as 30-50 % in these patients. [18] Patients with Eisenmenger's syndrome who become pregnant should be consulted to terminate pregnancy. [19]

For a patient who continues her pregnancy, hospitalization for the duration of pregnancy is often appropriate. Continuous administration of oxygen, the pulmonary vasodilator of choice, is mandatory. Maternal arterial partial pressure of oxygen should be maintained at a level of 70 mmHg or above. Fetal outcome correlates well with maternal hematocrit and successful pregnancy is unlikely with a hematocrit >65%. [20] Thromboembolic phenomenon cause about 43% of the maternal deaths and prophylactic anticoagulation is favoured by some. [21]

The primary goals of anesthetic management are as follows:

  • maintain adequate SVR
  • maintain intravascular volume and venous return, avoid aorto-caval compression
  • prevent pain, hypoxemia, hypercarbia, acidosis
  • avoid myocardial depression during general anesthesia [22],[23],[24]
Supplemental oxygen should be provided at all times during labor and pulse oxymeter is the most useful monitor for detecting acute changes in shunt flow. [25] An intra arterial catheter facilitates rapid detection of sudden changes in blood pressure and central venous pressure catheter can help reveal significant changes in cardiac filling pressures.

A pulmonary artery catheter may be relatively contraindicated for several reasons. [23],[26] First, it is difficult to position the balloon-tipped, flow directed catheter within pulmonary artery. Second, the risks of pulmonary artery rupture are great. Third, these patients may not tolerate catheter-induced arrhythmias. Fourth, measurement of cardiac output by thermo-dilution is unpredictable in the presence of large intra-cardiac shunt. And pulmonary artery pressure monitoring rarely yields useful clinical information in severe fixed pulmonary hypertension scenario. Trans-esophageal echocardiography may be a useful monitor instead.

For providing effective labor analgesia, intrathecal opioid administration is ideal in first stage of labor. For second stage epidural or intra-thecal local anesthetic or opioid or pudendal block provides satisfactory analgesia. Where maternal anticoagulation may contraindicate regional techniques, intravenous remifentanil infusion with or without patient controlled analgesia (PCA) is another option. [27] For elective caesarean section, favorable outcomes have been achieved with slow onset epidural anesthesia, which has become the technique of choice for parturients with Eisenmenger's syndrome. [24],[28] It is critical that anesthesiologists avoid aorto-caval compression and maintain adequate venous return. Intravenous crystalloid and small doses of phenylephrine are administered as needed to maintain preload, SVR and oxygen saturation.

There are several disadvantages with the use of general anesthesia - positive pressure ventilation causes decreased venous return, volatile agents cause myocardial depression and decrease SVR, rapid sequence induction with thiopentone or propofol decreases both contractility and SVR. All of these exacerbate the right to left shunt. [11] Moreover, the right to left shunt will also influence anesthetic induction as inhalational induction will be prolonged and intravenous induction might be hastened as these agents can bypass the lungs. [29] There is a risk of postoperative atelectasis following general anesthesia, which can worsen right to left shunt.

Successful delivery may be enhanced by means of improved oxygenation with inhaled nitric oxide for patients with pulmonary hypertension and hypoxymia. [30]

Primary Pulmonary Hypertension (PPH) - Syndrome of PPH is characterized by markedly elevated pulmonary artery pressure in the absence of an intra-cardiac or aorto-pulmonary shunt. [31] Pulmonary hypertension is tolerated poorly in the parturient. Deterioration typically occurs in the second trimester with symptoms of fatigue, dyspnea, syncope and chest pain. This is due to the physiological increase in cardiac output and blood volume by 40-50%. During labor, uterine contractions effectively add 500 ml of blood to the circulation. The pain and expulsive effort of labor increase right atrial pressure, blood pressure and cardiac output. Women with PPH are advised against pregnancy. In early pregnancy a termination is considered. Where PPH is not diagnosed until late in pregnancy an elective delivery at 32-34 weeks gestation is preferred, as premature spontaneous labor is common. [32] Unlike those with Eisenmenger's syndrome, patients with PPH often have a reactive pulmonary vasculature that can respond to vasodilator therapy. The maternal mortality may be as high as 30-40 % with a high incidence of IUGR, preterm delivery and fetal loss. [33] The goals of anesthetic management are similar to those of Eisenmenger's syndrome. Supplemental oxygen - a good pulmonary vasodilator, should be administered routinely. Intra-arterial blood pressure and central venous pressure monitoring is needed. Pulmonary artery catheterization carries risks. The benefits do not outweigh the risks in these groups of patients. Trans-esophageal echocardiography has been used intra-operatively during caesarean delivery. [34] Agents that have been used to treat PPH include inhaled nitric oxide (iNO), nitroglycerin, calcium entry blockers and prostaglandins. [35],[36],[37] Patients with PPH are at risk of thrombosis and thrombo-embolism. The Mayo Clinic group has reported that anticoagulation may improve the outcome in severe pulmonary hypertension. [31]

