Anesthetic management of a consecutive cohort of women with heart disease for labor and delivery

Anaesthetic Management and Peripartum Outcomes for Parturients With Valvular Heart Disease in a Tertiary Care Hospital of Pakistan

Introduction Parturients with valvular heart disease are at increased risk of maternal cardiac and neonatal complications. We aim to observe maternal cardiac complications in relation to the type of anaesthesia and mode of delivery as our primary objective and neonatal complications as the secondary outcomes. Methods We retrospectively reviewed all parturients with valvular heart disease undergoing delivery over a five-year period at the Aga Khan University Hospital, Karachi, Pakistan. to identify maternal cardiac and neonatal complications occurring during the peripartum period. Results Of 83 patients with valvular heart disease, 79.5% had rheumatic heart disease. Caesarian section (CS) was performed in 79.5% of patients and regional anaesthesia (RA) was given to 62.1%. Patients with cardiac risk index > 2 were delivered by CS and 64.5% received RA. One maternal and three neonatal deaths were reported with a complication event rate of 9.64% in parturients and 40.9% in neonates. Incidence of maternal cardiac events was one in 17 (5.8%) for vaginal deliveries versus seven in 66 (10.6 %) for CS. Maternal events for CS under RA was 5/66 (7.5 %) vs 2/66 (3%) under general anaesthesia. The incidence of peripartum maternal cardiac events when stratified by severity of cardiac disease was similar to a previously derived cardiac risk index for pregnant women with cardiac disease with no statistical difference in the adverse events rate from the estimated rates (p-value= 0.42). Conclusion Elective CS with RA was a common approach for high-risk parturients; however, the benefits cannot be ascertained. Despite low maternal and neonatal mortality, significant maternal cardiac and neonatal complications were observed.

Delivering Coordinated Cardio-Obstetric Care from Preconception through Postpartum

Coordinated preconception through postpartum cardio-obstetrics care is necessary to optimize both maternal and fetal health. Maternal mortality in the United States is increasing, largely driven by increasing cardiovascular (CV) disease burden during pregnancy and needs to be addressed emergently. Both for women with congenital and acquired heart disease, CV complications during pregnancy are associated with increased future risk of CV disease. Comprehensive cardio-obstetrics care is a powerful way of ensuring that women's CV risks before and during pregnancy are appropriately identified and treated and that they remain engaged in CV care long term to prevent future CV complications.

Anesthesia for Cesarean Section and Postpartum Cardiovascular Events in Congenital Heart Disease: A Retrospective Cohort Study

OBJECTIVE

To clarify the association between anesthetic technique and maternal and neonatal outcomes in parturients with congenital heart disease (CHD).

DESIGN

Retrospective, observational cohort study.

SETTING

An academic hospital.

PARTICIPANTS

A total of 263 consecutive parturients with CHD who underwent cesarean section from 1994 to 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The authors compared postpartum cardiovascular events (composite of heart failure, pulmonary hypertension, arrhythmia, and thromboembolic complications) and neonatal outcomes (intubation and Apgar score <7 at one or five minutes) by anesthetic technique. Among 263 cesarean sections, general anesthesia was performed in 47 (17.9%) parturients and neuraxial anesthesia in 214 (81.3%) parturients. Cardiovascular events were more common in the general anesthesia group (n = 7; 14.9%) than in the neuraxial anesthesia group (n = 17; 7.9%). Generalized linear mixed models assuming a binomial distribution (ie, mixed-effects logistic regression), with a random intercept for each modified World Health Organization classification for maternal cardiovascular risk, revealed that general anesthesia was not significantly associated with cardiovascular events (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.30-3.29). In addition, general anesthesia was associated with composite neonatal outcomes (Apgar score <7 at one or five minutes or need for neonatal intubation; OR, 13.3; 95% CI, 5.52-32.0).

CONCLUSION

Anesthetic technique is not significantly associated with postpartum composite cardiovascular events. General anesthesia is significantly associated with increased need for neonatal intubation and lower Apgar scores.

Anesthetic management of women with heart failure during pregnancy: a retrospective cohort study

BACKGROUND

The incidence of heart failure among pregnant women with pre-existing cardiac disease is quoted as 13%, with 10% requiring hospitalization. There is limited literature on heart failure in the pregnant population. The study objective was to describe the etiology and management of women hospitalized in our institution for heart failure during pregnancy.

METHODS

A retrospective cohort study investigated women who presented with heart failure in pregnancy between 2004 and 2017. Hospital records were interrogated using International Classification of Diseases v10 codes for heart failure. Patient characteristics, investigations, treatment, obstetric and anesthetic management, and maternal-fetal outcome data were collected and summarized using descriptive statistics.

