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Table of Contents
Year : 2012  |  Volume : 15  |  Issue : 1  |  Page : 44-46
Anesthetic management of peripartum cardiomyopathy using "epidural volume extension" technique: A case series

1 Department of anaesthesia and critical care, St. Stephen's Hospital, Tees Hazari, New Delhi, India
2 Department of Anaesthesiology, G.R. Medical college, Gwalior, MP, India

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Date of Submission05-Apr-2011
Date of Acceptance13-Sep-2011
Date of Web Publication5-Jan-2012


Peripartum cardiomyopathy is a rare cause of dilated cardiomyopathy in parturients, occurring in approximately one in 1000 deliveries, manifesting during the last few months or the first 5 months of the postpartum period. It can result in severe ventricular dysfunction during late puerperium. The major concern while managing these patients is to optimize fluid administration and avoid myocardial depression, while maintaining stable intraoperative hemodynamics. We present a case series of five parturients that were posted for elective cesarean section and managed successfully by the epidural volume extension technique.

Keywords: Anesthetic management, epidural volume extension technique, peripartum cardiomyopathy

How to cite this article:
Tiwari AK, Agrawal J, Tayal S, Chadha M, Singla A, Valson G, Tomar GS. Anesthetic management of peripartum cardiomyopathy using "epidural volume extension" technique: A case series. Ann Card Anaesth 2012;15:44-6

How to cite this URL:
Tiwari AK, Agrawal J, Tayal S, Chadha M, Singla A, Valson G, Tomar GS. Anesthetic management of peripartum cardiomyopathy using "epidural volume extension" technique: A case series. Ann Card Anaesth [serial online] 2012 [cited 2022 Nov 26];15:44-6. Available from:

   Introduction Top

Peripartum cardiomyopathy (PPCM) is a rare, life-threatening disease, with mortality ranging from 30 to 60%. [1] It is a rare cause of dilated cardiomyopathy resulting in severe ventricular dysfunction during late pregnancy or early puerperium. [2] We report a case series of five parturients who presented to our hospital for safe confinement.

   Case Report Top

We present five cases admitted to our obstetric unit, for safe confinement, who were under follow-up in our antenatal clinic. All patients were assessed and preanesthetic check up was performed. They were classified to their respective american society of anesthesiologist class, and careful airway assessment was carried out. [Table 1] summarizes important findings of all the patients.
Table 1: Important findings of the patient

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Early administration of labor analgesia to minimize cardiac stress associated with pain is of paramount importance in the anesthetic management of these patients and hence an epidural catheter was inserted preoperatively to manage pain. The epidural catheters were inserted at the L2-L3 intervertebral space with patients in the sitting position. Correct placement of the catheter was confirmed by injecting 3 ml of 2% lignocaine with adrenaline. Pain was managed with 0.25% ropivacaine and 25 mcg of fentanyl as an epidural infusion commenced at the rate of 4 ml/h and later titrated according to individual needs. All the patients were administerd antiaspiration prophylaxis in the form of tab metoclopromide 10 mg the night before surgery, and 1 h before shifting, nonparticulate antacid 30 ml of 0.3 M sodium citrate, tab ranitidine 150 mg PO and tab metoclopromide 10 mg were administered. Electrocardiography, pulse oximetry and noninvasive blood pressure were monitored once the patient arrived in the operating room. They were preloaded with 500 ml of ringer lactate and a wedge was placed under the right hip. Central venous canulation was performed through the right internal jugular vein to help us gain better knowledge of fluid status of the patients and also to infuse inotropic agents if required. Direct arterial pressure was also monitored in all the patients.

Once all the vital parameters were found to be within normal limits, we performed the modified combined spinal epidural (epidural volume extension [EVE] technique). Under aseptic precaution, 1 ml of 0.5% bupivacaine was injected intrathecally using a 25G quincke's needle in L3-L4. Patients were then made to lie supine and part preparation was immediately started to minimize anesthesia time. Five minutes later, 8 ml of normal saline was injected via epidural catheter which was placed preoperatively. Dermatome level of anesthesia was found to be T9, T7 and T4 at 3, 5 and 10 min after epidural saline injection, respectively, in all the patients. Intraoperative course was uneventful in all the cases, with patients remaining hemodynamically stable, and patients were shifted to the postanesthesia care unit with epidural catheter in situ. All the patients were discharged on day 7 postsurgery after performing a second echocardiogram to rule out any worsening in cardiac status.

   Discussion Top

PPCM is a rare form of dilated cardiomyopathy associated with pregnancy, and was first reported in the 19 th century by Ritchie. [3] It is defined as "the onset of acute heart failure in the last trimester or early post partum period in the absence of infectious, metabolic, toxic, ischemic or valvular cause of myocardial dysfunction." Although the exact etiology is unknown, a multitude of causes including viral, autoimmune and idiopathic have been proposed. The incidence of PPCM increases with increasing gestation, and age, presence of coexisting pre-eclampsia, prolonged tocolysis and African descent. [4]

Demakis in year 1971 [5] had put forwarded the criteria for the diagnosis PPCM, which includes:

  1. Development of heart failure in the last month of pregnancy or within the first 5 postpartum months.
  2. Absence of a determine etiology.
  3. Absence of a demonstrable heart disease before the last month of pregnancy.

Recently, echocardiographic criteria have also been added, which propose an ejection fraction of less than 45%, left ventricular end diastolic dimension greater than 2.7 cm/m 2 and fractional shortening of <30%.

