Obstetric epidural analgesia in aortic stenosis: a low-dose technique for labour and instrumental delivery

Severe subvalvular aortic stenosis in a pregnant woman

A 35-year-old pregnant female in her second trimester presented with heart failure manifestations with evidence of very severe fixed left ventricular outflow tract obstruction. The peak systolic gradient was 132 mmHg, which is the highest reported in the literature, secondary to congenital subaortic membrane. Similar case reports that we could find in the literature were reviewed to highlight the importance of such anomaly.

Vaginal delivery in a patient with severe aortic stenosis under epidural analgesia, a case report

BACKGROUND

A history of previous cardiac disease increases the maternal mortality risk by as much as 100%. There is no consensus on the absolute contraindications to vaginal delivery in valvular heart disease, but central regional anesthesia is traditionally considered contraindicated in patients with severe aortic stenosis.

CASE PRESENTATION

A 29-year-old primigravid woman with severe aortic stenosis was admitted to the obstetrics department for programmed labor induction. With epidural anesthesia and mini-invasive hemodynamic monitoring labor and operative vaginal delivery were well tolerated, and hemodynamic stability was always maintained.

CONCLUSIONS

Epidural analgesia and oxytocin induction are possible for the labor management of parturients with severe aortic stenosis given that continuous non-invasive followed by invasive hemodynamic monitoring can be provided and given the absence of any obstetric or cardiologic contraindications and the strong will of the patient.

Combined mitral and aortic stenosis in parturient: Anesthesia management for labor and delivery

Maternal heart disease complicates 0.2-3% of pregnancies. The optimal management of the pregnant patient with cardiac disease depends on the co-operative efforts of the obstetrician, the cardiologist and the anesthesiologist involved in peripartum care. A comprehensive understanding of physiology of pregnancy and pathophysiology of underlying cardiac disease is of primary importance in provision of obstetric analgesia or anesthesia for these high-risk groups of patients. We report a successful and uncomplicated use of epidural anesthesia for labor and delivery in patient with combined aortic and mitral stenosis.

Epidural analgesia and vaginal delivery in a patient with aortic stenosis and insufficiency

OBJECTIVE

To report a successful vaginal delivery using slow infusion of epidural analgesia in a patient with both severe aortic stenosis and insufficiency.

CLINICAL PRESENTATION AND INTERVENTION

A 26-year-old primigravid patient presented to our hospital for delivery. She had aortic stenosis and insufficiency due to rheumatic fever. Although the obstetrician recommended cesarean section owing to her cardiac status, she insisted upon vaginal delivery. We performed low-dose epidural analgesia with 10 ml of 0.125% ropivacaine and 20 μg fentanyl. She had spontaneous vaginal delivery without complication.

CONCLUSION

This case showed that in spite of the cardiac pathology, vaginal delivery under low-dose slow infusion of epidural analgesia was successful and therefore may be a safe alternative to cesarean section for cardiac patients.

Anaesthesia for the obstetric patient with (non-obstetric) systemic disease

The number of women with serious (non-obstetric) systemic diseases achieving pregnancy and requiring obstetric anaesthetic management is increasing. The conditions that are most likely to cause maternal morbidity and mortality are cardiac disease, respiratory disease, neuromuscular disease, haematological disease, connective and metabolic diseases and psychiatric conditions including substance abuse. This article discusses the anaesthetic management of the pregnant mother with such serious systemic diseases.

Peripartum anesthetic management of patients with aortic valve stenosis: a retrospective study and literature review

BACKGROUND

Anesthetic management of parturients with aortic stenosis is controversial. Early studies suggest maternal mortality was related to cardiac condition and anesthetic care. In this report, management of parturients with moderate or severe aortic stenosis in two institutions is compared, and published cases are reviewed.

METHODS

Peripartum anesthetic management of all parturients with moderate or severe aortic stenosis who gave birth between 1990 and 2005 at our institutions, is described. Patients with mild or non-valvular aortic stenosis were excluded.

