Presented by :- Dr MangilalModerator:- Dr AvnishBhardwaj
Introduction CARDIAC disease in pregnancy remains an important etiology of maternal ,fetal morbidity and mortality. Mitral stenosis is the most commonly acquired valve lesion encountered in pregnant women and is almost invariably caused by RHD. Pregnancy and the peripartum period worsen symptoms of cardiac disease.
Presenting Complaints A 37 year old woman presented at 28 weeks gestational age with inability to lie and became dyspneic even when speaking (class IV). Had complete placenta previa, possible placenta accreta.
Past History Patient complained of dyspnea with moderate exertion before pregnancy( class II ) Past medical history – No history of TB, DM , HTN, Asthma,convulsion,chest pain Drug history – no history of any drug allergy. Family history- not significant
Obs. history Gravida 2, Para 1 Previous h/o Cesarean section delivery 16 yr earlier
Clinical examination Physical examination revealed an arterial blood pressure of 102/60 mmHg, Regular heart rate of 108 beats/min, Respiratory rate of 22 breaths/min. There were diastolic(grade 2) and holosystolic( grade 3) apical murmurs. The patient’s lungs were clear to auscultation bilaterally, and she had mild pedal edema. Her symptoms improved with heart rate control using 25 mg metoprolol orally twice daily.
Investigation Electrocardiogram showed sinus tachycardia and left atrial enlargement. Transthoracic echocardiogram revealed moderate to severe mitral stenosis, moderate to severe mitral regurgitation, and moderate pulmonary hypertension with estimated pulmonary artery systolic pressure of 54 mmHg. There was moderate tricuspid regurgitation. Left and right ventricular systolic function were normal.PROVISIONAL DIAGNOSIS-PREGNANCY WITH MS
Management Cesarean section was planned at 36 weeks gestational age in a cardiac operating room with cardiopulmonary bypass capabilities on standby.
Prophylaxis against acid aspiration, 30 ml sodium bicitrate was administered orally in the holding area. Patient was positioned in the left uterine displacement Initial systemic arterial blood pressure was 125/65 (mean 76)mmHg. Her heart rate was 105 beats/min. Remifentanil (0.2 ǔgm/kg/min) was started to attenuate the sympathetic response to laryngoscopy and intubation.
Induction Etomidate, and Succinylcholine was used for relaxant administered in a rapid sequence fashion.Maintenance Remifentanil infusion(0.05– 0.1ug /kg/min), Low level of Isoflurane(less than 0.5 minimum alveolar concentration), Vecuronium for muscle relaxant. Higher doses of inhalational agents were avoided to prevent uterine atony. Depth of anesthesia was monitored using bispectral index values from 40–60 were maintained during the intraoperative period. The patient was ventilated using 100% oxygen to maintain normocarbia.
Intra op monitoring by TEE ,Colour doppler Three-dimensional ultrasound reconstruction of the mitral valve showed significant commissural fusion(mitral valve area 1.4cm2). Cesarean section was performed without complications. After delivery, 40 U oxytocin was administered intravenously in 2 hr.
Initially monitored in the operating room after extubation to ensure normocarbia and stable pulmonary artery pressures. Then transferred to the cardiac care unit for postoperative monitoring. The patient was discharged from the cardiac care unit on postoperative day 1 and from the hospital on postoperative day 5. She underwent mitral valve repair and tricuspid valve annuloplasty 4 months later.
Heart disease with pregnancy Epidemiology - incidence of cardiac disease in pregnant 0.2% to 3% of pregnancies are complicated by maternal heart disease in developed countries Heart diseases are still the second most common non obstetrical cause of maternal mortality Rheumatic heart disease accounts for majority of cases (~ 75%) in India while congenital heart disease are most common in developed countries -- Mitral stenosis is the most commonly acquired valve lesion in pregnant women and is almost caused by RHD.
.RHD Highly prevalent in developing countries. India, the prevalence of RHD is 6:1,000 ( school- aged children) Carditis occurs in 30–80% of patients with acute rheumatic fever, and at least 60% of untreated patients develop chronic RHD.
Physiological changes - Consideration In Pregnancy The most important changes in cardiac function occurs in the first 8 weeks of pregnancy with maximum changes at 28 weeks↓ Vascular resistance↓ Blood pressure↑ Heart rate ↑ Stroke volume ↑ CO↑ Blood volume 30% - 50%
The fall in the peripheral resistance is about 20-30% at 21-24 weeks & returns to normal at term. This fall is due to1. The trophoblastic erosion of endometrial vessels, the placental bed serves as a large arteriovenous shunt causing lowered systemic vascular resistance2. There is physiological vasodilatation which is believed to be secondary to endothelial prostacyclin and circulating progesterone.3 .Anemia decreases blood viscosity with resultant decrease in systemic vascular resistance.
