Indian Journal of Anaesthesia  
About us | Editorial board | Search | Ahead of print | Current Issue | Past Issues | Instructions
Home | Login  | Users Online: 1259  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size    




 
 Table of Contents    
REVIEW ARTICLE
Year : 2018  |  Volume : 62  |  Issue : 9  |  Page : 682-690  

Neuraxial anaesthesia in parturient with cardiac disease


Department of Cardiac Anaesthesia Cardiothoracic Sciences Centre, AIIMS, New Delhi, India

Date of Web Publication10-Sep-2018

Correspondence Address:
Prof. Minati Choudhury
Department of Cardiac Anaesthesia Cardiothoracic Sciences Centre, AIIMS, New Delhi - 110 029
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_474_18

Rights and Permissions
 


Parturient with corrected or uncorrected cardiac problem may undergo neuraxial anaesthesia for several reasons and in different trimesters. The altered physiological state in a parturient is further deranged in the presence of a cardiovascular lesion, producing the added risk to the parturient undergoing a neuraxial block. A detailed evaluation, knowledge regarding cardiovascular disease state, more vigilant monitoring, and a team approach can lead to a successful outcome.

Keywords: Anticoagulation, heart disease, neuraxial anaesthesia, pregnancy


How to cite this article:
Choudhury M. Neuraxial anaesthesia in parturient with cardiac disease. Indian J Anaesth 2018;62:682-90

How to cite this URL:
Choudhury M. Neuraxial anaesthesia in parturient with cardiac disease. Indian J Anaesth [serial online] 2018 [cited 2018 Sep 19];62:682-90. Available from: http://www.ijaweb.org/text.asp?2018/62/9/682/240830




   Introduction Top


Heart disease is the third most common cause of maternal death, and 20% of the patients suffering from cardiac disease have severe haemodynamic instability related to the underlying cardiac problem.[1] Parturients with cardiac disease often undergo surgery and neuraxial anaesthesia for various reasons and in different trimesters. There are few reports in the literature describing the management of parturients with cardiac disease during neuraxial anaesthesia. This article reviews current data and discusses important aspects of heart disease in relevance to neuraxial anaesthesia in a parturient. As labour and delivery are the most important aspect of pregnancy, the major focus of this article is on this segment.

The physiological changes occurring in the cardiovascular system due to pregnancy are exaggerated in the presence of a cardiac lesion.[2],[3] These cardiovascular changes along with coagulation abnormalities may discourage the use of neuraxial blockade due to the sympathetic blockade produced with the resulting haemodynamic changes. The author searched electronic databases including the following: MedLine, PubMed, and the Cochrane Central register of controlled clinical trials (until June 2018) and applied the following search terms: neuraxial block, spinal and epidural anaesthesia (EA), heart disease, surgery, and pregnant patient. Only the relevant English literature reports are considered in this review.

Approximately 60%–80% of parturients suffering from cardiac disease have congenital heart disease.[3] The commonest ones are tetralogy of Fallot, septal defects, and Eisenmenger's syndrome. Valvular heart disease comprises 15% cases, of which rheumatic mitral stenosis is the most common. [Table 1] lists the common cardiac diseases in which successful use of neuraxial anaesthesia has been performed.
Table 1: Common cardiovascular conditions in a parturient

Click here to view



   Physiological Changes during Pregnancy That Can Have Impact on Neuraxial Block Top


The four major changes that are important in the presence of cardiovascular disease are as follows:

