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Anesthesia for labor and delivery in high-risk heart disease: General considerations

Author
Katherine W Arendt, MD
Section Editors
David L Hepner, MD
Susan M Ramin, MD
Heidi M Connolly, MD, FASE
Jonathan B Mark, MD
Deputy Editor
Nancy A Nussmeier, MD, FAHA

INTRODUCTION

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 [2].

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) [4]. 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".)

                                     

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Literature review current through: Nov 2016. | This topic last updated: Mon Sep 26 00:00:00 GMT+00:00 2016.
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