RESULTS

One-hundred-and-twenty cases (in 93 122 deliveries) were identified across the 13-year period (antepartum heart failure 51%, postpartum heart failure 49%).The most common etiologies were pre-eclampsia (28%), cardiomyopathy (22%), and valvular heart disease (18%). Cesarean delivery occurred in 76% of cases (13% because of the maternal cardiac condition). Neuraxial techniques were used for most deliveries (cesarean 83%; vaginal 90%). For cesarean delivery, titrated epidural or general anesthesia was employed in 48% and 16%, respectively. Cardiac arrest occurred in two cases (1.7%) and 44% required coronary or intensive care unit admission.

CONCLUSIONS

The incidence of heart failure was 0.13% (1:776 deliveries). Pre-eclampsia was the leading cause but may have been historically under-acknowledged. Anesthetic and obstetrical decisions were tailored by means of multidisciplinary input, with cesarean delivery and regional anesthesia used in the majority. The postpartum period warrants heightened attention for these patients.

Placenta accreta complicated with peripartum cardiomyopathy

A 33-year-old G2P1 was referred to our hospital due to placenta accreta. During perioperative preparations, the patient was diagnosed with having a peripartum cardiomyopathy. The patient underwent caesarean hysterectomy at 36 weeks with an associated 2 L blood loss. Haemodynamic maintenance and stabilisation during the operation were challenging, with the combinations of fluid therapy, blood transfusions as well as vasoactive, antifibrinolytic and haemostatic drug. Postoperatively, the patient was managed in the intensive care unit and was subsequently transferred to intermediate care after less than 24 hours' observation. She was stable enough to be moved to the obstetrics ward the next day.

The Evaluation of Applied Anaesthetic Techniques for Caesarean in Parturients with Cardiac Diseases: Retrospective Analysis

OBJECTIVE

In this study, the effects of anaesthetic technique on mother and newborn were investigated in a retrospective analysis of parturients with cardiac diseases undergoing Caesarean section between 2006-2012.

METHODS

Our hospital's medical information system records were analyzed, and we found 107 parturients with cardiac disease and were undergoing Caesarean section, and their demographic data and obstetric, anaesthetic, and neonatal record forms were inspected.

RESULTS

Fifty-three (49.5%) pregnant women received general anaesthesia, and 54 (50.5%) received regional anaesthesia (34 spinal, 19 epidural and 1 CSE) (p=0.05). Week of pregnancy was lower for the group of general anaesthesia (p=0.007). Among cardiac parturients, valvular lesion rates were higher (75.7%). The relationship between existing cardiac disease and anaesthetic management was not significant (p=0.28). However, we determined that parturients with higher NYHA (New York Heart Association) classifications had higher general anaesthesia rates. (p=0.001). A rate of 39% of 74 NYHA I patients were undergoing general anaesthesia; this rate was 64% for NYHA II and 100% for NYHA III. The patients with cardiac surgery or medical treatment history had higher general anaesthesia rates (p=0.009). Although the general anaesthesia group newborn weights were lower (p=0.03), there was no difference between groups for APGAR scores. With regard to postoperative complications and hospital stay, the groups were similar.

CONCLUSION

We determined that general and epidural rates in parturients with cardiac diseases were similar, general anaesthesia was preferred for parturients who had higher NYHA classifications and surgical or medical treatment history. We considered that general anaesthesia criteria should reduce the anaesthesia management of parturients with cardiac disease; epidural or CSE anaesthesia applications should increase according to the patient's physical state, haemodynamic parameters, and obstetric indications.

Pregnancy in women with heart disease: risk assessment and management of heart failure

Heart disease, present in 0.5% to 3% of pregnant women, is an important cause of morbidity and the leading cause of death among pregnant women in the developed world. Certain heart conditions are associated with an increased risk of heart failure during pregnancy or the postpartum period; for these conditions, management during pregnancy benefits from multidisciplinary care at a center with expertise in pregnancy and heart disease. This article focuses on cardiac risks and management strategies for women with acquired and congenital heart disease who are at increased risk of heart failure during pregnancy.

