anaesthetic management of obstetric patient with ms. speaker dr. amandeep singh moderator dr. s...
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Anaesthetic management of Anaesthetic management of obstetric patient with MS.obstetric patient with MS.
SPEAKER DR. AMANDEEP SINGHSPEAKER DR. AMANDEEP SINGH
MODERATOR DR. S CHAWLA.MODERATOR DR. S CHAWLA.
www.anaesthesia.co.in [email protected]
Heart disease in pregnancy.Heart disease in pregnancy.
INCIDENCE, 3.6% to 1.6%.INCIDENCE, 3.6% to 1.6%. Rheumatic – 75% - 90% mitral stenosis.Rheumatic – 75% - 90% mitral stenosis. Congenital-25%.Congenital-25%. Maternal mortality; <1% in asymptomatic pt.Maternal mortality; <1% in asymptomatic pt. 17% in MS with AF.17% in MS with AF. 0.4% in NYHA class 1 and 2.0.4% in NYHA class 1 and 2. 6.8% in NYHA class 3 and 4.6.8% in NYHA class 3 and 4.
Rheumatic fever.Rheumatic fever.
Gp. A beta haemolytic streptococci.Gp. A beta haemolytic streptococci. Autoimmune attack on heart and connective Autoimmune attack on heart and connective
tissue.tissue. Inflammation of all 3 layers of heart, mainly Inflammation of all 3 layers of heart, mainly
endocardium- valve leaflet thickens, calcify endocardium- valve leaflet thickens, calcify and become funnel shaped.and become funnel shaped.
RF equal among M/F. MS 2-3 times common RF equal among M/F. MS 2-3 times common in females.in females.
Jones criteria for diagnosis of RF.Jones criteria for diagnosis of RF. Major criteria;Major criteria; 1. carditis1. carditis 2.artharitis2.artharitis 3.subcutaneous nodules3.subcutaneous nodules 4.chorea4.chorea 5.erythema marginatum5.erythema marginatum Minor criteria; clinicalMinor criteria; clinical; ;
1.fever1.fever 2. arthralgia2. arthralgia 3. previous RF or rheumatic heart disease. 3. previous RF or rheumatic heart disease.
Lab. Lab. 1. increased acute phase reactants; 1. increased acute phase reactants; ↑ ESR.↑ ESR. ↑ ↑ CRP CRP Leucocytosis.Leucocytosis. Essential criteria; evidence of recent Essential criteria; evidence of recent
streptoccocal infection.streptoccocal infection. 1. ↑ antistreptolysin o titer.1. ↑ antistreptolysin o titer. 2. positive throat culture. 2. positive throat culture. 3. recent scarlet fever.3. recent scarlet fever. DIAGNOSIS; 2 major or 1 major and 2 minor DIAGNOSIS; 2 major or 1 major and 2 minor
criteria in presence of essential criteria.criteria in presence of essential criteria.
Pathophisiology of MS.Pathophisiology of MS.
EFFECT OF PREGNANCYEFFECT OF PREGNANCY Anatomically moderate stenosis becomes Anatomically moderate stenosis becomes
functionally severe.functionally severe. Progressive stress on CVS leads to Progressive stress on CVS leads to
advancement of pt. from one NYHA class to advancement of pt. from one NYHA class to another.another.
Cardiac output Cardiac output ↑es by 30 -40% till 28wks.↑es by 30 -40% till 28wks. HR ↑es by 15% and SV by 30%.HR ↑es by 15% and SV by 30%.
Each uterine contraction in 1Each uterine contraction in 1stst stage of labour stage of labour ↑es CO by 10-15%↑es CO by 10-15%
In second stage by-45%.In second stage by-45%. Immediately after delivery by 80-150% .Immediately after delivery by 80-150% . BP usually remains constant because of BP usually remains constant because of
decrease in SVR.decrease in SVR. Pregnancy being a hypercoagulable state adds Pregnancy being a hypercoagulable state adds
to thromboembolism associated with AF.to thromboembolism associated with AF.
