Anesthesia for labor and delivery in high-risk heart disease: General considerations
- Katherine W Arendt, MD
Katherine W Arendt, MD
- Associate Professor of Anesthesiology
- Mayo Clinic
- Section Editors
- David L Hepner, MD
David L Hepner, MD
- Section Editor — Obstetric Anesthesia
- Associate Professor of Anaesthesia
- Harvard Medical School
- Susan M Ramin, MD
Susan M Ramin, MD
- Section Editor — Obstetrics
- The American Board of Obstetrics and Gynecology (ABOG)
- Heidi M Connolly, MD, FASE
Heidi M Connolly, MD, FASE
- Section Editor — Congenital Heart Disease
- Professor of Medicine
- Mayo Medical School
- Jonathan B Mark, MD
Jonathan B Mark, MD
- Section Editor — Cardiac Anesthesiology
- Professor of Anesthesiology
- Duke University Medical Center
- Chief, Anesthesiology Service
- Veterans Affairs Medical Center
Cardiovascular disease is now the leading cause of maternal mortality in the developed world [1-3]. Although the incidence of pregnancy among women with congenital heart disease is increasing, the main causes of cardiac death in pregnancy are acquired heart disease: myocardial infarction, aortic dissection, and cardiomyopathy .
Anesthetic management of the pregnant woman with high-risk cardiovascular disease requires an understanding of the individual patient's cardiac anatomy and pathophysiology; how the physiologic changes associated with pregnancy, labor, and delivery have affected the patient; and the hemodynamic alterations that may be induced by the choices of analgesic or anesthetic techniques. Ideally, an individualized management plan is developed in the antepartum period by a team of providers (cardiologist, obstetrician, and anesthesiologist) . Interdisciplinary communication and preparation are critically important since peripartum obstetric and cardiac complications may require rapid intervention.
This topic will discuss general considerations in the anesthetic management of the obstetric patient with high-risk acquired or congenital cardiovascular disease, emphasizing methods to minimize peripartum risk while providing optimal anesthetic care. All other aspects of management of heart disease during pregnancy, including specific cardiac pathology, are discussed separately (see "Acquired heart disease and pregnancy" and "Pregnancy in women with congenital heart disease: General principles"). Basic anesthetic considerations for obstetric patients also apply to those with cardiovascular disease. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics" and "Pharmacologic management of pain during labor and delivery" and "Neuraxial analgesia for labor and delivery (including instrumented delivery)".)
HEMODYNAMIC CHANGES DURING PREGNANCY, LABOR, AND DELIVERY
Understanding the hemodynamic changes related to pregnancy, labor, and delivery is essential so clinicians can anticipate which cardiac conditions predispose to decompensation in the peripartum period and select appropriate anesthetic monitoring and techniques to minimize this risk.
Antepartum — Cardiovascular and hemodynamic changes begin as early as the fourth week of gestation and persist for several months postpartum. Systemic vascular resistance (SVR) decreases, heart rate (HR) increases by 15 to 20 beats/minute, and preload increases due to an increase in blood volume. These changes result in a 30 to 50 percent increase in cardiac output (CO) above baseline. A physiologic dilutional anemia also develops. Cardiovascular and hemodynamic adaptations to normal pregnancy are summarized in the figures (figure 1A-C) and discussed in detail separately. (See "Maternal cardiovascular and hemodynamic adaptations to pregnancy".)
- Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010; 116:1302.
- Cantwell R, Clutton-Brock T, Cooper G, et al. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118 Suppl 1:1.
- Creanga AA, Berg CJ, Syverson C, et al. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015; 125:5.
- European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM), 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.
- Ueland K, Hansen JM. Maternal cardiovascular dynamics. II. Posture and uterine contractions. Am J Obstet Gynecol 1969; 103:1.
- Kjeldsen J. Hemodynamic investigations during labour and delivery. Acta Obstet Gynecol Scand Suppl 1979; 89:1.
- Tihtonen K, Kööbi T, Yli-Hankala A, Uotila J. Maternal hemodynamics during cesarean delivery assessed by whole-body impedance cardiography. Acta Obstet Gynecol Scand 2005; 84:355.
- Niswonger JW, Langmade CF. Cardiovascular changes in vaginal deliveries and cesarean sections. Am J Obstet Gynecol 1970; 107:337.