Adult congenital heart disease and pregnancy

Adults with congenital heart disease now form the largest group of women with cardiac disease becoming pregnant in the developed world. This is both a mark of impressive steps forward in the management of congenital heart disease and also a challenge to the medical community to develop systems of care that will best serve these women and their babies. Each woman with congenital heart disease presents a unique pattern of challenges for the cardiologist, obstetrician, and anesthesiologist, and their care should be tailored to deal with their individual circumstances. As this population of patients continues to grow, we must continue to learn and improve our diagnostic tools and management strategies to refine their care. This review intends to focus on reviewing the outcomes in this set of patients and also an approach to the assessment and the management of these patients, primarily for an audience of obstetricians, pediatricians, and anesthesiologists.

Management of cardiovascular diseases during pregnancy

The prevalence of cardiovascular diseases (CVDs) in women of childbearing age is rising. The successes in medical and surgical treatment of congenital heart disease have led to an increasing number of women at childbearing age presenting with problems of treated congenital heart disease. Furthermore, in developing countries and in immigrants from these countries, rheumatic valvular heart disease still plays a significant role in young women. Increasing age of pregnant women and increasing prevalence of atherosclerotic risk factors have led to an increase in women with coronary artery disease at pregnancy. Successful management of pregnancy in women with CVDs requires early diagnosis, a thorough risk stratification, and appropriate management by a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, and primary care physicians. The following review is based on the recent European guidelines on the management of CVDs during pregnancy, which aim at providing concise and simple recommendations for these challenging problems.

Is vaginal delivery or caesarean section the safer mode of delivery in patients with adult congenital heart disease?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is vaginal delivery or caesarean section (CS) the safer mode of delivery in patients with adult congenital heart disease? Of the 119 studies, 13 papers represented the best evidence on the topic. Recommendations are based on 29 262 patients. Those having undergone successful corrective or palliative cardiac surgery for congenital heart disease, in addition to patients with unoperated congenital heart disease are a high-risk obstetric population. Heart disease is a leading cause of maternal mortality in the USA and the UK. Traditionally, CS was regarded as the mode of delivery of choice for high-risk patients, but growing experience in this field has now made this advice appear controversial. Patients are stratified into high- and low-risk, depending on the degree of heart failure symptoms [New York Heart Association (NYHA) class]. All studies demonstrated adverse outcomes in ACHD patients compared with normal age-matched controls. This pertained to a higher overall risk of maternal cardiac death, neonatal death, preterm birth, fetal growth restriction and longer hospital stay. On univariate regression analysis, the variables that imparted the highest risk to mother and foetus, were right ventricular failure, pulmonary regurgitation and pulmonary hypertension (P < 0.001). Induction of labour was deemed safe and was not associated with higher CS rates. There was no increase in maternal or neonatal complications in patients who were NYHA class I and II at labour. Patients who were NYHA class III and IV at labour had higher complication rates with adverse feto-maternal outcomes (P < 0.0001) and longer intensive care unit and hospital stay (Spearman's correlation 0.326, P = 0.007). The largest cohort from the USA (26 973 ACHD births) demonstrated that ventricular septal defect was associated with the highest risk of maternal death and complications (P < 0.05). The data would indicate that patients NYHA class I and II symptoms are suitable for VD. For most NYHA III and IV patients a trail of labour is safe with expedited delivery under good analgesic control as dictated by obstetric needs. Due to high complication risks, CS may be indicated in a proportion of patients.

Cardiac risks and management of complications in pregnant women with congenital heart disease

There are a growing number of women with congenital heart disease reaching adulthood and contemplating and/or undergoing pregnancy. However, pregnancy imposes hemodynamic stress on the heart and this can result in maternal, fetal and neonatal complications. Most women with congenital heart disease do well during pregnancy, but some women with high-risk cardiac lesions will not tolerate the hemodynamic changes of pregnancy. Physicians must be aware of the potential risks for the mother both during and after pregnancy, the risks to the fetus and neonate, and the risks and benefits of medications and procedures used during pregnancy. For women with complex cardiac conditions, management during pregnancy benefits from multidisciplinary care involving cardiologists with expertise in pregnancy, obstetricians with expertise in maternal fetal medicine, neonatologists and obstetric anesthetists, among others. This review will focus on the cardiac risks faced by women with congenital heart disease; particularly those at high risk, and on management strategies to mitigate risk and address cardiac complications.

The pregnant patient with congenital heart disease

Advances in the surgical palliation and correction of congenital heart lesions have improved survival and increased the number of patients living into adulthood. Although pregnancy outcomes will be favorable for most patients with congenital heart disease, the cardiovascular challenges associated with pregnancy and delivery are best managed with a multidisciplinary approach during the puerperium. This review addresses the prevalence, physiology, risk assessment, peripartum complications, and anesthetic management of the pregnant patient with underlying congenital heart disease.