  1. Normal pregnancy is associated with a 30%–50% increase in blood volume, corresponding increase in plasma volume, and increase in cardiac output (CO). There is dilutional anaemia in spite of an increase in red cell mass over the third trimester because of an increase in plasma volume.[2] Stroke volume (SV) normally increases by 25%–35% with the remaining increase in CO being accounted for rise in heart rate (HR). Cardiac compromise with pulmonary oedema or biventricular failure may present in parturients earlier making the management of neuraxial anaesthesia more difficult. The early signs of cardiac compromise may become apparent in the first trimester and peak during second trimester, around 24 weeks when CO reaches the maximum and remains high till delivery
  2. There is a progressive decrease in systemic vascular resistance (SVR) throughout gestation, and hence mean arterial pressure (MAP) is preserved at normal values despite an increase in CO. This has importance in patients with aortic stenosis and those with right to left shunt lesions
  3. During labour, CO further increases by 10%-20% due to pain, anxiety, and autotransfusion during uterine contractions. SV and HR increase and decrease with each contraction, with peaks as high as 50% above the prelabour values. In the immediate postpartum period, CO peaks as the evacuated uterus contracts and blood from myometrial veins is autotransfused into the systemic venous system and gradually decreases thereafter. After vaginal delivery, the increase in CO and SV persists for 60–90 min, whereas HR decreases and blood pressure remains unchanged. After caesarean delivery, MAP remains unaltered and CO increases by 30%–50%, compared with predelivery values. These changes usually persist for 10–15 min and may precipitate pulmonary oedema in a decompensated heart
  4. Hypercoagulability associated with pregnancy and the possible need for anticoagulation (e.g., patients in chronic atrial fibrillation (AF), prosthetic heart valve, and pulmonary thromboembolism) increase the risk of thrombosis or bleeding during neuraxial block. [Table 2] represents the major haemodynamic changes in different cardiac conditions.


Apart from the physiological responses towards pregnancy and delivery, the other factors that affect haemodynamic status during neuraxial block include gestational age, intravascular fluid status, positioning of the patient, and the route, dose, and choice of uterotonic agents.
Table 2: Haemodynamic state in different cardiac diseases

Click here to view



   Indications and Contraindications of Neuraxial Block Top


Not all the parturients suffering from cardiac disease are fit to undergo a neuraxial block. The following lines depict some indications and contraindications of neuraxial anaesthesia in parturients with cardiac disease.

Indications

  1. Patient's demand
  2. Associated preeclampsia
  3. Breech delivery or multiple pregnancy
  4. Trial of pregnancy and labour after previous caesarean delivery
  5. Obese parturient.


Contraindications

  1. Patient refusal
  2. Expected severe bleeding when on anticoagulant treatment
  3. Uncontrolled haemorrhage
  4. Severe hypovolemia
  5. Severe spinal deformity.



   Preanaesthetic Cosiderations Top


Parturient may require neuraxial anaesthesia during labour, delivery, or during the second trimester for procedures such as appendicectomy and ovarian cyst removal. Many reports have been published of successful administration of neuraxial blockade in parturient with cardiac disease coming for these procedures.

A detailed evaluation of the underlying cardiac problem including risk stratification is essential to consider for extensive monitoring/switch over to general anaesthesia and need for the help of a specialised team with experience of cardiovascular anaesthesia and intraoperative echocardiography. Pertinent cardiac testing (angiography, computerised tomography, or magnetic resonance imaging) apart from the routine echocardiography can determine the disorder that can affect the anaesthesia management. If available, serum β-type natriuretic peptide can be done for the parturient with the potential to develop heart failure during additional stress of surgery or anaesthesia. Patients with coartation of aorta are at increased risk of hypertension and ecampsia and neuraxial block should be avoided. Bleeding at the time of surgery/delivery is more common in patients having cyanotic heart disease and/or on anticoagulation.

Infective endocarditis (IE) prophylaxis is needed in parturient with highest risk of IE, for example, those with prosthetic heart valve, history of IE before, and with some complex congenital lesions. In high-risk parturient, the preferred regime is ampicillin 1.5 mg/kg (maximum 120 mg) given intravenously 30 min before neuraxial block followed by ampicillin 1 g given intravenously/intramuscularly or amoxicillin 1 g given orally 6 h later.[4] The parturient needs to undergo some risk assessment scores, for example, CARPREG or ZAHARA and KHAIRY score to predict maternal cardiovascular events.[4] Patients with NYHA class >II, with a prior cardiac event (heart failure, stroke, or arrhythmia), critical mitral or aortic stenosis, severe left ventricular dysfunction, presence of a valve prosthesis or severe pulmonary regurgitation, and smoking history have an increased risk of both maternal and neonatal events during the course of pregnancy, labour, and delivery.


