Anesthesia for open heart surgery in the pregnant patient

CPB-assisted aortic valve replacement in a pregnant 27-year-old with endocarditis

A 27-year-old, G(3)P( 2)A(0) female with acute Staph aureus (SA) endocarditis successfully underwent CPB-assisted aortic valve replacement with a bioprosthetic aortic valve at 22 weeks' gestation. This patient's presentation of acute endocarditis complicated by septic shock, congestive heart failure, severe aortic insufficiency, multiple septic embolic events and borderline renal failure appeared on the daunting background of chronic heavy tobacco usage, hepatitis C positivity, long-term IV drug abuse and a pregnancy into its twenty-second week. Optimal treatment strategies implemented for both mother and fetus throughout the perioperative period contributed to a successful outcome for both.

Cardiac operations during pregnancy: review of factors influencing fetal outcome

Women with underlying rheumatic heart disease, even if well compensated, can easily be affected by acute heart failure caused by out-of-the-ordinary cardiorespiratory requirements during pregnancy. In such cases, medical therapy is not always sufficient to drive a heart, and open heart operation might be necessary. Many factors associated with cardiac operations requiring cardiopulmonary bypass, such as hypothermia, can adversely affect both the mother and the fetus, but the morbidity and mortality rates are higher for the fetus than the mother. Because fetal heart tones were lost during cardiopulmonary bypass and were reheard in the intensive care unit in our case presentation, we have presumed that the loss of fetal heart tones should not always indicate fetal death and have discussed harmful factors in relation with the fetal morbidity and mortality in light of the literature.

Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996

The outcomes of cardiovascular operations during pregnancy, at delivery, and post partum were reviewed from published material in the period 1984-1996. Surgery during pregnancy resulted in fetal-neonatal morbidity and mortality of 9% and 30%, respectively, and in maternal morbidity and mortality of 24% and 6%, respectively. Duration of pregnancy at surgery and duration and temperature of cardiopulmonary bypass did not influence fetal-neonatal outcome. Maternal complications and mortality of surgery immediately after delivery were 29% and 12%, respectively, and for surgery performed with a postpartum interval the respective rates were 38% and 14%. Hospitalization after week 27 of gestation and extreme emergency contributed significantly to poor maternal outcome. Maternal deaths were reported in 9% of valvular procedures and in 22% of aortic or arterial dissection repairs and pulmonary embolectomies. Fetal-neonatal risks of maternal surgery during pregnancy are high and unpredictable. Maternal risks of cardiovascular procedures during pregnancy are moderate, significantly increase if an operation is performed at or after delivery, and, overall, should be considered as higher than those in nonpregnant cardiovascular surgical patients.

Cardiopulmonary bypass in pregnancy

The cardiopathic patient can sustain acute heart failure during pregnancy. In such cases, if open heart operation is necessary to save the patient's life, the fetus could be seriously compromised after exposure to cardiopulmonary bypass. From 1958 to 1992, 69 reports of cardiac operations during pregnancy with the aid of cardiopulmonary bypass have been published. Maternal mortality was 2.9%. Embryofetal mortality was 20.2%. Examining only the last 40 patients, maternal and embryofetal mortality were 0.0% and 12.5%, respectively. Embryofetal mortality was 24.0% when hypothermia was used, compared with 0.0% while operating in normothermia. Maternal mortality did not change. The use of hypothermia during cardiopulmonary bypass provoked uterine contractions in several patients. Hypothermia decreases O2 exchange through the placenta. Pump flow and mean arterial pressure during cardiopulmonary bypass seem to be the most important parameters that influence fetal oxygenation. We speculate that cardiac operation is not a contraindication to pregnancy prolongation.

Valvular heart surgery during pregnancy

The pathophysiology of mitral and valvular heart disease is presented with an emphasis on the relationship of these conditions to pregnancy. Management options are discussed. Special attention is directed to patients who have prosthetic valves in place and who become pregnant. The care of this group of patients may be difficult, and treatment strategies are presented.

Perioperative care of the pregnant surgical patient

Successful perioperative management of the pregnant surgical patient requires a multidisciplinary nursing approach to decrease perinatal morbidity and mortality. A comprehensive perioperative patient care plan and coordination with obstetric and neonatal team members enhance the surgical outcome for both the mother and her child.

Congenital aortic stenosis and pregnancy--a reappraisal

OBJECTIVE

This study was performed to determine the maternal and fetal outcome in pregnant patients with congenital aortic stenosis without previous valvular replacement.

STUDY DESIGN

A retrospective review of 25 pregnancies in 13 patients delivered at our centers from September 1976 to September 1992 was undertaken.

RESULTS

Five (38%) patients had associated congenital heart lesions, three (23%) had severe stenosis (echocardiographically estimated valve area < or = 0.7 cm2), two had prior open aortic valve commissurotomy, and one had balloon valvuloplasty during pregnancy. There were no maternal deaths. Of the 25 pregnancies, five (20%) resulted in therapeutic abortions. There was no perinatal mortality, preterm labor, or increased incidence of pregnancy complications or fetal growth retardation in the remaining 20 pregnancies. One infant (5%) had congenital heart disease.

CONCLUSION

Pregnancy outcome is generally satisfactory in patients with congenital aortic stenosis.

Open mitral commissurotomy during pregnancy. A case study

Pregnancy increases cardiovascular stress and can cause an asymptomatic woman with mitral disease to become symptomatic. Correction of the mitral defect by open heart surgery may be necessary. In cases where open heart surgery is conducted, special nursing considerations for the pregnant woman and her fetus must be recognized to ensure optimum maternal and fetal outcome. Therefore, a multidisciplinary nursing approach is indicated. A case study and nursing care plan are presented.

Anesthesia, cardiopulmonary bypass, and the pregnant patient

For the perioperative management of pregnant patients with severe cardiac or aortic disease who require a cardiac surgical procedure and cardiopulmonary bypass, a close, cohesive, working relationship must exist among several medical and surgical specialties. For appropriate management, the well-being of both the mother and the fetus must be considered. The best interests of the mother and the fetus may not coincide, and optimal therapy for one may be inappropriate for the other. We present 10 cases of severe cardiac or aortic disease in pregnant women who required surgical intervention. Eight patients underwent cardiopulmonary bypass during pregnancy, and two patients had cesarean section performed immediately before cardiopulmonary bypass. We also discuss the pertinent pharmacologic aspects related to the perioperative period and the management of cardiopulmonary bypass for the pregnant patient.