MITRAL STENOSIS WITH PREGNANCY

- DR. ANKITA PATNI

- ANAESTHESIOLOGY

INTRODUCTION

• Rheumatic mitral stenosis forms 88% of the heart

diseases complicating pregnancy in the tertiary

referral centre in India.

• Rheumatic mitral stenosis complicating

pregnancy is still a frequent cause of maternal

death.

• A better understanding of the physiological

changes in pregnancy and the pathological impact

of mitral stenosis over pregnancy and a

multidisciplinary approach; where the

anaesthesiologist plays a major role, in diagnosis

and management, reduce the mortality and

morbidity.

CARDIOVASCULAR CHANGES DURING PREGNANCY

Parameter Percentage of change

Cardiac output 40–50% Increase

Stroke volume 30% Increase

Heart rate 15–25% Increase

Intravascular volume 45% Increase

Systemic vascular resistance 20% Decrease

Systolic BP Minimal

Diastolic BP 20% Decrease at mid-pregnancyPre-pregnant values at term

CVP Unchanged

O2 consumption 30–40% Increase

HEMODYNAMICS DURING LABOUR

Parameter Stage of labour Percentage of change

Cardiac output Latent phase 10% Increase

Active phase 25% Increase

Expulsive phase 40% Increase

Immediate post-partum 75–80% Increase

Heart rate All stages Increase

CVP All stages Increase

HEMODYNAMICS DURING PUERPERIUM

Parameter Post-partum Percentage of Change

Cardiac output Within 1 h 30% above pre-labour values

24–48 h Just below pre-labour values

2 weeks 10% above pre-pregnant values

12–24 weeks Baseline pre-pregnancy values

Heart rate Immediate Decrease

2 weeks Pre-pregnant values

Stroke volume 48 h Remains above pre-labour values

24 weeks 10% above pre-pregnant values

MS PREGNANCY

DELIVERY

DECREASE LA

emptying

DECREASE LV

Filling

INCREASE HR

DECREASESV

DECREASECO

Fixed CO state; Heart cannot cope up with increased demand.

AUTOTRANSFUSION from uterus

PULMONARY CONGESTION

Long-standin

g

Irreversible chronic Pulmonary Hypertension

LA Dilates

LA pressure INCREASES

At DIASTOL

E

Pressure gradient develops between LA and LVHemodynamic Hallmark of MS

• MS- impairs left ventricular filling- decrease in EDV (pre-load)- decrease in SV- fall in CO.

• Reduced ventricular filling-decrease ventricular wall stress (after-load)- decrease in ESV

• Decrease in EDV > Decrease in ESV = Decrease in SV

SEVERITY GRADING OF MS

Measurement

Normal Mild Moderate Severe

Mitral valve area

(cm2)

4.0–6.0 1.5–2.5 1.0–1.5 <1.0

Mean pressure

gradient (mmHg)

<2 2–6 6–12 >12

Pulmonary artery

mean pressure

(mmHg)

10–20 <30 30–50 >50

4-6 cms2

< 2.5 cms2

1.5- 2.5 cms2

1.0 – 1.5 cms2

< 1.0 cms2

Mild MS – 1.5 – 2.5 Cms2 (Dyspnea on severe exertion)Moderate MS – 1.0 – 1.5 Cms2 (PND ± pulmonary oedema)Severe/ Critical- < 1.0 Cms2 (Orthopnea – Class IV)

Symptoms start < 2.5 Cms2

Normal Orifice: 4 – 6 Cms2

MODIFIED NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION (NYHA)

Class I No functional limitation of activity

Asymptomatic except during severe exertion.