   Monitoring Top


The extensiveness of monitoring depends on the severity of disease. In case of mild disease, monitoring includes noninvasive blood pressure measurement, electrocardiography (ECG), tocodynamometry, and foetal HR monitoring. In moderate to severe disease, the following additional monitoring aids may be applied depending on the availability. External defibrillator paddles should be placed before surgery in patients especially prone to intractable tachyarrhythmia. Filter in all intravenous lines in patients with shunt lesion to prevent paradoxical air embolism.

Pulse oxymetry: For rapid detection of desaturation, for example, tetralogy of Fallot's patient developing hypercyanotic spell.

ECG: Continuous five lead monitoring and ST segment monitoring is required for the detection of myocardial ischemia in patients with aortic stenosis (AS), coronary artery disease (CAD), or hypertrophic obstructive cardiomyopathy (HOCM) or arrhythmia in other patients.

Intra-arterial catheter: In moderate to severe disease patients for minute-to-minute monitoring of arterial pressure, arterial blood gas sampling, and management of vasoactive drugs, if any.

Central venous pressure (CVP): In high-risk patients especially those who are prone to hypotension, pulmonary oedema, or peripartum haemorrhage, a CVP line is a guide to fluid therapy and administration of inotropes and vasodilators.

Pulmonary artery catheter: Rarely used, for example, in a patient with severe pulmonary hypertension in which it guides titration of pulmonary vasodilators.

Echocardiography: Have some role in assessment of ventricular function both pre and post surgery or delivery and direct visualisation of the ventricles to know the volume status.


   Neuraxial Anaesthesia Top


Neuraxial anaesthesia [Table 3] is the preferred technique if (a) the surgery is nonemergent and (b) the cardiac disease is mild to moderate. The indications are (1) in the second trimester: torsion ovarian cyst, hysterotomy, lower limb surgeries, etc; (2) and most importantly for conduct of labour and delivery. It is preferred over general anaesthesia for the following reasons:
Table 3: Types of neuraxial anaesthesia, advantages and disadvantages, drug, and doses

Click here to view


  1. Attenuates pain
  2. Decreases the release of catecholamines
  3. Allows a passive stage 2 of labour
  4. Provides adequate surgical anaesthesia.


Mitral stenosis is the commonest lesion in pregnancy in our country. The symptoms depend on the severity of stenosis. However, the usual features are breathlessness, palpitation, chest pain, haemoptysis, pulmonary oedema, and thromboembolism. Knowing the severity of mitral stenosis (MS) is of paramount importance [Table 4] to manage neuraxial block during labour and delivery. AF is common in parturients. An increase in HR decreases left ventricular filling time and thereby a fall in CO. This in combination with an increase in plasma volume as well as increase in preload (due to autotransfusion) following delivery may lead to pulmonary oedema.[5] The anaesthetic goals in these parturients are as follows: maintenance of acceptable HR, immediate treatment of acute AF, avoidance of aortocaval compression, maintenance of adequate venous return and normal blood pressure, adequate analgesia, as well as avoidance of hypoxia, hypercarbia, and acidosis.
Table 4: Gradation of severity of mitral stenosis

Click here to view


Management of labour

Combined spinal epidural with intrathecal opioid such as fentanyl in the first stage followed by titrated dose of local anaesthetic (LA) in the second stage is beneficial to prevent stress-related tachycardia. The addition of fentanyl to dilute LA mixture enhances the quality of analgesia without contributing to the sympathetic blockade. The fall in SVR in this stage is managed with small bolus (50–100 μg) of phenylephrine. Ephedrine is avoided unless there is relative bradycardia (HR <70/min). For a critically ill parturient, opioid alone may be administered through epidural/intrathecal route. Adequate perineal and segmental analgesia reduce stress-induced increase in HR and potentiate the urge to push. This allows foetal descent to be accomplished by uterine contractions and avoiding the deleterious effects of Valsalva maneuver during the second stage of labour. Low SA (when EA is not used) may be administered for a controlled second stage and delivery.