SYMPTOMSSYMPTOMS
Can be precipitated by Can be precipitated by ExertionExertion ExcitementExcitement FeverFever Severe anemiaSevere anemia Paroxysmal tachycardiaParoxysmal tachycardia pregnancypregnancy
symptomssymptoms
fatiguefatigue Dyspnea on exertionDyspnea on exertion OrthopneaOrthopnea Paroxysmal nocturnal dyspneaParoxysmal nocturnal dyspnea Dyspnea at restDyspnea at rest HemoptysisHemoptysis Pulmonary or systemic embolizationPulmonary or systemic embolization
Physical examinationPhysical examination
Inspection and palpationInspection and palpation Sev MS – malar flush and pinched and blue faciesSev MS – malar flush and pinched and blue facies Sinus rhythm – JVP with prominent a wavesSinus rhythm – JVP with prominent a waves AF – JVP with c-v wavesAF – JVP with c-v waves Systemic BP is normal or lowSystemic BP is normal or low RV tap along L sternal border – enlarged RVRV tap along L sternal border – enlarged RV Diastolic thrill at cardiac apexDiastolic thrill at cardiac apex Tapping apex beat – palpable S1 + displacement of Tapping apex beat – palpable S1 + displacement of
LV by enlarged RVLV by enlarged RV
auscultationauscultation
S1 – accentuated and snapping, and slightly S1 – accentuated and snapping, and slightly delayeddelayed
S2 – split with P2 accentuatedS2 – split with P2 accentuated Opening snap – heard best in expiration Opening snap – heard best in expiration
at or just medial to cardiac apex,at or just medial to cardiac apex, L sternal edge, L sternal edge, base of heart. base of heart.
auscultationauscultation
Low pitched , rumbling diastolic murmur, Low pitched , rumbling diastolic murmur, heard best at apex with bell of stetho with pt. heard best at apex with bell of stetho with pt. in L lat position in expiration. Aacentuated in L lat position in expiration. Aacentuated with mild exercisewith mild exercise
Presystolic accentuation in pts. with sinus Presystolic accentuation in pts. with sinus rhythmrhythm
MANAGEMENT OF PATIENTMANAGEMENT OF PATIENT INVESTIGATIONS;INVESTIGATIONS; 1.Complete haemogram, coagulation profile, 1.Complete haemogram, coagulation profile,
serum electrolytes, RFT, urine C/E.serum electrolytes, RFT, urine C/E. 2. ECG; P mitale, AF , RAD, RAH .2. ECG; P mitale, AF , RAD, RAH .
X-ray findingsX-ray findings straightening of left heartstraightening of left heart Prominence of main pulmonary arteriesProminence of main pulmonary arteries Dilation of upper lobe pulmonary veinsDilation of upper lobe pulmonary veins Double atrial shadow.Double atrial shadow. Kerly B lines.Kerly B lines. Pulmonary edema.Pulmonary edema. Backward displacement of esophagus by Backward displacement of esophagus by
enlarges LAenlarges LA
ECHOCARDIOGRAPHYECHOCARDIOGRAPHY Diagnostic mainstayDiagnostic mainstay Severity of stenosisSeverity of stenosis Mitral orifice sizeMitral orifice size Anatomy of mitral valveAnatomy of mitral valve Estimate of transvalvular gradient Estimate of transvalvular gradient
pressure gradient pressure gradient ∞ 4v²∞ 4v² Presence and severity of MRPresence and severity of MR Size of cardiac chambersSize of cardiac chambers Estimation of PA pressuresEstimation of PA pressures suitability of BMVsuitability of BMV
modern management of mitral modern management of mitral stenosis, Circulation 2005;112;432-stenosis, Circulation 2005;112;432-
437437
Grades of MS severityGrades of MS severitySeverity MVA,
cm2
Gradient,
mm Hg
PAP
Mild >1.8 2–4 Normal
Moderate 1.2–1.6 4–9 Normal
Moderate to severe
1.0–1.2 10–15 Mild pulmonary HTN
Severe <1.0 15 Mild to severe
Pulmonary HTN
Severity of MSSeverity of MS
MEDICAL MANAGEMENTMEDICAL MANAGEMENT 1. DIURETICS; 1. DIURETICS; ↓ preload ,decongest lungs.↓ preload ,decongest lungs. 2. DIGOXIN; therapy needs to be continued 2. DIGOXIN; therapy needs to be continued
through pregnancy (aim to control HR < 110)through pregnancy (aim to control HR < 110) 4.Anticoagulants for AF to be continued.4.Anticoagulants for AF to be continued. Heparin 5000 u BD S/C till 12 wk. Heparin 5000 u BD S/C till 12 wk.