Epidural anesthesia allows for a pain-free first and second stage of labor and facilitates elective forceps delivery. Several reports have noted the successful use of epidural anesthesia for caesarean section. [38],[39] Slow induction of epidural anesthesia is important. Hypotension should be treated with intravenous fluids and ephedrine should be avoided as it can increase pulmonary artery pressure. For cases where regional anesthesia is contraindicated (concurrent anticoagulant therapy), intravenous dexmedetomidine has been shown to be beneficial as an adjunct to general anesthesia for providing pain relief and hemodynamic stability. [40]

Anesthetic goals are:

  • Supplemental oxygen
  • Invasive hemodynamic monitoring, avoid pulmonary artery catheter
  • Treat pulmonary hypertension
  • Slow induction of epidural anesthesia
  • Treat hypotension with fluids, avoid ephedrine
Peripartum Cardiomyopathy (PPCM) - It is defined as a devastating form of heart failure with onset during the last months of pregnancy or during the first five months postpartum. [41] The incidence is 1 in 3000 to 4000 live births. [42] The etiology is unknown. Viral, auto-immune and toxic factors have been implicated. [43] It remains unclear whether PPCM represents a unique syndrome or a pregnancy related exacerbation of some other form of cardiomyopathy. Approximately 50 % of women will have complete or near complete recovery of ventricular function. The remaining women will undergo progressive clinical deterioration resulting in cardiac transplantation or early death. [44] Obstetric management involves expedient delivery of the fetus by caesarean or instrumental vaginal delivery. Anticoagulation is indicated as PPCM increases the risk of thromboembolism. [45] General anesthesia may result in profound myocardial depression. [46] Use of regional anesthesia (slow induction of epidural anesthesia guided by pulmonary artery pressure measurements) has been reported. [47] Regional anesthesia can be used safely except for those with most severe cardiovascular compromise and the timing of administration used for thromboprophylaxis may prevent it's use in some cases. [48] Intrapartum monitoring with trans-esophageal echocardiography is beneficial.

Anesthetic goals

  • Avoid general anesthesia if possible
  • Slow induction of epidural anesthesia is better
  • Pulmonary artery pressure monitoring
  • Reduction of preload and afterload
Hypertrophic Obstructive Cardiomyopathy (HOCM) - It is an unknown form of cardiomyopathy that affects the interventricular septum in the area of left ventricular outflow tract. [49] Women with HOCM have an increased risk of maternal mortality and sudden death. [50] The prevalence of HOCM is 1 in 500 to 1 in 1000. The physiological alterations of pregnancy augment or reveal the symptoms of HOCM like chest pain, dyspnea and palpitations. Impaired diastolic filling results in raised left ventricular end-diastolic, left atrial and pulmonary wedge pressures. The diagnosis of HOCM is made by echocardiography demonstrating unexplained asymmetrical myocardial hypertrophy with maximal wall thickness >2 standard deviations for age. In less than half the women, the condition is diagnosed before the first pregnancy. There is a much lower mortality than with PPCM, and the majority of women have a good outcome. Medical management includes treatment with a beta adrenergic receptor antagonist which should be continued during pregnancy. Beta adrenergic block reduces contractility and heart rate, thereby increasing diastolic filling time and improving ventricular filling. [51] Vasodilatation and hypotension are avoided as it reduces the venous return and ventricular filling. If vasopressors are required, a pure alpha receptor agonist is preferred to vasoconstrictors with ionotropic action [52] Trans-esophageal echocardiography may be helpful. Women of child bearing age who are symptomatic or have a history of syncope or pre-syncope should be considered candidates for insertion of a pacemaker or an automatic implantable cardioverter defibrillator (AICD) before conception. [53]

The goals of anesthetic management are to: [22],[54],[55],[56]