Risk of haemodynamic stress At the time of labor and delivery, pain and anxiety increase catecholamine release with resultant increases in heart rate, arterial blood pressure, and cardiac output. Auto-transfusion of up to 500 ml with each contraction , increases preload and, hence cardiac output. After delivery, there is an additional increase in venous return as a result of auto-transfusion from the contracting uterus as well as from the loss of foetal compression of the inferior vena cava.
Features in Pregnancy which can mimic cardiac disease1. Dyspnoea - due to hyperventilation, elevated diaphragm.2. Pedal Edema3. Cardiac impulse- Diffused and shifted laterally due to elevated diaphragm.4. Jugular veins may be distended and JVP raised.5. Systolic ejection murmurs along the left sternal border occur in 96% of pregnant women and are believed to be caused by increased flow across the aortic and pulmonary valves.
Criteria to diagnose cardiac diseaseduring pregnancy: 1.Presence of diastolic murmurs. 2.Systolic murmurs of severe intensity (grade III) 3.Unequivocal enlargement of heart (X-ray) 4.Presence of severe arrythmias, atrial fibrillation or flutter .
Risk of cardiovascular complications duringpregnancy Risk of cardiovascular complications during pregnancy High risk Low risk Intermediate risk of of of complicationscomplications (≤ 1%) complications (5-15%) or death (≥25%)
Low risk of complications (≤ 1%): Corrected tetralogy of fallot Atrial septal defect Ventricular septal defect Patent ductus arteriosus Mild pulmonic or tricuspid valve disease Mitral stenosis (NYHA class I, II) Mild regurgitant valve lesion Bioprosthetic valve Compensated heart failure (NYHA class I, II)
Intermediate risk of complications (5-15%): Mechanical valve prosthesis Aortic stenosis (mild to moderate) Mitral stenosis with atrial fibrillation Mitral stenosis (NYHA class III, IV) Uncorrected cyanotic congenital heart disease (tetralogy of fallot) Uncorrected coarctation of the aorta Previous myocardial infarction
High risk of complications or death (≥25%): Pulmonary hypertension (severe) Eisenminger syndrome Marfan disease with aortic root involvement Peripartum cardiomyopathy Severe aortic stenosis NYHA class IV heart failure
The indications for Termination ofpregnancy1. Eisenmenger’s syndrome.2. Marfan’s syndrome with aortic involvement3. Pulmonary hypertension.4. Coarctation of aorta with valvular involvement. Termination should be done before 12 weeks of pregnancy.
The New York Heart Association (NYHA) Grading of functional capacity of the heart: No functional limitation of activity Symptoms with extraCLASS I ordinary physical work. Mild limitation of physical activity. Symptoms with ordinaryCLASS II physical work Marked limitation of physical Symptoms with less thanCLASS III activity ordinary physical workCLASS IV Severe limitation of physical Symptoms at rest activity
Prognosis depends on the functional status NYHA classes I and II lesions usually do well during pregnancy and have a favorable prognosis (mortality rate of <1%). NYHA classes III and IV -mortality rate of 5% to15%. These patients should be advised againstbecoming pregnant.
Risk factors for cardiac failure during pregnancy Infection Anemia Obesity Hypertension Hyperthyroidism Multiple pregnancy
Etiology The main cardiac diseases occuring with pregnancy are Rheumatic heart disease Congenital heart disease Coronary heart disease Cardiomyopathy
Mitral stenosis Most common manifestation of rheumatic heart disease Incidence: ~ 90% Symptoms develop ~ 30 years after rheumatic fever Symptoms occur mitral valve orifice <2cm² (normal: 4-6 cm²)
Mitral Stenosis:Pathophysiology Normal valve area: 4-6 cm2 Mild mitral stenosis: MVA 1.5-2.5 cm2 Minimal symptoms Mod. mitral stenosis MVA 1.0-1.5 cm2 usually does not produce symptoms at rest Severe mitral stenosis MVA < 1.0 cm2
Mitral Stenosis: Symptoms Breathlessness Fatigue Oedema, ascites Palpitation Haemoptysis Cough Chest pain mitral facies or malar flush Symptoms of thromboembolic complications (e.g. stroke, ischaemic limb) Worsened by conditions that cardiac output. ◦ Exertion,fever, anemia, tachycardia,, pregnancy, thyrotoxicosis
Signs of Mitral StenosisPalpation: Small volume pulse Tapping apex-palpable S1 Palpable S2 Atrial fibrillation Signs of raised pulmonary capillary pressure Crepitations, pulmonary oedema, effusions Signs of pulmonary hypertension RV heave, loud P2Auscultation: Loud S1 S2 to OS interval inversely proportional to severity Diastolic rumble: length proportional to severity In severe MS with low flow- S1, OS & rumble may be inaudible
Mitral Stenosis: Physical Examination S1 S2 OS S1• First heart sound (S1) is loud and snapping• Opening snap (OS)• Low pitch diastolic rumble at the apex• Pre-systolic accentuation (esp. if in sinus rhythm)
Mitral Stenosis:Complications Atrial dysrrhythmias Systemic embolization (10-25%) ◦ Risk of embolization is related to, age, presence of atrial fibrillation, previous embolic events Congestive heart failure Pulmonary infarcts (result of severe CHF) Hemoptysis ◦ Massive: 20 to ruptured bronchial veins (pulmonary HTN) ◦ Streaking/pink froth: pulmonary edema, or infection Endocarditis Pulmonary infections
Mitral stenosis:CXR The cardiac size is Unequivocal 1. the left atrial appendage is prominent (LAA). 2. Main pulmonary artery (MPA) segment is just outside the left border, indicating pulmonary hypertension. 3. The enlargement of left pulmonary artery (LPA) and right pulmonary artery (RPA) are just modest, if at all. 4. The horizontal fissure is visible, indicating collection of edema fluid in the fissure. 5.The aortic knuckle (Ao) is also seen well.