Warfarin 3mg OD Upto 36 wk. Warfarin 3mg OD Upto 36 wk. Heparin ……..7 days postpartum. Heparin ……..7 days postpartum.
5.IM penidura/3wk throughout pregnancy.5.IM penidura/3wk throughout pregnancy.
Definitive therpy Definitive therpy Mechanical relief of obstruction.Mechanical relief of obstruction. BMV, Open comissurotomy, mitral valve BMV, Open comissurotomy, mitral valve
replacement.replacement. Indications; Indications;
1.symptomatic pt., NYHA 1.symptomatic pt., NYHA ≥gr2, ≥gr2, 2.PHT, 2.PHT, 3.medical therapy has failed to relieve 3.medical therapy has failed to relieve symptoms.symptoms.
BMV is preferred option , in 16 -24 wk.BMV is preferred option , in 16 -24 wk.
Management of pregnancy.Management of pregnancy.
AdmissionAdmission;; NYHA gr.1- 2wk prior to EDOD.NYHA gr.1- 2wk prior to EDOD. NYHA gr 2- at 28 wk. NYHA gr 2- at 28 wk. NYHA gr3/4 - throughout pregnancy.NYHA gr3/4 - throughout pregnancy.
Management of 1Management of 1stst stage stage;; Bed rest, lt.lateral position, 02 by side.Bed rest, lt.lateral position, 02 by side. No role of induction.No role of induction. Cautious fluid ;75 ml/hr.Cautious fluid ;75 ml/hr. Antibiotic prophylaxis ampicillin 2g iv and Antibiotic prophylaxis ampicillin 2g iv and
Gentamycin 1.5mg/kg iv on onset of labour and after Gentamycin 1.5mg/kg iv on onset of labour and after 8 hr.8 hr.
Hemodynamic goalsHemodynamic goals
Avoid tachycardiaAvoid tachycardia
AF with fast rate – Not toleratedAF with fast rate – Not tolerated Acute AFAcute AF Cardioversion starting with 25JCardioversion starting with 25J Or Or ββ-blocker (propranolol 0.2-0.5 mg iv every 3 -blocker (propranolol 0.2-0.5 mg iv every 3
mins, maximum 0.1 mg/kg)mins, maximum 0.1 mg/kg) Or digoxin Or digoxin 0.5mg iv over 10 mins followed by 0.25 mg iv every 0.5mg iv over 10 mins followed by 0.25 mg iv every
2 hrs to achieve full digitalisation2 hrs to achieve full digitalisation Each dose has an effect in 15 mins with full effect in Each dose has an effect in 15 mins with full effect in
1 – 2 hrs 1 – 2 hrs
avoid Sinus tachycardia – avoid Sinus tachycardia –
HR>140, or decrease in CO, increase in PCWPHR>140, or decrease in CO, increase in PCWP Reverse the precipitating eventReverse the precipitating event
Pain Pain Light anesthesia Light anesthesia Hypercarbia Hypercarbia AcidosisAcidosis
Or administer Or administer ββ-blocker-blocker
Avoid marked increase in central blood Avoid marked increase in central blood volume volume OvertransfusionOvertransfusion Trendelenburg positionTrendelenburg position Auto transfusionAuto transfusion
Monitered by CVP or PCWPMonitered by CVP or PCWP Marked decrease in SVR may not be toleratedMarked decrease in SVR may not be tolerated
Avoid increase in PVRAvoid increase in PVR HypercarbiaHypercarbia Hypoxia Hypoxia AcidosisAcidosis Lung hyperinflationLung hyperinflation Volume overloadVolume overload
Prostaglandins for uterine atony – cautionProstaglandins for uterine atony – caution Pulmonary vasodilatorsPulmonary vasodilators Prolonged mechanical ventilation may be reqiuredProlonged mechanical ventilation may be reqiured
Vaginal deliveryVaginal delivery Epidural analgesia;prevents increase in CO to Epidural analgesia;prevents increase in CO to
higher extents. higher extents. ↓↓es pain and tachycardia, es pain and tachycardia, prevents fatigue and exertion.prevents fatigue and exertion.