Class II Mild limitation of physical activity

Symptomatic with moderate activity

Class III Marked limitation of physical activity

Symptomatic with minimal activity

Class IV Severe limitation of physical activity

Symptomatic at rest

PREDICTORS OF MORTALITY AND MORBIDITY

Severity of MS

Severe- 67%

Moderate- 38%

Mild- 26%

NYHA Class

Class I and II- <1%

Class III and IV- Between 5 and 15%

Class III and IV- Perinatal mortality- 20-

30%

CARPREG SCORE• THE CARDIAC DISEASE IN PREGNANCY (CARPREG) RISK SCORE (TABLE I) CAN BE

CALCULATED TO ESTIMATE A WOMAN'S CARDIAC RISK DURING PREGNANCY. IT

IS IS BASED ON 4 RISK PREDICTORS:

Mortality:

0 point-5%,1 point-27%,>1 point-75%

AETIOLOGY OF MS

1. RHEUMATIC HEART DISEASE

2. CONGENITAL – PARACHUTE MITRAL

VALVE

3. HUNTER’S SYNDROME

4. HURLER’S SYNDROME

5. DRUGS – METHYSERGIDE

6. CARCINOID SYNDROME

7. AMYLOIDOSIS

8. MITRAL ANNULAR CALCIFICATION

9. RHEUMATOID ARTHRITIS

10. SYSTEMIC LUPUS ERYTHEMATOSIS

11. INFECTIVE ENDOCARDITIS WITH

LARGE VEGETATIONS.

12. LUTEMBACHER’S SYNDROME:

ATRIAL SEPTAL DEFECT (ASD) + MITRAL

STENOSIS (MS) RHEUMATIC ORIGIN

SYMPTOMS OF MS

1. DYSPNOEA

2. ORTHOPNEA

3. PAROXYSMAL NOCTURNAL

DYSPNEA

4. PALPITATION

5. FATIGUABILITY

6. HAEMOPTYSIS

7. RECURRENT BRONCHITIS

8. COUGH

9. CHEST PAIN

10. RIGHT HYPOCHONDRIAL PAIN

(HEPATOMEGALY)

DIAGNOSIS OF MS

DIAGNOSTIC TOOLS

Clinical Examina

tion

ECG

Chest X-Ray

Echocardiography

Doppler examinati

on

Cardiac Catheteriz

ation

Echocardiography provides information regarding the area of the mitral valve, size of the left atrium, presence of thrombus and the size and function of the left ventricle and right-sided chambers.

Doppler examination provides information about the severity of the stenosis, the presence of other associated valve lesions and the degree of pulmonary hypertension

Diagnostic cardiac catheterization is necessary only when echocardiography is non-diagnostic or results are discordant with clinical findings.

GENERAL PHYSICAL EXAMINATION

OEDEMA

SEVERE MITRAL

STENOSIS

ULTIMATELY

LEADS TO RIGHT

HEART FAILURE.

HEPATOMEGALY

SEEN IN RIGHT

VENTRICULAR

FAILURE AND

PULMONARY

HYPERTENSION.

MITRAL FACIES

LOW CARDIAC OUTPUT IN MITRAL STENOSIS CAUSES PERIPHERAL

VASOCONSTRICTION PRODUCING PINKISH PURPLE PATCHES ON CHEEKS.

MITRAL FLUSH DUE TO VASODILATATION (VASCULAR STASIS) IS

SEEN

SEEN IN FAIR SKINNED INDIVIDUALS

CARDIOVASCULAR EXAMINATION-INSPECTION

• PRECORDIAL BULGE INDICATES EARLY ONSET AND LONGER

DURATION OF CARDIAC DISEASE.

• SCAR MARKS REVEAL PREVIOUS SURGERIES

• ENGORGED NECK VEINS INDICATE HIGH RIGHT HEART PRESSURES

CARDIOVASCULAR EXAMINATION-PALPATION

• TAPPING CHARACTER OF THE APEX BEAT (PALPABLE S1) IS TYPICAL.

• PALPABLE DIASTOLIC THRILL IN MITRAL AREA BEST FELT IN LEFT LATERAL

POSITION IN FULL EXPIRATION.

• PARASTERNAL HEAVE

• IF ONE FINDS ENGORGED SUPERFICIAL VEINS LOOK FOR DIRECTION OF FLOW.

