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
- Vincenzo Berghella, MD
Vincenzo Berghella, MD
- Section Editor — Obstetrics
- Director, Maternal-Fetal Medicine
- Professor, Obstetrics and Gynecology
- Thomas Jefferson University
- 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 Anesthesia
- 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".)
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- 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