Second stage; Second stage; delay is to be curtailed using delay is to be curtailed using ventouse or forceps.ventouse or forceps.
IV ergometrine is to be withheld.IV ergometrine is to be withheld. Third stageThird stage; slight blood loss is benificial.; slight blood loss is benificial. Oxytocin infusion only if exessive blood loss.Oxytocin infusion only if exessive blood loss. IV frusemide can be given.IV frusemide can be given.
Elective LSCSElective LSCS
Premedication ; tab ranitidine 150 mgPremedication ; tab ranitidine 150 mg tab perinorm 10 mgtab perinorm 10 mg Endocarditis prophylaxis.Endocarditis prophylaxis. MONITORINGMONITORING; ; NYHA Gr1/2 - ECG, NIBP, Pulse oximeter, NYHA Gr1/2 - ECG, NIBP, Pulse oximeter,
EtCO2, Temparature, Esophageal stethoscope, EtCO2, Temparature, Esophageal stethoscope, Foley's catheter for UO.Foley's catheter for UO.
NYHA Gr.3/4- IABP,CVP/Swan ganz cather NYHA Gr.3/4- IABP,CVP/Swan ganz cather [PAP,PCWP,CO][PAP,PCWP,CO]
Regional v/s GA.Regional v/s GA.
For mitral valve disease regional anaesthesia is For mitral valve disease regional anaesthesia is benifecial since it decreases both preload and benifecial since it decreases both preload and afterload and decongests lungs.afterload and decongests lungs.
GA is prefered if; PHT, AF , assosiated AS, GA is prefered if; PHT, AF , assosiated AS, emergency or patient is haemodynamically emergency or patient is haemodynamically unstable.unstable.
Technique for GATechnique for GA
Anaesthesia machine and intubation trolley are Anaesthesia machine and intubation trolley are checked.checked.
Patient supine ,wedge under right hip.Patient supine ,wedge under right hip. Monitors applied.Monitors applied. Large bore IV cannula.Large bore IV cannula. Preoxygenation for 3 min.Preoxygenation for 3 min. RSI with preset doses of Thiopentone and RSI with preset doses of Thiopentone and
Succinylcholine. Cricoid pressure maintained Succinylcholine. Cricoid pressure maintained till cuff is inflated.till cuff is inflated.
Drugs that produce tachycardia are to be Drugs that produce tachycardia are to be avoidedavoided
AtropineAtropine Pancuronium Pancuronium PethidinePethidine KetamineKetamine
Maintanence ; O2 ; N2O 50% each. Maintanence ; O2 ; N2O 50% each. Halothane preferred [Halothane preferred [↓HR, least vasodialating] ↓HR, least vasodialating] Atracurium 0.5mg/kg. Atracurium 0.5mg/kg.
Maintain sinus rythum. In presence of AF, Maintain sinus rythum. In presence of AF, control ventricular rate with Digoxin or control ventricular rate with Digoxin or Diltiazam.Diltiazam.
If sudden SVT develops; DC Cardioversion.If sudden SVT develops; DC Cardioversion. Maitain SVR. Phenylephrine can be used.Maitain SVR. Phenylephrine can be used. After delivery of baby, Morphine 0.15mg/kg.After delivery of baby, Morphine 0.15mg/kg. Oxytocin cautiously if exessive blood loss.Oxytocin cautiously if exessive blood loss. Smooth Extubation. Smooth Extubation.
Post op care in ICUPost op care in ICU If ventilated post opIf ventilated post op ABGABG Pulmonary mechanics and Pulmonary mechanics and CXRCXR Should be monitoredShould be monitored