CARDIOVASCULAR EXAMINATION-AUSCULTATION

• S1 IS SHARP, SHORT, ACCENTUATED

• OPENING SNAP AFTER S2

• LOW PITCHED MID-DIASTOLIC RUMBLING MURMUR WITH

PRESYSTOLIC ACCENTUATION IN MITRAL AREA.

• MURMUR BEST HEARD AT CARDIAC APEX WITH BELL OF

STETHOSCOPE IN LEFT LATERAL POSITION AT HEIGHT OF

EXPIRATION

ECG FINDINGS

1. BROAD NOTCHED “P” WAVES SIGNIFYING ATRIAL ENLARGEMENT.

2. ATRIAL FIBRILLATION (F- WAVES REPLACING P-WAVES)

3. RIGHT VENTRICULAR ENLARGEMENT

CXR

1. LEFT ATRIAL ENLARGEMENT –

MITRALISATION OF HEART

2. STRAIGHTENING OF LEFT HEART

BORDER

3. ELEVATION OF LEFT MAINSTEM

BRONCHUS

4. EVIDENCE OF MITRAL

CALCIFICATION, EVIDENCE OF

PULMONARY EDEMA, PULMONARY

VASCULAR CONGESTION.

5. KERLEY’S B LINES

6. DOUBLE CONTOUR OF THE RIGHT

BORDER OF HEART

CHEST X-RAY

Kerleyb lines

ECHOCARDIOGRAPHY

MANAGEMENT

MEDICAL

DIURETICS, β-

BLOCKERS

AF- DIGOXIN,

ANTI-COAGULANTS

SURGICAL

VALVULOPLASTY

VALVE

REPLACEMENT

OBSTETRICAL

VAGINAL

CAESAREAN

SECTION

MEDICAL MANAGEMENT

FIRST LINE OF TREATMENT IN SYMPTOMATICS

• BED REST

• OXYGEN THERAPY

• DIURETICS

• BETA-ADRENERGIC RECEPTOR BLOCKADE- USEFUL TO PREVENT TACHYCARDIA DURING PREGNANCY. PROPRANOLOL OR ATENOLOL DECREASES THE INCIDENCE OF MATERNAL PULMONARY OEDEMA WITHOUT ADVERSE EFFECTS ON THE FOETUS OR NEONATE.

• ANTIBIOTIC PROPHYLAXIS FOR ENDOCARDITIS IS RESERVED ONLY FOR PATIENTS WITH A PREVIOUS HISTORY OF ENDOCARDITIS OR PRESENCE OF ESTABLISHED INFECTION.

ASSOCIATED WITH ATRIAL FIBRILLATION

• DIGOXIN AND BETA BLOCKERS TO

REVERT IT TO SINUS RHYTHM.

• ANTICOAGULATION TO PREVENT

SYSTEMIC EMBOLIZATION.

• CARDIOVERSION SHOULD BE

PERFORMED IF PHARMACOLOGIC

THERAPY FAILS TO CONTROL THE

VENTRICULAR RESPONSE.

ANTICOAGULATION DURING PREGNANCY

• SC/IV HEPARIN FOR UP TO 12 WEEKS ANTEPARTUM (APTT 1.5–2.5-TIMES OF

NORMAL)

• WARFARIN FROM 12 TO 36 WEEKS (MAINTAIN INR 2.5– 3.0)

• SC/IV HEPARIN AFTER 36 WEEKS

• THERAPY WITH LOW-MOLECULAR WEIGHT HEPARIN (LMWH) INSTEAD OF

UNFRACTIONATED HEPARIN IS GAINING POPULARITY. ALTHOUGH AN “ANTI XA”

ACTIVITY IS USED TO MONITOR LMWH, NO ANTI-XA ACTIVITY-BASED

GUIDELINES HAVE BEEN ISSUED TILL DATE.

