Anesthetic management for the peripartum care of women with Fontan physiology

Peripartum anesthesia management and outcomes of patients with congenital heart disease: a single-center retrospective analysis (2009-2023)

BACKGROUND

Advances in medicine have enabled more patients with congenital heart disease (CHD) to become pregnant. However, these patients face significant challenges during the peripartum period. Current peripartum anesthesia guidelines for CHD patients mainly rely on case reports and small series.

METHODS

In this retrospective study at a high-volume tertiary care center, we analyzed peripartum anesthetic approaches, postpartum hemorrhage (PPH) incidence, and maternal outcomes in CHD patients stratified by the modified World Health Organization (mWHO) classification.

RESULTS

Among 85 473 deliveries between 2009 and 2023, 409 occurred in 282 patients with CHD. Cesarean deliveries were significantly more frequent in mWHO class III, p=0.005. Labor epidural analgesia was the most common analgesic modality for vaginal deliveries (epidural rate was 71.1% with no differences between mWHO classes). Anesthesia management for cesarean deliveries varied significantly by class p<0.001. While spinal anesthesia was predominant in classes I and II, combined spinal-epidural anesthesia was more common in class III. PPH incidence was 6.4%, with no significant difference across classes, and no association was found between mWHO class severity and PPH risk (OR 0.97; 95% CI; 0.93 to 1.02, p=0.2). Higher mWHO classes correlated with significantly higher intensive care unit (ICU) admission rates, longer hospital stays, and one-year cardiac hospitalizations.

CONCLUSION

In this retrospective study on the peripartum anesthetic management and outcomes of CHD patients stratified by mWHO class, cases with greater mWHO class were more likely to deliver preterm, by cesarean delivery, with a combined spinal-epidural anesthetic and an arterial line placement for that cesarean delivery. They overall had a longer hospital stay and were more likely to be admitted to the ICU. However, the overall risk of PPH did not increase with mWHO class severity.

Anesthetic management in pregnant women with Fontan circulation: a case series

BACKGROUND

Given the advances in medicine, women with Fontan circulation are now reaching childbearing age. However, data on the mode of delivery and anesthetic management of these patients are limited. We report the cases of five pregnant women with Fontan circulation.

CASE PRESENTATION

The mean age at delivery was 28 ± 3 years, and the mean gestational period was 34 weeks and 3 days. Anticoagulation therapy was switched from warfarin and aspirin to continuous intravenous heparin. The modes of delivery were scheduled cesarean section (C/S) in one, emergency C/S in three, and vaginal delivery with epidural labor analgesia in one patient. Three patients underwent C/S under regional anesthesia; one received general anesthesia. The perinatal complications were heart failure, worsening valve regurgitation, and postoperative hematoma in three, four, and two patients, respectively.

CONCLUSIONS

For C/S in women with Fontan circulation, regional anesthesia should be considered. Epidural labor analgesia can help prevent the decrease in pulmonary blood flow due to straining. We initiated labor analgesia or C/S with regional anesthesia at the appropriate time in four patients.

Anesthetic management of cesarean hysterectomy using intra-aortic balloon occlusion in a patient with Fontan circulation and placenta increta: a case report

BACKGROUND

In patients with Fontan circulation, hemorrhage can cause life-threatening circulatory collapse, since Fontan circulation strongly depends on the preload. Furthermore, parturients with placenta accreta spectrum are at a high risk of rapid and massive hemorrhage. Herein, we report the case of an intra-aortic balloon occlusion used for a Fontan-palliated parturient with placenta increta with successful anesthetic management.

CASE PRESENTATION

A 35-year-old-female with Fontan circulation diagnosed with placenta increta underwent a cesarean hysterectomy. The main goal during anesthetic management was to maintain sufficient preload. Infrarenal intra-aortic balloon occlusion was used to reduce intraoperative hemorrhage. The hemodynamic changes caused were well tolerated in this case.

CONCLUSIONS

Intra-aortic balloon occlusion was used in a Fontan-palliated parturient with placenta increta with successful anesthetic management.

Trends in outcomes of pregnancy in patients with congenital heart disease

PURPOSE OF REVIEW

This review aims to analyze the trends in the management of pregnant patients with congenital heart disease (CHD).

RECENT FINDINGS

The literature that this article reviews specifically highlights the importance of multidisciplinary and specialized care, the unique and variable physiologic differences within the umbrella of CHD in pregnancy, and recommendations for obstetric and anesthetic care in the prenatal and peripartum period.

SUMMARY

The findings that this article summarizes have profound implications for clinical practice and management of the patient with CHD, including the optimization of preoperative screening, facilitation of ideal prenatal care to include qualified specialists and resources, and recommendations for optimal anesthetic management during labor and delivery.

Cardiac disease in pregnancy

In the developed world, cardiovascular disease has become the most frequent cause of death during pregnancy and postpartum, outnumbering by far obstetric causes of death such as bleeding or thromboembolism. Many factors contribute to this phenomenon, including an increasing age of pregnant women, co-morbidities, and an unhealthy lifestyle. The cardiovascular system is not only significantly challenged by physiological alterations in pregnancy but also by obstetric medication. Depending upon the severity of the underlying condition, pregnant women with cardiovascular disease should be managed by a multidisciplinary heart team in which anaesthesiologists play an important role. Profound knowledge of the cardiac pathophysiology is a prerequisite for the successful anaesthesiologic management of pregnant patients with cardiovascular disease. As there is no difference in general and regional anaesthesia regarding maternal outcomes, neuraxial anaesthesia using incremental techniques should be preferred for labour and (caesarean) delivery if not contraindicated by non-cardiac issues.