Management of caesarian delivery

In moderate to severe disease, SA is avoided due to acute fall in SVR following the block. EA with titrated dose of LA is preferred over SA as the former results in better control of haemodynamic state due to slower onset of blockade. Prophylactic use of vasopressors and intravascular volume loading are best avoided. A careful titration of anaesthetic and analgesic dose allows judicious and appropriate volume supplementation in a critical parturient. These parturients are prone to hypotension not only because of EA, but also due to venous pooling, prior beta-adrenergic blockade, and diuretic therapy. About 50–100 μg of phenylephrine or 20–40 μg of metaraminol is used in case of hypotension with little or no untoward effect on uteroplacental circulation. Caution use of oxytocin is warranted.

Few details about the anticipated changes during neuraxial block in parturients with other cardiovascular disease, anaesthetic goals, and neuraxial block of choice that anaesthesiologists should know are described in [Table 5].
Table 5: Physiologic changes during neuraxial block, anaesthetic goal, and neuraxial block of choice

Click here to view



   Special Groups Top


Congenital cardiac lesions with a palliative surgery

Successful palliative repair for a cardiac lesion before pregnancy is associated with some degree of maternal foetal risk even in best of hands. There are few reports available describing the successful use of EA or combined spinal epidural anaesthesia in these lesions. [Table 6] represents the most common palliative intracardiac shunt in which successful pregnancy and delivery happened.[29],[30],[31],[32]
Table 6: Palliative cardiac shunt lesions

Click here to view


Prosthetic heart valve and anticoagulation

Parturient receives anticoagulation for several reasons, of which prosthetic heart valve is one. Chronic use of anticoagulation may give rise to thrombocytopaenia. The ideal level of platelets before neuraxial block should be more than 100,000/mm−3 according to different studies. There are some suggested durations for discontinuation of anticoagulant administration before and after neuraxial block and epidural catheter [Table 7].[33],[34],[35],[36]
Table 7: Duration to discontinue/continue anticoagulant before/after neuraxial block

Click here to view


Postoperative analgesia in these cases is usually with an opioid or α-agonist or a combination of opioid and nonsteroidal anti-inflammatory drugs intravenously. Patient-controlled analgesia is an alternative mode of analgesia in these group of patients.


   Summary Top


Optimal management during neuraxial anaesthesia requires a thorough assessment of the anatomic and functional capacity of the diseased heart along with an analysis of how the described major physiologic changes are likely to affect the specific limitations imposed by the intrinsic disease, patient's tolerance to pain during labour or surgery, impact of uterine contraction-induced autotransfusion, postpartum changes induced by relief of vena caval obstruction, potential for postpartum haemorrhage, and use of uterine oxytocic agents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Elkayam U, Goland S, Pieper PG, Silverside CK. High-risk cardiac disease in pregnancy: Part I. J Am Coll Cardiol 2016;68:396-410.  Back to cited text no. 1
    
2.
Talbot L, Maclennan K. Physiology of pregnancy. Anaesth Intensive Care med 2016; 17:341-5.  Back to cited text no. 2
    
3.
Perloff JK. Pregnancy and congenital heart disease. J Am Coll Cardiol 1991; 18:340-2.  Back to cited text no. 3
    
4.
European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM), Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: The Task Force on the Management of Cardiovascular Diseases During Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:3147-97.  Back to cited text no. 4
    
5.
Ziskind Z, Etchin A, Frenkel Y, Mashiach S, Lusky A, Goor DA, et al. Epidural anesthesia with the trendelenburg position for cesarean section with or without a cardiac surgical procedure in patients with severe mitral stenosis: A hemodynamic study. J Cardiothorac Anesth 1990; 4:354-9.  Back to cited text no. 5
    
