Management of Labor and Delivery in

Cardiovascular Disease:Cardiologist Perspective

Niloufar SamieiMD, FACCAssociate Professor in CardiologyRajaei Cardiovascular Medical and Research Center

• Introduction•Hemodynamics of Labor•General Principles•Specific lesions

Introduction• Leading cause of maternal mortality in the

developed world• Over a half of all maternal death can be eliminated• Increase the incidence of pregnancy in CHD• Acquired heart disease as the main cause of death• Team working( Obstetrician, Cardiologist,

Anesthesiologist, Neonatalogist)• Individualized plan• Interdisciplinary communication and preparation

Hemodynamic changes of labor as unique time

• Anxiety, fear and apprehension• Progressive increase in CO• Rise of CO 3-3.5 l/min during 2nd stage• Autotransfuison : 300-500 ml/contraction• Autotransfusion: postpartum 1000ml• Average blood loss 500cc/ NVD for a singleton,

100cc/ CS and vaginal twins• Other factors: anemia, preeclampsia, infection• Fluctuation of HR and SV• Early post partum: increased CO and SV,

decrease of HR , stable mean arterial pressure

Hemodynamic changes of labor

• NVD: within 10 min after delivery CO and SV increase 59% and 71% respectively

• Persist for at least 1 hour

• C/S: CO increase by 30-50% within 2 minutes

• Persist for 10 minutes

General Principles• Risk stratification: choice of delivery, location• Pain control• Strict input/output• Continuous ECG monitoring• Oxygen supplementation• Intravenous filters if shunt is present• Arterial line• Patient positioning (semi recumbent/lateral tilt)• Fetal monitoring• Thrombosis/ endocarditis prophylaxis• Invasive monitoring

Risk Stratification• Prior Fontan procedure• Severe PAH• Cyanotic CHD• Complex repair CHD with residua• CHD with malignant arrhythmia• Severe AS• MS with NYHA class II to IV symptoms• AI or MR with NYHA class III or IV symptoms• AV or MV disease with severe LV dysfunction• Marfan syndrome• Prosthetic valves

Labor • Vaginal delivery is generally preferred• Scheduling labor instead of spontaneous form in

women at high risk• Placement of monitoring devices, IV access and

other preparation for analgesia and anesthesia before starting of contractions

• Check of vital sign between contractions• Any sign or symptom of cardiac decompensation:

indication for intensive medical care• If neuroaxial analgesia is not an option : route for

delivery should be reconsidered

Vaginal “Cardiac Delivery”• Epidural analgesia

• Fetal descent during the majority of the 2nd stage is accomplished exclusively by uterine contractions without the aid of maternal expulsive effort

• Low or outlet operative delivery

• Still controversial

•Trial of pushing

•Pulse oximetry waveform

•Mostly on earlobe

Monitoring• Continuous ECG

• Arrhythmias

• Myocardial ischemia

• A 5 lead ECG with computerized St segment trending

• Specialized nursing care

External Defibrillator or Pacemaker Pads

• Patients with history of poorly tolerated tachy arrhythmias

• Patients with CIED reprogrammed for operation or deactivated in detection of tachy/ bradycardia by magnet

Pulse Oximetry

• Continuous

• Audible and visible waveform

• Particularly in cyanotic CHD or right to left vascular shunt

Intra Venous Catheter Filters

•Prevent paradoxical air emboli

• Intracardiac shunts

•Extracardiac shunts

Intra arterial catheter• Invasive monitoring of arterial BP• Hypotension can be detected promptly

and treated• Analysis of uterine contractions and

maternal expulsive effort on overall hemodynamics

• Should be inserted before induction of anesthesia in unstable high risk patients undergoing CS

• Also facilitates ABG and vasoactive drug administration

Central Venous Catheter• In unstable patients with high risk

cardiovascular disease

• For administration of vasoactive drugs

• For monitoring of CVP

• Should not be used as a sole guide for fluid management

• Helpful when CVP values are either high or low

Pulmonary Artery Catheter

• Rarely indicated

• High risk for complication

• Helpful in some situations

• PAH requiring titration of pulmonary vasodilatory agents such as nitric oxide

Echocardiography• TTE or TEE

• Determine the cause of any unexplained persistent or life threatening circulatory instability

• During GA, TEE is the best method to assess volume status, regional and global cardiac function

Vasoactive Drugs• Should be prepared in advance

• Syringes and infusions

• Phenylephrine

• Efedrine

• Norepinefrine

Neuroaxial Analgesia• Reduction in CO peaks throughout labor• Should be placed early in labor• Epidural or low dose combined epidural-spinal• monitoring of systemic BP is necessary• Excellent analgesia• Dense analgesia can be achieved• Titration is possible• A passive 2nd stage• In case of urgent CS , surgical block can be

established

Specific Lesions• Aortic rupture or disection risk

• Fixed cardiac output lesions

-avoid hypotension

-avoid pulmonary edema

• Shunts/ Eisenmenger syndrome/PH

• PPM/ICD

• IHD

Endocarditis Prophylaxis• Prosthetic cardiac valve or prosthetic material used for

cardiac valve repair• Previous infective endocarditis• Congenital heart disease (CHD)• Unrepaired cyanotic CHD, including those with palliative

shunts and conduits• Completely repaired CHD with prosthetic material or

device either by surgery or catheter intervention during the first 6 months after the procedure[

• Repaired CHD with residual defects• Cardiac transplantation recipients who develop cardiac

valvulopathy

Post Partum Period• Care should be given with bolus of oxytocine• Controlled intravenous infusion• Several days of close monitoring in patients with

diminished LV function• Prophylactic diuretics and ACEI• Routine post delivery echo• Risk of thromboembolism• A short observation period (48Hours) for low risk

patient• Lactation