SURGICAL MANAGEMENT

II Trimester

Valvuloplasty

PERCUTANEOUS (success rate is

nearly 100%. It increases the valve area to

>1.5 cm2 without a substantial increase in

mitral regurgitation.)

OPEN (foetal loss is high in

open commissurotomy as

compared to percutaneous,

at a ratio of 1:8)

Valve Replacement

Reserved for severe cases

with calcified valve and in

mural thrombus.

OBSTETRIC MANAGEMENTVAGINAL DELIVERY

• Tachycardia, secondary to

labour pain, increases

flow across the mitral

valve, producing sudden

rises in left atrial

pressure, leading to acute

pulmonary oedema.

VAGINAL DELIVERY

• The second stage of delivery should be cut short byinstrumentation.

• Maintenance of left uterine displacement for good venousreturn.

• Supplemental oxygen administration with pulse oximetrymonitoring to minimize increases in pulmonary vascularresistance, fetal heart rate monitoring should be carried out.

• Invasive cardiac monitoring like radial artery cannulation andpulmonary catheter are beneficial in assessing the cardiacoutput, pulmonary artery pressure and for guiding fluid anddrug therapy, especially in NYHA III and IV patients.

• Sudden drops in systemic vascular resistance (SVR) in thepresence of a fixed cardiac output can be prevented by smallbolus doses of phenylephrine, with volume expansion whennecessary.

Good LABOUR ANALGESIA is must.

EpiduralCSE

OBSTETRIC MANAGEMENTCaesarean

section

Epidural/SpinalCombined Spinal

Epidural

General

Anaesthesia

Only for obstetric

reasons

Epidural anaesthesia might not be anideal technique as it requires slowinduction, delay in the onset of actionwhich may not be possible in anemergency situation. Moreover largevolume of local anesthetic is neededfor adequate blockade.

Subarachnoid causes rapid onset of extensive sympathetic blockade with intense vasodilatation, sudden hypotension and severe tachycardia.

Technique of choice. CSE offers rapid onset and

improved analgesia It offers ability to use low dose

spinal with room for post operative analgesia

OBSTETRIC MANAGEMENT

Category 1 - Immediate

threat to life of woman or

fetus (baby needs to be

removed in 30 min. of

making the decision to do

LSCS)

Category 2 - Maternal or

fetal compromise, not

immediately life

threatening(some time can

be spent for resuscitation)

Category 4- At a time to

suit the woman and

maternity team

Category 3 - Needing early

delivery but no maternal or

fetal compromise

GOALS FOR ANAESTHETIC MANAGEMENT

• MAINTENANCE OF AN ACCEPTABLE SLOW HEART RATE

• IMMEDIATE TREATMENT OF ACUTE ATRIAL FIBRILLATION AND REVERSION TO

SINUS RHYTHM

• AVOIDANCE OF AORTOCAVAL COMPRESSION

• MAINTENANCE OF ADEQUATE VENOUS RETURN

• MAINTENANCE OF ADEQUATE SVR

• PREVENTION OF PAIN, HYPOXAEMIA, HYPERCARBIA AND ACIDOSIS, WHICH MAY

INCREASE PULMONARY VASCULAR RESISTANCE.

EPIDURAL ANALGESIA• ONE OF THE MAJOR ADVANTAGES OF EPIDURAL ANALGESIA IS THAT IT CAN BE

ADMINISTERED IN INCREMENTAL DOSES AND THAT THE TOTAL DOSE COULD BE

TITRATED TO THE DESIRED SENSORY LEVEL.

• SLOWER ONSET OF ANAESTHESIA

• THE SEGMENTAL BLOCKADE SPARES THE LOWER EXTREMITY “MUSCLE PUMP,”

AIDING IN VENOUS RETURN, AND ALSO DECREASES THE INCIDENCE OF

THROMBOEMBOLIC EVENTS.

• INVASIVE HAEMODYNAMIC MONITORING, JUDICIOUS INTRAVENOUS

ADMINISTRATION OF CRYSTALLOID AND ADMINISTRATION OF SMALL BOLUS

DOSES OF PHENYLEPHRINE MAINTAIN MATERNAL HAEMODYNAMIC STABILITY.