- Ueland K, Gills RE, Hansen JM. Maternal cardiovascular dynamics. I. Cesarean section under subarachnoid block anesthesia. Am J Obstet Gynecol 1968; 100:42.
- Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001; 104:515.
- Khairy P, Ouyang DW, Fernandes SM, et al. Pregnancy outcomes in women with congenital heart disease. Circulation 2006; 113:517.
- van Mook WN, Peeters L. Severe cardiac disease in pregnancy, part I: hemodynamic changes and complaints during pregnancy, and general management of cardiac disease in pregnancy. Curr Opin Crit Care 2005; 11:430.
- Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
- Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J 2007; 28:230.
- Jastrow N, Meyer P, Khairy P, et al. Prediction of complications in pregnant women with cardiac diseases referred to a tertiary center. Int J Cardiol 2011; 151:209.
- Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 2010; 31:2124.
- Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation 2008; 118:e714.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:e521.
- Fayad G, Larrue B, Modine T, et al. Extracorporeal membrane oxygenation in severe acute respiratory failure in postpartum woman with rheumatic mitral valve disease: benefit, factors furthering the success of this procedure, and review of the literature. J Extra Corpor Technol 2007; 39:112.
- Rasmusson K, Brunisholz K, Budge D, et al. Peripartum cardiomyopathy: post-transplant outcomes from the United Network for Organ Sharing Database. J Heart Lung Transplant 2012; 31:180.
- Brar N, Garabedian A, Moshiyakhov M, et al. Peripartum cardiomyopathy and cardiogenic shock supported with percutaneous left ventricular assist device. Cath Lab Digest 2012; 20 http://www.cathlabdigest.com/articles/Peripartum-Cardiomyopathy-Cardiogenic-Shock-Supported-Percutaneous-Left-Ventricular-Assist- (Accessed on June 23, 2016).
- LaRue S, Shanks A, Wang IW, et al. Left ventricular assist device in pregnancy. Obstet Gynecol 2011; 118:426.
- Ford AA, Wylie BJ, Waksmonski CA, Simpson LL. Maternal congenital cardiac disease: outcomes of pregnancy in a single tertiary care center. Obstet Gynecol 2008; 112:828.
- Maxwell BG, El-Sayed YY, Riley ET, Carvalho B. Peripartum outcomes and anaesthetic management of parturients with moderate to complex congenital heart disease or pulmonary hypertension*. Anaesthesia 2013; 68:52.
- Goldszmidt E, Macarthur A, Silversides C, et al. Anesthetic management of a consecutive cohort of women with heart disease for labor and delivery. Int J Obstet Anesth 2010; 19:266.
- Stevenson RE, Burton OM, Ferlauto GJ, Taylor HA. Hazards of oral anticoagulants during pregnancy. JAMA 1980; 243:1549.
- Hall JG, Pauli RM, Wilson KM. Maternal and fetal sequelae of anticoagulation during pregnancy. Am J Med 1980; 68:122.
- Weis FR Jr, Markello R, Mo B, Bochiechio P. Cardiovascular effects of oxytocin. Obstet Gynecol 1975; 46:211.
- Secher NJ, Arnsbo P, Wallin L. Haemodynamic effects of oxytocin (syntocinon) and methyl ergometrine (methergin) on the systemic and pulmonary circulations of pregnant anaesthetized women. Acta Obstet Gynecol Scand 1978; 57:97.
- Ramsey PS, Hogg BB, Savage KG, et al. Cardiovascular effects of intravaginal misoprostol in the mid trimester of pregnancy. Am J Obstet Gynecol 2000; 183:1100.
- O'Leary AM. Severe bronchospasm and hypotension after 15-methyl prostaglandin F(2alpha) in atonic post partum haemorrhage. Int J Obstet Anesth 1994; 3:42.
- Andersen LH, Secher NJ. Pattern of total and regional lung function in subjects with bronchoconstriction induced by 15-me PGF2 alpha. Thorax 1976; 31:685.
- Secher NJ, Thayssen P, Arnsbo P, Olsen J. Effect of prostaglandin E2 and F2alpha on the systemic and pulmonary circulation in pregnant anesthetized women. Acta Obstet Gynecol Scand 1982; 61:213.
- Abouleish E. Postpartum hypertension and convulsion after oxytocic drugs. Anesth Analg 1976; 55:813.
- McCubbin JM, Sibai BM, Ardella TN, Anderson GD. Cardiopulmonary arrest due to acute maternal hypermagnesaemia. Lancet 1981; 1:1058.
