CONCLUSIONS: - Cardiologist, obstetrician and anestesiologist should cooperate to each other - The advantage of regional anesthesia is patients can communicate if symptoms occur - If palpitations, chest pain and shortness of breath happened, immediate action should be performed - RA should be given using lower dose of local anesthetics opioids and slow induction - GA : standard technique “rapid sequence induction”

1. Anesthesia Management
for Maternal with Heart Diseases
Purwoko
Dept. of Anesthesiology and Intensive Therapy
Dr. Moewardi General Hospital / Sebelas Maret Univ
Surakarta
2014

2. Introduction
 Latest management for maternal with heart
disease requiring surgery.
 Techniques of regional anesthesia in patients
with heart disease need little adjustment.
 Monitoring of fluid and several heart function.

3.  The prevalence of heart disease in
pregnancy is 0.4 - 1%
 High risk maternal requires an
understanding of the impact of pregnancy
and heart lesions on hemodynamic
response
 Objective : To discuss anesthesia
management for maternal with common
heart lesions which requires non cardiac
surgery.

4. Physiological changes in pregnancy
• Stroke volume ↑↑, Heart rate ↑↑.
• Cardiac output ↑↑
• Sistemic vascular resistance ↓ ± 20%
• Blood flow to uterus ↑↑ 700-900 ml / hour
(increasing heart load)
• - Healthy heart no problem
- Abnormal heart  problem

5. 1. Congenital Heart Disease
 Patent ductus arteriosus (PDA), Atrial
Septal Defect (ASD) and Ventricular Septal
Defect (VSD) are common congenital heart
diseases
 Increased cardiovascular volume during
pregnancy →increasing atrial volume that
leads to enlargement of both atria and
susceptibility of supraventriculare
dysrhythmias

6.  Actions performed on the CHD patients :
1. Prevention of air bubbles into the intravenous
access.
2. Epidural anesthesia is better using NaCl, slow
onset of epidural analgesia
3. Oxygen supplementation
4. Antibiotic prophylaxis is recommended.

7. Tetralogy of Fallot (TOF)
 Minimizing hemodynamic changes that
leads to increased R to L shunt.
 It is important to prevent decreased in SVR,
venous return or myocardial depression
 Both GA or RA techniques can be used.

8. • For GA, induction agents chosen are
those that cause the most minimal
hemodynamic changes, for examples
narcotics and etomidate.
• Regional anesthesia techniques can be
used with special attention.
• Single Shot spinal anesthesia should be
avoided.
• Slow induction of epidural anesthesia is
recommended

9. Eisenmenger Syndrome
 Abnormalities : pulmonary hypertension,
right-to-left shunting produces arterial
hypoxemia.
 Clinical manifestations include dyspnoea,
clubbing, polycythemia, peripheral edema
and cyanosis.
 Avoid decreased of SVR.

10.  RA or GA may be used if only there are no
contraindications . RA can be done using
epidural dose titration.
 Oxygen should be given
 Blood loss should be replaced with colloid,
crystalloid or blood components.
 Invasive Monitoring should be done such as
arterial Line and CVP
 Ampycillin and Gentamicin should be given as
prophylaxis drugs against infective
endocarditis and repeated every 8 hours after
the initial dose.

11. Valvular Heart Diseases
1. Mitral stenosis
 Maintain heart rate, venous return and
SVR remained low (slow)
 Avoid aorto caval compression,
aggressive treatment of atrial fibrillation,
maintaining sinus rhythm.
 prevent pain, hypoxemia, hypercarbia
and acidosis ↑↑ SVR.
 Both RA or GA can be used.

12.  Epidural anesthesia is an option
 Vasopressors: low dose of phenylephrine.
 GA also provide stable hemodynamics,
 Etomidate is best used as an induction
agent.
 Beta blockers such as esmolol and
moderate dose of opioids should be
administered before induction

13. 2. Mitral regurgitation
• Pregnancy will induce a state of hyper
coagulation and systemic embolism.
• Epidural anesthesia can prevent an increase in
SVR, and prevent pulmonary congestion.
• Invasive blood pressure monitoring
• Antibiotics profilaxis is recommended
• GA : Ketamin and Pancuronium

14. • The main consideration is maintaining
slight increase in heart rate to prevent an
increase in SVR and central blood volume.
• Prevent hypoxemia, hypercarbia, acidosis
that will lead to an increase in PVR.
• Avoiding Aortocaval compression and
myocardial depression.