6.
Rayburn WF, Fontana ME. Mitral valve prolapse and pregnancy. Am J Obstet Gynecol 1981; 141:9-11.  Back to cited text no. 6
    
7.
Sugrue D, Blake S, MacDonald D. Pregnancy complicated by maternal heart disease at the National Maternity Hospital, Dublin, Ireland, 1969 to 1978. Am J Obstet Gynecol 1981; 139:1-6.  Back to cited text no. 7
    
8.
Choi HJ, Chui L, Hurd JM, Tremper KK. Epidural anesthesia for a woman with severe aortic stenosis undergoing a cesarean section. Anesthesiol Rev 1992; 19:61.  Back to cited text no. 8
    
9.
Sen S, Chatterjee S, Mazumder P, Mukherji S. Epidural anesthesia: A safe option for cesarean section in parturient with severe pulmonary hypertension. J Nat Sci Biol Med 2016; 7:182-5.  Back to cited text no. 9
    
10.
Chohan U, Afshan G, Mone A. Anaesthesia for caesarean section in patients with cardiac disease. J Pak Med Assoc 2006; 56:32-8.  Back to cited text no. 10
    
11.
Duan R, Xu X, Wang X, Yu H, You Y, Liu X, et al. Pregnancy outcome in women with eisenmenger's syndrome: A case series from West China. BMC Pregnancy Childbirth 2016; 16:356.  Back to cited text no. 11
    
12.
Ghai B, Mohan V, Khetarpal M, Malhotra N. Epidural anesthesia for cesarean section in a patient with Eisenmenger's syndrome. Int J Obstet Anesth 2002;11:44-7  Back to cited text no. 12
    
13.
Atanassoff PG, Schmid ER, Jenni R, Arbenz U, Alon E, Pasch T. Epidural anesthesia for a cesarean section in a patient with pulmonary atresia and ventricular septal defect. J Clin Anesth 1991; 3:399-402.  Back to cited text no. 13
    
14.
Solanki SL, Jain A, Singh A, Sharma A. Low-dose sequential combined-spinal epidural anesthesia for Cesarean section in patient with uncorrected tetrology of Fallot. Saudi J Anaesth 2011; 5:320-2.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Sharma SK, Gambling DR, Gajraj NM, Truong C, Sidawi EJ. Anesthetic management of a parturient with mixed mitral valve disease and uncontrolled atrial fibrillation. Int J Obstet Anesth 1994; 3:157-62.  Back to cited text no. 15
    
16.
Krenz EI, Hart SR, Russo M, Alkadri M. Epidural anesthesia for cesarean delivery in a patient with severe pulmonary artery hypertension and a right-to-left shunt. Ochsner J 2011; 11:78-80.  Back to cited text no. 16
    
17.
Slomka F, Salmeron S, Zetlaoui P, Cohen H, Simonneau G, Samii K, et al. Primary pulmonary hypertension and pregnancy: Anesthetic management for delivery. Anesthesiology 1988; 69:959-61.  Back to cited text no. 17
    
18.
Hands ME, Johnson MD, Saltzman DH, Rutherford JD. The cardiac, obstetric, and anesthetic management of pregnancy complicated by acute myocardial infarction. J Clin Anesth 1990; 2:258-68.  Back to cited text no. 18
    
19.
Rosenlund RC, Marx GF. Anaesthetic management of a parturient with prior myocardial infarction and coronary artery bypass graft. Can J Anaesth 1988; 35:515-7.  Back to cited text no. 19
    
20.
Ruys TP, Bekkers JA, Duvekot JJ, Roos-Hesselink JW. A pregnant patient with native aortic coarctation and aneurysm. Aorta (Stamford) 2014; 2:110-2.  Back to cited text no. 20
    
21.
Kim G, Ko JS, Choi DH. Epidural anesthesia for cesarean section in a patient with Marfan syndrome and dural ectasia – A case report- Korean J Anesthesiol 2011; 60:214-6.  Back to cited text no. 21
    
