This document discusses mitral stenosis in pregnancy. It begins by introducing mitral stenosis and its prevalence as a cause of maternal death in India. It then discusses the physiological cardiovascular changes that occur during pregnancy, labor, and the postpartum period. Several sections describe the pathophysiology of mitral stenosis and how it impacts hemodynamics during pregnancy. The document outlines methods for diagnosing and grading the severity of mitral stenosis, as well as predicting mortality and morbidity risks. General management approaches are discussed including medical, surgical, and obstetrical options. The goals of anesthetic management during delivery are provided. In summary, this document provides an overview of mitral stenosis in pregnancy, including its effects, diagnostic evaluation, severity grading

1. MITRAL STENOSIS WITH
PREGNANCY
- DR. ANKITA PATNI
- ANAESTHESIOLOGY

2. 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.

3. 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-pregnancy
Pre-pregnant values at term
CVP Unchanged
O2 consumption 30–40% Increase

4. 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

5. 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

6. MS PREGNANCY
DELIVERY
DECREAS
E LA
emptying
DECREAS
E LV
Filling
INCREASE
HR
DECREASE
SV
DECREASE
CO
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
develop
s
between
LA and
LVHemodynam
ic Hallmark
of MS

7. • 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

8. SEVERITY GRADING OF MS
Measuremen
t
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

9. 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

10. 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

11. 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%

12. 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%

13. 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

14. 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)

15. DIAGNOSIS OF MS
DIAGNOSTIC
TOOLS
Clinical
Examina
tion
ECG
Chest X-
Ray
Echocardi
ography
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
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.

16. 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

17. 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

18. 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.

19. 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

20. ECG FINDINGS
1. BROAD NOTCHED “P” WAVES SIGNIFYING ATRIAL ENLARGEMENT.
2. ATRIAL FIBRILLATION (F- WAVES REPLACING P-WAVES)
3. RIGHT VENTRICULAR ENLARGEMENT

21. 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

22. CHEST X-RAY
Kerley
b lines

23. ECHOCARDIOGRAPHY

25. MANAGEMENT
MEDICAL
DIURETICS, β-
BLOCKERS
AF- DIGOXIN,
ANTI-COAGULANTS
SURGICAL
VALVULOPLASTY
VALVE
REPLACEMENT
OBSTETRICAL
VAGINAL
CAESAREAN
SECTION

26. 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.

27. 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.

28. 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.

29. OBSTETRIC MANAGEMENT
VAGINAL
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 by
instrumentation.
• Maintenance of left uterine displacement for good venous
return.
• Supplemental oxygen administration with pulse oximetry
monitoring to minimize increases in pulmonary vascular
resistance, fetal heart rate monitoring should be carried out.
• Invasive cardiac monitoring like radial artery cannulation and
pulmonary catheter are beneficial in assessing the cardiac
output, pulmonary artery pressure and for guiding fluid and
drug therapy, especially in NYHA III and IV patients.
• Sudden drops in systemic vascular resistance (SVR) in the
presence of a fixed cardiac output can be prevented by small
bolus doses of phenylephrine, with volume expansion when
necessary.
Good LABOUR
ANALGESIA is must.
Epidural
CS
E

30. OBSTETRIC MANAGEMENT
Caesarean
section
Epidural/Spinal
Combined Spinal
Epidural
General
Anaesthesia
Only for obstetric
reasons
Epidural anaesthesia might not be an
ideal technique as it requires slow
induction, delay in the onset of action
which may not be possible in an
emergency situation. Moreover large
volume of local anesthetic is needed
for 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

31. 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

32. 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.

33. 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.

34. 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

35. 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.

36. 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

37. 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.

38. 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

39. 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.

40. 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

41. 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

42. 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

43. 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

44. OUTLINES OF MANAGEMENT
1. 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, REGULAR
FOLLOW UPS STARTING FROM EARLY PREGNANCY. IT IS ADVISABLE TO MANAGE THEM IN HIGHER
CENTERS WHERE MULTIDISCIPLINARY SUPPORT IS AVAILABLE(MULTIDISCIPLINARY APPROACH:
MANAGEMENT BY A TEAM OF SPECIALISTS APART FROM OBSTETRICIANS THAT INCLUDES THE
CARDIOLOGIST(FAILURE PREVENTION, ARRHYTHMIA MANAGEMENT), CT SURGEON(EMERGENT
CARDIAC 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

45. 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

46. 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.

47. THANK YOU