- Ellis JE, Shah MN, Briller JE, et al. A comparison of methods for the detection of myocardial ischemia during noncardiac surgery: automated ST-segment analysis systems, electrocardiography, and transesophageal echocardiography. Anesth Analg 1992; 75:764.
- Leung JM, Voskanian A, Bellows WH, Pastor D. Automated electrocardiograph ST segment trending monitors: accuracy in detecting myocardial ischemia. Anesth Analg 1998; 87:4.
- Slogoff S, Keats AS, David Y, Igo SR. Incidence of perioperative myocardial ischemia detected by different electrocardiographic systems. Anesthesiology 1990; 73:1074.
- London MJ, Hollenberg M, Wong MG, et al. Intraoperative myocardial ischemia: localization by continuous 12-lead electrocardiography. Anesthesiology 1988; 69:232.
- Hamlyn EL, Douglass CA, Plaat F, et al. Low-dose sequential combined spinal-epidural: an anaesthetic technique for caesarean section in patients with significant cardiac disease. Int J Obstet Anesth 2005; 14:355.
- Oxorn D. The risks of central neuraxial anesthesia. Anesthesiology 1998; 88:272.
- Ioscovich AM, Goldszmidt E, Fadeev AV, et al. Peripartum anesthetic management of patients with aortic valve stenosis: a retrospective study and literature review. Int J Obstet Anesth 2009; 18:379.
- Autore C, Brauneis S, Apponi F, et al. Epidural anesthesia for cesarean section in patients with hypertrophic cardiomyopathy: a report of three cases. Anesthesiology 1999; 90:1205.
- Arendt KW, Muehlschegel JD, Tsen LC. Cardiovascular alterations in the parturient undergoing cesarean delivery with neuraxial anesthesia. Expert Rev Obstet Gynecol 2012; 1:59.
- American Society of Anesthesiologists Task Force on Neuraxial Opioids, Horlocker TT, Burton AW, et al. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology 2009; 110:218.
- Ngan Kee WD, Lee A, Khaw KS, et al. A randomized double-blinded comparison of phenylephrine and ephedrine infusion combinations to maintain blood pressure during spinal anesthesia for cesarean delivery: the effects on fetal acid-base status and hemodynamic control. Anesth Analg 2008; 107:1295.
- Crossley GH, Poole JE, Rozner MA, et al. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management this document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Heart Rhythm 2011; 8:1114.
- American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated report by the american society of anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. Anesthesiology 2011; 114:247.
- Dob DP, Yentis SM. UK registry of high-risk obstetric anaesthesia: report on cardiorespiratory disease. Int J Obstet Anesth 2001; 10:267.
- Bonnin M, Mercier FJ, Sitbon O, et al. Severe pulmonary hypertension during pregnancy: mode of delivery and anesthetic management of 15 consecutive cases. Anesthesiology 2005; 102:1133.
- HEMODYNAMIC CHANGES DURING PREGNANCY, LABOR, AND DELIVERY
- PRENATAL ANESTHESIA EVALUATION
- Risk stratification
- - Congenital and genetic heart disease
- - Valvular heart disease
- Prepartum anesthesia consultation
- OBSTETRIC ISSUES
- Induction of labor
- Route of delivery
- - Vaginal "cardiac delivery"
- Endocarditis prophylaxis
- Effects of drugs commonly used in the labor unit
- GENERAL PRINCIPLES OF ANESTHETIC MANAGEMENT
- - Electrocardiogram
- - External defibrillator pads
- - Pulse oximetry
- - Intravenous catheter filters
- - Intra-arterial catheter
- - Central venous catheter
- - Pulmonary artery catheter
- - Transesophageal or transthoracic echocardiography
- Preparation of vasoactive agents
- Neuraxial analgesia for labor
- - Epidural technique for labor
- CSE technique for labor
- Test dose administration
- Parenteral analgesia for labor
- Neuraxial anesthesia for cesarean delivery
- - Epidural technique for cesarean delivery
- CSE technique for cesarean delivery
- General anesthesia technique for cesarean delivery
- MANAGEMENT OF IMPLANTABLE CARDIOVERTER DEFIBRILLATORS AND PACEMAKERS
- MANAGEMENT OF ARRHYTHMIAS
- POSTPARTUM CARE
- SUMMARY AND RECOMMENDATIONS