• NEURAXIAL BLOCK IN AN ANTICOAGULATED PATIENT HAS THE RISK OF

EPIDURAL HAEMATOMA.

Allows the maternal cardiovascular system to compensate for the occurrence of

sympathetic blockade, resulting in a lower risk of hypotension and decreased

uteroplacental perfusion.

COMBINED SPINAL-EPIDURAL

PROCEDURE PER SE

• CSE IS PERFORMED IN LATERAL DECUBITUS POSITION UNDER STRICT ASEPTIC PRECAUTIONS

EPIDURAL SPACE IS IDENTIFIED WITH 18 G TUOHY NEEDLE USING LOR WITH SALINE. SPINAL

NEEDLE IS INTRODUCED THROUGH THE TUOHY NEEDLE AND SUBARACHNOID BLOCK IS

PERFORMED.20-30 ΜG OF FENTANYL ALONG WITH 2.5 -5MG OF 0.5% BUPIVACAINE IS GIVEN.

THIS IS FOLLOWED BY INSERTION OF EPIDURAL CATHETER THROUGH WHICH 3 ML OF 2%

XYLOCAINE WITH EPINEPHRINE IS GIVEN.

• POST OPERATIVE ANALGESIA IS MAINTAINED AS SHOWN IN THE TABLE BELOW

DRUG INITIAL INJECTION CONTINUOUS INFUSION

• BUPIVACAINE 10-15 ML OF A 0.25%-0.125% SOLUTION 0.0625%-0.125% SOLUTION AT 8-15

ML/HR

• ROPIVACAINE 10-15 ML OF A 0.1%-0.2% SOLUTION 0.5%-0.2% SOLUTION AT 8-15 ML/HR

• FENTANYL 50-100 MICROGRAM IN A 10-ML VOLUME 1-4

MICROGRAM/ML

MYTHS AND WORRIES ABOUT REGIONAL ANAESTHESIA

1. PRELOADING IS MANDATORY AND HAZARDOUS--CVP GUIDED FLUID

MANAGEMENT NEGATES OVERLOADING AND MAINTAINS ADEQUATE CARDIAC

OUTPUT

2. REGIONAL ANAESTHESIA IS ASSOCIATED WITH SUDDEN FALL IN BP. LOCAL

ANAESTHETIC WITH OPIOID COMBINATION INTRATHECALLY FOLLOWED BY

EPIDURAL TO TITRATE THE DESIRED LEVEL OF BLOCK DOES NOT PRODUCE RAPID

FALL IN BP.

3. DELAY IN PERFORMING THE ACTUAL PROCEDURE: THIS DOESNT HAPPEN WITH

EXPERT HANDS

4. THE COMPLICATIONS OF CSE-LIKE TOTAL SPINAL, LA TOXICITY, EPIDURAL

HEMATOMA AND ABSCESS ARE NEGLIGIBLE WITH SENIOR ANESTHESIOLOGISTS.

REGIONAL ANAESTHESIA

CONTROVERSIES ABOUT CSE:

• RISK OF EPIDURAL CATHETER

THROUGH THE DURAL HOLE

• PERCEIVED INCREASE IN

NEUROTRAUMA

CONTRAINDICATIONS TO REGIONAL ANAESTHESIA

• ACTIVE HEAVY BLEEDING

• UNCORRECTED COAGULOPATHY (E.G. HELLP

SYNDROME (HEMOLYSIS, ELEVATED LIVER

ENZYMES, LOW PLATELETS) ASSOCIATED WITH

PRE-ECLAMPSIA)

• THROMBOCYTOPENIA

• SYSTEMIC SEPSIS

• LOCAL SEPSIS AT SITE OF INSERTION

• PATIENT REFUSAL

GUIDELINES FOR GENERAL

ANAESTHESIA

• ANAESTHETIC GOALS:

1. MAINTAIN THE HEART RATE AROUND 80-100

B/MIN .