Presence of this condition poses additional challenges for the anesthesiologist. First and foremost is its diagnosis as the symptoms of heart failure such as dyspnea, fatigue and pedal edema may just be passed as due to normal physiological changes in a parturient. The first line of therapy includes diuretics, vasodilators accompanied by diuretics and sodium restriction. Post delivery, the patient can be switched over to other available modalities like angiotensin-converting enzyme inhibitors, beta blockade and anticoagulation. More recently, selenium pentoxyfylline and immunoglobulins have all been shown to have a beneficial effect. However, if these modalities fail to improve the symptomatology, cardiac transplantation may be indicated. We had planned for elective cesarean section in all our patients so as to avoid the stress associated with normal vaginal delivery.

The optimal anesthetic technique for patients with PPCM scheduled to undergo cesarean section is controversial as both general and regional anesthesia have been described with success. [6] However, the main anesthetic goals in these patients under any kind of anesthesia includes:

  1. Avoidance of myocardial depression and maintaining stable hemodynamics.
  2. Maternal and fetal safety.
  3. Maintaining normovolemia and preventing increase in the ventricular afterload.
  4. Maintaining uteroplacental adequacy.

General anesthesia may be used for urgent caesarean section. [6] The stress of laryngoscopy and intubation coupled with the myocardial depressant effects of anesthetics are not beneficial for these pateints. Therefore, the authors searched for alternate techniques including regional anesthesia. Regional anesthesia also produces vasodilatation, which is beneficial in reducing afterload and improving forward flow. Spinal anesthesia if opted for in these cases can result in a abrupt fall in blood pressure, which would have had a detrimental effect in our patient as cardiac function was already compromised. These patients have been managed by the CSE technique as well, [7] but to the best of our knowledge, this is one of the first case series where the patients have been managed by the EVE technique, where saline has been injected in the epidural space. We report successful anesthetic management of five patients with PPCM managed by a unique EVE technique, which offers the reliability and rapidity of spinal anesthesia and the flexibility of epidural anesthesia. It also offers early sensory-motor recovery [8] along with lower umbilical and maternal concentration of local anesthetics, leading to better neurobehavioral outcome of newborns and increased patient satisfaction. This technique avoids stress response, myocardial depression of inhalational anesthetic agents, neonatal depression and reduction in venous return due to positive-pressure ventilation.

Blumgart et al. [9] hypothesized that epidural injection of a local anesthetic or saline 5 min after spinal anesthesia in patients undergoing cesarean section produces significantly higher levels of analgesia compared with spinal anesthesia alone. Combined spinal epidural with the EVE technique was found to have a dose-sparing effect, with only 55% of the bupivacaine dose required, allowing more rapid motor recovery of the lower limbs, which may have an impact on shortening the post anesthesia care unit stay. Adequate preloading with crystalloids along with a low dose of spinal anesthetics, which was followed by epidural saline injection, helped us to attain the desired level of block for cesarean section, avoiding a precipitous decrease in blood pressure. The epidural catheter also helped provide postoperative analgesia.

   Conclusion Top

The aim of this presentation is to highlight the effectiveness of this novel technique in PPCM. EVE technique allows one to achieve surgical anesthesia with smaller quantities of local anesthetic while hemodynamic control is preserved.

   References Top

1.Chan F, Ngan Kee WD. Idiopathic dilated cardiomyopathy presenting in pregnancy. Can J Anaesth 1999;46:1146-9.  Back to cited text no. 1
2.Homans DC. Peripartum cardiomyopathy. N Engl J Med 1985;312:1432-7.  Back to cited text no. 2
3.Ritchie C. Clinical contributions to the diagnosis and treatment of certain chronic diseases of the heart. Med Surg J 1849;12:333.  Back to cited text no. 3
4.Heider AL, Kuller JA, Strauss RA, Wells SR. Peripartum cardiomyopathy: A review of the literature. Obstet Gynecol Surv 1999;54:526-31.  Back to cited text no. 4
5.Demakis JG, Rahimtoola SH, Sutton GC, Meadows WR, Szanto PB, Tobin JR, et al. Natural course of peripartum cardiomyopathy. Circulation 1971;44:1053-61.  Back to cited text no. 5
6.Shrestha BR, Thapa C. Peripartum cardiomyopathy undergoing caesarean section under epidural anaesthesia. Kathmandu Univ Med J (KUMJ) 2006;4:503-5.  Back to cited text no. 6
7.Indira K, Sanjeev K, Sunanda G. Sequential combined spinal epidural anaesthesia for caesarean section in Peripartum cardiomyopathy. Indian J Anaesth 2007;51:137-9.  Back to cited text no. 7
  Medknow Journal  
8.Lew E, Yeo SW, Thomas E. Combined spinal-epidural anesthesia using epidural volume extension leads to faster motor recovery after elective caesarean delivery: A prospective, randomized, double-blind study. Anesth Analg 2004;98:810-4.  Back to cited text no. 8
9.Blumgart CH, Ryall D, Dennison B, Thompson-Hill LM. Mechanism of extension of spinal anesthesia by extradural injection of local anaesthetic. Br J Anaesth 1992;69:457-60.  Back to cited text no. 9

Correspondence Address:
Akhilesh Kumar Tiwari
Opposite SAI Sub Center, Post Sarojini Nagar, Shanti Nagar, Kanpur Road, Lucknow, UP - 226 008
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.91481

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