Mitral Stenosis:ECG LAE RVH Premature contractions Atrial flutter and/or fibrillation freq. in pts with mod- severe MS for several years No P waves . A fib develops in 30% to rhythm is irregularly irregular 40% of patients with symptoms right ventricular hypertrophy. Right axis deviation and deep S waves in the lateral leads. Combination of atrial fibrillation and right ventricular hypertrophy suggests mitral stenosis.
Mitral Stenosis: Role ofEchocardiography Diagnosis of Mitral Stenosis Assessment of hemodynamic severity ◦ mean gradient, mitral valve area, pulmonary artery pressure Assessment of right ventricular size and function. Assessment of valve morphology to determine suitability for percutaneous mitral balloon valvuloplasty Diagnosis and assessment of concomitant valvular lesions Reevaluation of patients with known MS with changing symptoms or signs.
Mitral Stenosis:Therapy Medical Diuretics for LHF/RHF Anticoagulation: In Atrial Fibrillation AF requires aggressive treatment with digoxin and β-blockers . If pharmacotherapy fails, cardioversion should be performed. After cardioversion bed rest in left lateral position and diuretics should be given to ameliorates pulmonary oedema. Endocarditis prophylaxis β -blockers used to prevents tachycardia. Propanolol can be administered without any adverse effect on foetus or neonate Atenolol should be avoided in the early stages of pregnancy and only given with caution in the later stages because of its association with fetal growth retardation
Surgical management » Before pregnancy- if significant MS is recognised before pregnancy : Surgery is recommended Mitral commisurotomy Mitral valve replacement – is preferred Bioprosthetic valve is preferred » During pregnancy-1. Palliative Mitral Valvotomy : temporarily delays progression of MS and may enable successful completion of pregnancy. Best time is in 2nd trimester.2. Mitral commisurotomy : in case of severe symptoms it can be performed at any stage of gestation.3. Balloon Mitral Valvuloplasty : it is safe and effective in women with pliable valve .This circumvents open heart surgery and risks of anaesthesia and surgery for mother and foetus.
Anaesthetic Goals: Prevention of pain Avoid tachycardia (diastolic filling time further decreased) Events that increase the pulmonary vascular resistance like hypoxaemia, hypercarbia and acidosis should be avoided Avoid increases in blood volume (result in pulmonary edema) Avoid rapid and severe drop in SVR (compensatory increase in HR can lead to further decompensation) Immediate treatment of acute atrial fibrillation
The main principles of management with regardto valvular heart disease in Pregnancy• Early identification of the disease, and the assessment of the severity of thelesion.• High-risk lesions, for either mother or fetus, should be managed in a highcare environment where invasive monitoring is possible, both pre- and postdelivery.• Regional anaesthesia techniques in labour are an attractive option, andmay be employed with good outcomes in many patients.• Carefully titrated epidural anaesthesia for labour is associated with lesssympathetic blockade than spinal or epidural anaesthesia for caesareandelivery.• Severe mitral or aortic stenosis, or any valvular heart condition associatedwith pulmonary oedema or heart failure, are contraindications toregional anaesthesia.