  • maintain intravascular volume and venous return, avoid aorto-caval compression
  • maintain adequate SVR
  • maintain slow heart rate and sinus rhythm, aggressively treat atrial fibrillation and other tachy-arrhythmias
  • prevent increase in myocardial contractility
An elective caesarean delivery may be performed safely with epidural anesthesia. [54] HOCM represents a relative contraindication to single shot spinal anesthesia for caesarean section as the rapid onset sympathectomy is hazardous. During general anesthesia volatile agents decrease myocardial contractility which is advantageous in these patients and remains the preferred choice. The most common adverse occurrence following general anesthesia in these patients is reversible congestive heart failure. [56]

Ischemic Heart Disease - Myocardial infarction, fortunately is a rare event during pregnancy. However, the incidence of myocardial ischemia during pregnancy may be increasing for several reasons. First, there is a greater prevalence of delayed childbearing. Second, many young women continue to abuse tobacco. Third, there is an increased incidence of cocaine abuse by women of child bearing age. Finally, the use of oral contraceptives after 35 years of age may increase the risk of ischemic heart disease. [11]

Medical management of the pregnant women with coronary artery disease requires attention to other disease states (anemia, thyrotoxicosis, hypertension, infection, substance abuse) that may adversely affect myocardial oxygen supply and demand. [57] The pharmacological agents, nitrates, beta adrenergic receptor antagonists, calcium entry antagonists used in treatment of myocardial ischemia in non-pregnant patients are also used during pregnancy with attention to both mother and fetus.

Amongst antiplatelet agents, clopidogrel is avoided in pregnancy for safety issues but low dose aspirin can be used without any contraindication for regional anesthetic technique that may be employed for labor analgesia or caesarean delivery, provided the platelet count is more than 80,000 mm -3 and bleeding time is normal. [58] Most patients with severe cardiac diseases in pregnancy can be managed medically. Ischemia that is unresponsive to medical management may require percutaneous transluminal coronary angioplasty (PTCA) [59] or coronary artery bypass surgery (CABG). [60]

In order to reduce fetal radiation exposure from fluoroscopy, guidance by means of transesophageal echocardiography may be used. Maternal and fetal mortality rates with interventional procedures are low. Pregnancy appears to increase the mortality risk associated with cardiac surgery. [61] No consensus exists regarding the optimal method of delivery in these patients. It seems reasonable to reserve caesarean section for obstetric indications unless maternal hemodynamic instability mandates immediate delivery. The ECG and SpO 2 should be monitored continuously during labor and vaginal or caesarean delivery. Supplemental oxygen should be administered during labor and delivery. Epidural anesthesia provides excellent pain relief and reduces maternal concentrations of catecholamines and thus chance of coronary artery vasoconstriction. Phenylephrine is the preferred vasopressor for treatment of hypotension in these patients as ephedrine increase maternal heart rate, increase myocardial oxygen demand and aggravate myocardial ischemia. When general anesthesia is given, a modified rapid sequence induction (using etomidate, remifentanil and succinylcholine) can be performed over one or two minutes without compromising hemodynamics. Single shot spinal anesthesia results in rapid onset of sympathectomy and increased risk of severe hypotension. [11] Continuous epidural anesthesia is the preferred technique for cesarean section. [62],[63] General anesthesia is to be considered only when regional anesthesia is contraindicated (concurrent use of anticoagulant or when antiplatelet drug can't be stopped as in case of recent coronary stent placement).

Bolus dose oxytocin is to be avoided, as it can cause profound vasodilatation and compensatory tachycardia resulting in reduced coronary diastolic filling. It may be administered as 5-10 units in 100 milliliters saline over five minutes followed by 20 units in 500 milliliters saline over four hours, reducing the rate if heart rate increases. Last but not the least, fetal heart rate monitoring should be continued throughout the peripartum period [64] .

Anesthetic goals

  • to monitor SpO 2 and ECG continuously
  • phenylephrine is the preferred vasopressor
  • avoid hypotension

   Conclusion Top


A comprehensive understanding of the physiology of pregnancy and pathophysiology of maternal cardiac disease is of importance for anesthesiologists, gynecologists and cardiologists involved in peri-partum care in patients with maternal cardiac disease. A careful consideration of maternal and fetal risks is imminent for the decision about which mode of delivery and peri-partum analgesia and anesthesia management should be chosen.

 
   References Top

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