2. MAINTAIN LEFT ATRIAL PRESSURE HIGH ENOUGH TO

TAKE ADVANTAGE OF THE INCREASED PRELOAD

RESERVE.

3. AVOID PULMONARY ARTERY HYPERTENSION BY

TREATING HYPERCARBIA, HYPOXEMIA, AND

ACIDEMIA.

4. AGGRESSIVELY TREAT PULMONARY ARTERY

HYPERTENSION WITH VASODILATOR THERAPY TO

AVOID RV FAILURE. IF RV FAILURE DOES OCCUR,

INOTROPIC SUPPORT OF THE RV AND PULMONARY

VASODILATION MAY BE NECESSARY. THE PRESENCE

OF PAH IS THE MAJOR FACTOR THAT INCREASE THE

MORTALITY.

GENERAL ANAESTHESIA

HAS THE ADVANTAGES

OF SPEED OF

INDUCTION, CONTROL

OF THE AIRWAY, AND

SUPERIOR

HEMODYNAMICS.

ANAESTHETIC GOALS

5. AVOID FACTORS WHICH DEPRESS THE MYOCARDIUM (INHALATION AGENTS AND DRUGS)

6. MAINTAIN AWARENESS OF POTENTIAL FOR LV RUPTURE.

7. AGGRESSIVE TREATMENT OF ARRHYTHMIAS IF THEY OCCUR

8. AVOID PROFOUND CHANGES IN SVR

9. ATTENUATE PRESSOR RESPONSE (INTUBATION, EXTUBATION, LIGHT PLANE OF ANESTHESIA)

10. ADEQUATE ANALGESIA AND ADEQUATE MUSCLE RELAXATION GUIDED BY NEURO MUSCULAR

MONITORING

11. ASPIRATION PROPHYLAXIS

12. BLOOD LOSS ASSESSMENT AND PROMPT REPLACEMENT

GENERAL ANAESTHESIA

• INDUCTION OF ANAESTHESIA

1. AVOID KETAMINE× – INCREASES HEART RATE, BLOOD PRESSURE

2. AVOID ATRACURIUM× – INCREASED HISTAMINE RELEASE CAUSES HYPOTENSION WHICH

MANIFESTS AS TACHYCARDIA.

• A BETA-ADRENERGIC RECEPTOR ANTAGONIST AND AN ADEQUATE DOSE OF OPIOID LIKE

FENTANYL SHOULD BE ADMINISTERED BEFORE OR DURING THE INDUCTION OF GENERAL

ANAESTHESIA.

• ESMOLOL HAS A RAPID ONSET AND SHORT DURATION OF ACTION, IT IS A BETTER CHOICE IN

CONTROLLING TACHYCARDIA. SINCE FOETAL BRADYCARDIA HAS BEEN REPORTED AFTER

ESMOLOL, FOETAL HEART RATE SHOULD BE MONITORED.

GENERAL ANAESTHESIA• MAINTENANCE OF ANAESTHESIA

1. DRUGS SHOULD HAVE MINIMAL EFFECTS ON HEMODYNAMIC PATTERN

2. BALANCED ANAESTHESIA WITH N2O/ NARCOTIC/ VOLATILE ANAESTHETIC

3. N2O CAUSES INSIGNIFICANT PULMONARY VASOCONSTRICTION. IT IS SIGNIFICANT ONLY IF

PULMONARY HYPERTENSION EXISTS. SO, ONE NEEDS TO TREAT PULMONARY HYPERTENSION

PREOPERATIVELY.