RESULTS

There were 12 parturients, six with moderate and six with severe aortic stenosis. Two patients with moderate aortic stenosis were New York Heart Association (NYHA) classification II, the others were asymptomatic. Five patients with severe aortic stenosis were symptomatic (NYHA classification II or III). Two patients with moderate and three with severe aortic stenosis underwent cesarean delivery; epidural anesthesia was used for two. Two patients with moderate and all with serious aortic stenosis were observed postpartum for 24 to 48 h in a high-dependency unit. There were no severe maternal or neonatal complications.

CONCLUSIONS

Carefully titrated regional analgesia is usually well tolerated in patients undergoing vaginal or cesarean delivery even in the presence of severe aortic stenosis. Standard monitoring is usually adequate for vaginal delivery, but invasive monitoring may facilitate management in some patients. An arterial line allows close monitoring of systemic blood pressure. Facilities for close 24-48-h post-partum observation should be available. A multidisciplinary approach is needed.

Controversies in pregnancy and congenital heart disease

As increasing numbers of children with congenital heart disorders reach adulthood, the family physician, cardiologist, and obstetrician will increasingly be called upon to give advice regarding the safety of pregnancy. This need has been further highlighted by the recognition that maternal mortality associated with cardiac disease is rising. Unfortunately, this field of practice remains relatively "evidence-sparse" with many management decisions being guided by anecdote and "best guess" common sense. Not surprisingly, this results in many fundamental controversies over the optimal care these patients should receive. This article highlights, through the use of case histories, some of these contentious areas, reflecting the different manifestations of congenital maternal cardiac disease and highlighting the limitations of our knowledge.

Practical management of the parturient with congenital heart disease

Cardiac disease is becoming more common in women presenting for maternity care and is a major cause of maternal mortality in the UK. We present a review of the management of parturients with congenital heart disease, focusing on practical aspects and the problems that may be expected.

UK registry of high-risk obstetric anaesthesia: report on cardiorespiratory disease

Forms were sent to members of the Obstetric Anaesthetists' Association requesting information on cardiorespiratory disease in pregnancy. Reports of 274 pregnancies in 259 women were received over four years (1997-2000). There were 83 valve lesions, 52 complex congenital heart disease, 112 miscellaneous heart disease and 27 respiratory disease. Half the mothers were classified as New York Heart Association grade I, 29% grade II, 14% grade III, 5% grade IV and six unknown. Thirty-nine mothers were seen by an anaesthetist only just before delivery. Regional analgesia for labour was more likely to be planned for severe (82%) than for mild symptoms (55%; P=0.039), but severity of symptoms did not affect choice of anaesthesia for caesarean section. Eighty-one women were delivered by elective caesarean section, 59 by emergency caesarean section, 82 had spontaneous and 49 assisted vaginal delivery. Three women suffered miscarriages. Regional analgesia was used in 73% of vaginal deliveries, Entonox or pethidine in 15% and no analgesia in 12%. Spinal anaesthesia was used in 21% of caesarean sections, an incremental regional technique (incremental epidural or combined spinal-epidural) in 40% and general anaesthesia in 39%. Forty-three women were admitted to intensive care units electively and 10 unplanned. Ninety-five per cent survived pregnancy in the same state as antepartum, 2% deteriorated and seven died. Ninety-four per cent of babies (258 babies) were delivered in good condition, nine in poor condition and seven died. Despite lack of denominator data and potential biases among the reported cases, the Registry provides a valuable snapshot of current practice in the UK.

UK registry of high-risk obstetric anaesthesia: arrhythmias, cardiomyopathy, aortic stenosis, transposition of the great arteries and Marfan’s syndrome

The UK registry of high-risk obstetric anaesthesia was set up in late 1996 to collect reports of high-risk pregnancy, pool them into a central database and disseminate the results. At the time of analysis for this paper (December 31, 2001) 308 cardiorespiratory reports had been received. The five most common conditions, occurring in 125 cases (41% of the total), were arrhythmias (43 cases), cardiomyopathy (26 cases), aortic stenosis (24 cases), transposition of the great arteries (18 cases) and Marfan's syndrome (14 cases). We describe the features and management of these cases.