22.
Indira K, Sanjeev K, Sunanda G. Sequential combined spinal epidural anaesthesia for cesarian section inperipartum cardiomyopathy. Ind J Anaesth 2007; 51:137.  Back to cited text no. 22
    
23.
Ituk US, Habib AS, Polin CM, Allen TK. Anesthetic management and outcomes of parturients with dilated cardiomyopathy in an academic centre. Can J Anaesth 2015; 62:278-88.  Back to cited text no. 23
    
24.
Sinha R, Rewari V. Takayasu aortoarteritis with dilated cardiomyopathy: Anesthetic management of labor analgesia. Acta Anaesthesiol Taiwan 2010; 48:99-102.  Back to cited text no. 24
    
25.
Pryn A, Bryden F, Reeve W, Young S, Patrick A, McGrady EM, et al. Cardiomyopathy in pregnancy and caesarean section: Four case reports. Int J Obstet Anesth 2007; 16:68-73.  Back to cited text no. 25
    
26.
Shnaider R, Ezri T, Szmuk P, Larson S, Warters RD, Katz J, et al. Combined spinal-epidural anesthesia for cesarean section in a patient with peripartum dilated cardiomyopathy. Can J Anaesth 2001; 48:681-3.  Back to cited text no. 26
    
27.
Kasai H, Gohda Y, Sasaki K, Kemmotsu O. Anesthetic management of caesarean section in a patient with primary pulmonary hypertension. Masui 1988; 37:476-82.  Back to cited text no. 27
    
28.
Weitzel NS, Gravlee GP. Cardiac disease in the obstetric patient. In: Bucklin BA, Gambling DR, Wlody D, editors. A Practical Approach to Obstetric Anesthesia. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 403-34.  Back to cited text no. 28
    
29.
Camann WR, Goldman GA, Johnson MD, Moore J, Greene M. Cesarean delivery in a patient with a transplanted heart. Anesthesiology 1989; 71:618-20.  Back to cited text no. 29
    
30.
Holzman RS, Nargozian CD, Marnach R, McMillan CO. Epidural anesthesia in patients with palliated cyanotic congenital heart disease. J Cardiothorac Vasc Anesth 1992; 6:340-3.  Back to cited text no. 30
    
31.
Carp H, Jayaram A, Vadhera R, Nichols M, Morton M. Epidural anesthesia for cesarean delivery and vaginal birth after maternal Fontan repair: Report of two cases. Anesth Analg 1994; 78:1190-2.  Back to cited text no. 31
    
32.
Monteiro RS, Dob DP, Cauldwell MR, Gatzoulis MA. Anaesthetic management of parturients with univentricular congenital heart disease and the Fontan operation. Int J Obstet Anesth 2016; 28:83-91.  Back to cited text no. 32
    
33.
Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama CM, et al. Regional anaesthesia and antithrombotic agents: Recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 2010; 27:999-1015.  Back to cited text no. 33
    
34.
Osta WA, Akbary H, Fuleihan SF. Epidural analgesia in vascular surgery patients actively taking clopidogrel. Br J Anaesth 2010; 104:429-32.  Back to cited text no. 34
    
35.
Bates SM, Greer IA, Hirsh J, Ginsberg JS. Use of antithrombotic agents during pregnancy: The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004; 126:627S-44S.  Back to cited text no. 35
    
36.
Furui T, Kurauchi O, Oguchi H, Nomura S, Mizutani S, Tomoda Y, et al. Pregnancy and successful delivery in a patient with triple heart valve prosthesis. Int J Gynaecol Obstet 1993;41:89-92.  Back to cited text no. 36
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
    Physiological Ch...
    Indications and ...
    Preanaesthetic C...
   Monitoring
    Neuraxial Anaest...
   Special Groups
   Summary
    References
    Article Tables

 Article Access Statistics
    Viewed289    
    Printed2    
    Emailed0    
    PDF Downloaded326    
    Comments [Add]    

Recommend this journal