4. CARDIAC STABLE MUSCLE RELAXANTS ARE TO BE USED. (PREFERABLY AVOID PANCURONIUM

×)

5. AVOID LIGHTER PLANES OF ANAESTHESIA (TO AVOID TACHYCARDIA)

6. FLUID MANAGEMENT:

• AVOID HYPERVOLEMIA - -> WORSENS PULMONARY EDEMA

• AVOID HYPOVOLEMIA - -> SACRIFICES ALREADY DECREASED LEFT VENTRICULAR

FILLING, WHICH FURTHER DECREASES CARDIAC OUTPUT. HYPOVOLEMIA

SECONDARY TO BLOOD LOSS AND VASODILATORY EFFECTS OF ANAESTHESIA OUGHT TO BE

GENERAL ANAESTHESIA

• AFTER DELIVERY OF THE FOETUS, OXYTOCIN 10–20 U IN 1,000 ML OF CRYSTALLOID

SHOULD BE ADMINISTERED AT A RATE OF 40– 80 MU/MIN. AN INFUSION OF

OXYTOCIN CAN LOWER THE SVR AS WELL AS ELEVATE THE PULMONARY VASCULAR

RESISTANCE, RESULTING IN A DROP IN CARDIAC OUTPUT. CARE MUST BE TAKEN

DURING ITS ADMINISTRATION.

• METHYLERGOMETRINE, OR 15-METHYLPROSTAGLANDIN F2, PRODUCES SEVERE

HYPERTENSION, TACHYCARDIA AND INCREASED PULMONARY VASCULAR

RESISTANCE.

• POST-OPERATIVELY

AVOID PAIN AS PAIN BEGETS HYPOVENTILATION WHICH LEADS TO RESPIRATORY

ACIDOSIS, HYPOXEMIA WHICH MANIFESTS AS RAISED HEART RATE AND PULMONARY

VASCULAR RESISTANCE.

ADVANTAGES OF GA

1. RAPIDLY ESTABLISHED

2. BETTER HEMODYNAMIC STABILITY

3. PREVENTION OF ASPIRATION AS THE

AIRWAY IS ISOLATED

4. HIGH FIO2 -WHICH WILL REDUCE PVR

5. VENTILATION CONTROLLED TO AVOID

HYPERCARBIA-WHICH WILL INCREASE PVR

6. FRC IS INCREASED BY CONTROLLED

VENTILATION

7. VENTILATION OF ATELECTATIC AREAS –

BETTER V/Q

8. SINUS RHYTHM CAN BE MAINTAINED. IN

CASE OF SVT AND VENTRICULAR ARRHYTHMIAS

PROMPTLY REVERTED BY CARDIOVERSION

9. PEAK AIRWAY PRESSURE CAN BE KEPT <20

CMS H2O

10. ELECTIVE POST OPERATIVE VENTILATION TO

TIDE OVER THE CCF THAT MAY BE POSSIBLE

AFTER PARTURITION

11. EFFECTIVE MANAGEMENT OF PULMONARY

OEDEMA - IPPV WITH PEEP, LIBERAL USE OF

HIGH DOSE MORPHINE

COMPLICATIONS OF GA

1. FAILED INTUBATION

2. ASPIRATION( MORE COMMON IN

UNPREPARED CASE)