Anaesthetic OptionsVAGINAL DELIVERY : The role of the anaesthesiologist begins by providing good labour analgesia. Epidural anaesthesia is recommended, unless obstetrically contraindicated. Caesarean section is indicated for OBSTETRIC REASONS ONLY. Tachycardia, secondary to labour pain, increases flow across the mitral valve, producing sudden rises in left atrial pressure, leading to acute pulmonary oedema. This tachycardia is averted by epidural analgesia without significantly altering the patient haemodynamics.
Mitral stenosis : RegionalAnaesthesia I stage of labour : MS does not change management-adequate analgesia is essential to minimize tachycardia. Epidural analgesia is effective. Adequate hydration should be maintained. Intrathecal opioid such as Fentanyl 25 μg produces good analgesia without major haemodynamic changes. II stage of labour : Minimize maternal expulsive efforts, allowing fetal descent to be accomplished by uterine contractions. This is to avoid the deleterious effects of the Valsalva maneuver, which causes an undesirable increase in venous return. Intrathecal opioid with low dose LA can be given for analgesia and anaesthesia. The 2nd stage should be cut short by instrumentation. LA to provides perineal anaesthesia
• CSE : intrathecal opioid +/- small dose of LA followed by slow epiduralinfusion of a dilute solution of LA +/- opioid. (0.125% bupivacaine +2µg/ml fentanyl).• Epinephrine should be avoided as it may induce tachycardia.• Phenylephrine- vesopressor of choice (no tachycardia)• Invasive cardiac monitoring like radial artery cannulation andpulmonary catheter are beneficial in assessing the cardiacoutput, pulmonary artery pressure and for guiding fluid and drugtherapy, especially in NYHA III and IV patients.• Foetal heart rate monitoring should be carried out during all stages oflabour.• Pulse oximetry monitoring is mandatory.• Supplementary epidural anaesthesia can be maintained throughout theimmediate post-partum period and the catheter left in situ could provideanaesthesia for immediate or post-partum tubal sterilization.
CAESAREAN-SECTION General anaesthesia NYHA class 3 and 4 patients . Regional anaesthesia is preferred over general anaesthesia in NYHA class 1 and2 patients – Regional : Spinal & Epidural Epidural anaesthesia - preferred over spinal anaesthesia : More predictability and control over hemodynamic changes. maintains systemic vascular resistance. gradual onset of sympathetic block Slower induction of anaesthesia and ensures maternal hemodynamic stability.
Mitral stenosis:GA General anaesthesia has the disadvantage of increased Pulmonary Arterial pressure and tachycardia during laryngoscopy and tracheal intubation. Premedication : sedative and anxiolytics are avoided. Only counseling done to alleviate the anxiety. Preoxygenation:done with 100% o2 for 5 min. Induction :Inj. Thiopentone 3-4 mg/kg Intubation: Inj.succinylcholine 1-1.5mg/kg Maintained with opioids, neuromuscular blockers, nitrous oxide, and oxygen. A beta-adrenergic receptor antagonist, fentanyl, I.v xylocard should be administered before or during the induction of anaesthesia to blunt intubation response. The adverse effects of positive-pressure ventilation on the venous return may ultimately leads to cardiac failure.
Continued…… Tachycardia inducing drugs like atropine, ketamine, pancuronium and meperidine, should be totally avoided. Esmolol has a rapid onset and short duration of action, it is a better choice in controlling tachycardia. Modified rapid sequence induction using etomidate, remifentanyl and succinylcholine is an ideal choice in tight stenosis with pulmonary hypertension. General anesthesia provides the advantages of definitive airway control and the ability to use transesophageal echocardiographic monitoring throughout the procedure. Higher doses of inhalational agents should be avoided to prevent uterine atony.•Emergence must be carefully controlled to ensure avoidance oftachycardia
Continued…… Diuretics should also be used cautiously because hypovolemia can impair fetal blood supply Reversal: Avoid tachycardia, extubation is done when patient is fully awake. After delivery oxytocin should be administered as intravenous infusion preferably slowly. Stat i.v dosing should be avoided These Patients are at risk for haemodynamic compromise and pulmonary oedema during postpartum period,so require ICU care. For postoperative analgesia :I.V opioid or NSAIDS
Conclusion Irrespective of the mode of delivery and anaesthetic technique, these patients are at a great risk of haemodynamic stress due to autotransfusion of blood from the uterus. This may lead to pulmonary hypertension, pulmonary oedema and cardiac failure. Therefore, intensive monitoring and therapy should be continued till the haemodynamic parameters return to normal. As a rule, regurgitant valvular lesions are far better tolerated in pregnancy than are stenotic lesions.. Patients with severe symptomatic valvular heart disease should ideally be counselled against pregnancy. In the event of pregnancy, early consultation between obstetrician and anaesthesiologist allows for planning with regards to both the timing of delivery and optimal analgesia/ anaesthesia.