15. 3. Aorta Stenosis
 In aorta stenosis, transvascular gradient will
progressively increased during pregnancy, this
is due to an increase in blood volume and
decrease in SVR.
 Avoid tachycardia and bradycardia, maintain
intravascular volume and "venous return", avoid
aortocaval compression and myocardial
depression, maintain heart rate as the normal
condition because decrease in heart rate will
decrease cardiac output

16.  GA: combination of etomidate and mid-dose
opioids with succinylcholine for
"Rapid Sequence intubation".
 Myocardial depression due to volatile
anesthetic agents should be avoided
 Pulmonary artery catheter monitoring is
controversial, CVP monitoring is needed
and must be maintained at high normal
level

17. 4. Aorta Insufficiency
 Pathophysiology that occurs due to the "volume overload" on
the LV, with hypertrophy and dilatation and increased LVEDV,
decreased ejection fraction (EF) and signs and symptoms of
edema pumonal.
 Minimalizing pain is an attempt to prevent release of
catecholamines , which may increase SVR
 Avoid bradycardia because it can lead to an increase in
regurgitant flow.

18. • Epidural anesthesia is
preferable/recommended
• Induction agent using etomidate,
endotracheal intubation using
suxamethonium
• Remifentanyl for analgesia

19. 5. Prosthetic Valves
 The high risk of fetal and maternal
complications
 The use of anticoagulant therapy is contra
indication for regional anesthesia.
 GA: the use of an additional monitoring tool
such as CVP, PA catheter and A-Line

20. Peripartum Cardiomyopathy (PPCM)
 Heart failure can occurs in the 3rd trimester, EF less
than 45% and diastolic dimensions greater than
2.72cm / m2
 Avoiding myocardial depression and attention to fluid
management with the use of diuretics and
vasodilators, as well as keeping the heart rate within
the normal range with sinus rhythm.
 Titration slowly CSA / CEA
 GA: monitoring invasive, PA Line, A Line
 Narcotics for the induction and maintenance of
anesthesia

21. Maternal arrhythmias during pregnancy
Cathecolamine Sensitive Ventricular Tachycardia (VT)
 Often due to the VT re-entry (ca)
 Patients with a history of VT are required to continue the
anti-arrhythmia medication during pregnancy.
 CSE drug delivery slowly (slow incremental)

22. Congenital Heart Block and Bradyarrhytmia
 The use of pacemaker; QT interval lengthening or
if there is enlargement of the left atrium.
 Access CVC and "trans Venous Pacing wires
should be prepared in addition to the patient
during the surgery
 Epidural analgesia is recommended for surgery
and postoperative pain.

23. Maternal postoperative period in
heart disease
 Patients with less - severe cardiac dysfunction that undergo
surgery should be monitored in Intensive Care Unit (ICU)
 The first 24-72 hours of fluid displacement will appear
significantly.
 Adequate postoperative analgesia should be provided in the
form of "continuous epidural analgesia" or "patient controlled
IV analgesia”.
 Provision of early ambulation to minimize the occurrence of
"deep vein thrombosis and paradoxical emboli"

24. "Outcome" of fetal and maternal heart disease
requiring surgery
• Mortality that is less than 1% have been
reported in patients with NYHA Class I and
II, whereas in NYHA Class III and IV are
about 5-15%.

25. Conclusions
 Cardiologist, obstetrician and anestesiologist should
cooperate to each other
 The advantage of regional anesthesia is patients can
communicate if symptoms occur
 If palpitations, chest pain and shortness of breath
happened, immediate action should be performed
 RA should be given using lower dose of local
anesthetics opioids and slow induction
 GA : standard technique “rapid sequence induction”

26. THANK YOU