3. HYPERTENSIVE CRISIS

4. ARRHYTHMIA-HYPOXIA,

HYPERCARBIA, INHALATIONAL

AGENTS, DRUGS

5. USE OF POLY PHARMACY AND

ANAPHYLAXIS

6. AWARENESS

7. UTERINE ATONY WITH INHALATION

AGENTS

8. NEED FOR ADEQUATE POST OP.

ANALGESIA

9. NEONATAL DEPRESSION

10. DELAYED RECOVERY

11. ANAESTHETIC DRUG INTERACTIONS

12. INCREASED INCIDENCE OF PONV

13. PROLONGED STAY ICU

OUTLINES OF MANAGEMENT1. PRE-CONCEPTUAL COUNSELING- NYHA III AND IV ARE ADVISED CORRECTIVE

CARDIAC BEFORE PREGNANCY. IT IS ADVISABLE FOR CERTAIN CARDIAC DISEASES WHERE PREGNANCY IS TO BE AVOIDED

• THEY HAVE TO BE REGISTERED, INTERVIEWED REGARDING FUNCTIONAL DIFFICULTIES, REGULARFOLLOW UPS STARTING FROM EARLY PREGNANCY. IT IS ADVISABLE TO MANAGE THEM IN HIGHERCENTERS WHERE MULTIDISCIPLINARY SUPPORT IS AVAILABLE(MULTIDISCIPLINARY APPROACH:MANAGEMENT BY A TEAM OF SPECIALISTS APART FROM OBSTETRICIANS THAT INCLUDES THECARDIOLOGIST(FAILURE PREVENTION, ARRHYTHMIA MANAGEMENT), CT SURGEON(EMERGENTCARDIAC SURGERY), NEONATOLOGIST(PRETERM BABY) ANESTHESIOLOGIST(PAIN RELIEF-EPIDURAL,MECHANICAL VENTILATION IF NECESSARY)

2. CORRECT FACTORS WHICH WILL BURDEN THE CARDIAC LESION LIKE ANEMIA, OBESITY, HYPERTENSION, ARRHYTHMIA

3. PREVENTION OF INFECTION

OUTLINES OF MANAGEMENT

4. OPTIMIZATION OF HEART RATE WITH PHARMACOLOGICAL AGENTS

5. PREGNANCY IS A HYPERCOAGULABLE STATE, WHICH INCREASES THE RISK OF THROMBOEMBOLIC EVENTS, ESPECIALLY IN THE CARDIAC PATIENT WITH A PROSTHETIC HEART VALVE, VALVULAR HEART DISEASE, OR HEART FAILURE. ANTICOAGULANT THERAPY SHOULD BE CONSIDERED IN THESE HIGH-RISK PATIENTS TO PREVENT THROMBOEMBOLISM OR THROMBUS FORMATION.

6. IE PROPHYLAXIS -(AS PER THE ACOG GUIDELINES- SOME OF THE DRUGS RECOMMENDED BY ACC/AHA ARE NOT RECOMMENDED FOR PREGNANT PATIENTS)

7. MONITORS- OTHER THAN THE ASA STANDARDS RECOMMENDATION- ADVANCED MONITORS LIKE INVASIVE ARTERIAL PRESSURE, CVP -, PCWP AND TEE ARE RECOMMENDED. THEY SHOULD BE CONTINUED IN THE POST PARTUM PERIOD UPTO 72 HRS AT LEAST

OUTLINES OF MANAGEMENT

8. PLANNING THE MODE OF DELIVERY-VAGINAL DELIVERY IS BETTER TOLERATED(LESS BLOOD LOSS, LESS CATECHOLAMINE), PAIN RELIEF DURING LABOR - RECOMMENDED, SHORTENING THE SECOND STAGE- OUTLET FORCEPS, EPISIOTOMY.

9. LARGE BOLUSES OF OXYTOCICS SHOULD BE AVOIDED AS THEY CAUSE PROFOUND HYPOTENSION. ERGOMETRINE BETTER AVOIDED. PGF2 ALPHA AND MESOPROSTOL ARE USED CAUTIOUSLY.

10. IF PLANNED FOR CESAREAN SECTION CHOICE OF ANESTHETIC SHOULD BE DIRECTED TO KEEP THE HAEMODYNAMIC STABLE (AS NEAR NORMAL SYSTEMIC VASCULAR RESISTANCE, PRELOAD, AFTERLOAD AS POSSIBLE)ADEQUATE REPLACEMENT OF BLOOD LOSS.

11. ALL PATIENTS WITH CARDIAC DISEASE SHOULD BE KEPT IN HIGH DEPENDENCY UNIT AND MONITORED AFTER THE DELIVERY FOR A MINIMUM PERIOD OF 72HRS

12. PLAN AND ADVISE CARDIAC SURGERY IN THE SECOND TRIMESTER IF IS WARRANTED IN THE INTEREST OF THE MOTHER'S WELL BEING.

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