anesthesia for termination of pregnancy in patient with eisenmenger’s syndrome

7/27/2019 Anesthesia for Termination of Pregnancy in Patient with Eisenmenger’s Syndrome

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Anesthesia for Termination

of Pregnancy in Patient

with Eisenmenger’sSyndrome

Erwin Siregar



Background

• Pregnant woman with cardiac disease >>>• High risk !!!!



Hemodynamic Changes

Normal pregnancy:

Changes begin during 2nd-7th weeks of pregnancy,

and peaks in the late 2nd trimester

– Blood volume 40-50 % due to activation of Renin Aldosterone axis – Anemia of pregnancy

– CO 30 -50 % :

• preload

• afterload

• maternal HR 10-15 /minute – BP decrease by 10 mmHg

• SVR

• Addition of utero-placental bed of low-resistance



Normal pregnancy :

– Fatigue

– Dyspnoe

– Poor exercise tolerance



How about pregnant women with heartdisease ????



Pregnant Pt with Cardiac Disease

Several points to ponder

• Basic characteristics of each cardiac disease

• Present status of cardiac disease? – Hemodynamic fluctuations ?

– Pulmonary complications ?

• Regional ? General ?• What appropriate monitors ?



KISS (Keep it Simple, Stupid)

• If the patient is comfortable in the supine position regional or general

• If the patient is comfortable only in the semi or sitting position with/ out difficulty in breathing :

General anesthesia• Monitors :

– Potential for hemodynamic fluctuations :Invasive :

• AL• CVP

• PA catheters (Pulmonary Hypertension)



Pregnant women with heart disease

• NYHA predictor of outcome• NYHA class III atau IV :

– Mortality rate 7 %

– Morbidity rate 30 % – No pregnancy please !!!!!



Risk Factor

• Siu et al (1997)

– Prior cardiac events (heart failure, transient

ischemic attack, stroke prior to pregnancy) – Cyanosis or poor functional class

– Left heart obstruction

– Systemic ventricular dysfunction



Classification

Three classification

– Low risk lesions

– Moderate risk lesions – High risk lesions



Low risk lesions

– Atrial Septal defect

– Ventricular septal defect

– Patent ductus arteriosus

– Asymptomatic AS with low mean gradient (<50 mmHg), andnormal LV function

– AR with normal LV function and NYHA class I or II

– MVP (isolated or with mild / moderate MR and normal LVfunction)

– MR with normal LV function and NYHA class I or II

– Mild /moderate MS (MVA > 1.5 cm2, mean gradient< 5mmHg) without severe pulmonary hypertension

– Mild/ moderate PS

– Repaired acyanotic congenital heart disease without residualcardiac dysfunction



Moderate risk lesions

• Large left to right shunt• Coarctation of the aorta

• Marfan’s syndrome with a normal aortic root

• Moderate/ severe MS

• Mild/ moderate AS

• Severe PS

• History of prior peripartum cardiomyopathy with

no residual ventricular dysfunction



High risk lesions

• Eisenmenger’s syndrome

• Severe PH• Complex cyanotic heart disease (TOF, Ebstein’s

anomaly, Tr Art, TGA, tricuspid atresia)

• Marfan’s syndrome with aortic root or valve involvement

• Severe AS with or without symptoms• Aortic and / or mitral valve disease with moderate/ severeLV dysfunction (EF < 40 %)

• NYHA class III to IV symptoms associated with anyvalvular disease or with cardiomyopathy of any etiology

• History of peripartum cardiomyopathy with persistent LVdysfunction



Eisenmenger’s Syndrome Caused by continuous exposure of the pulmonary circulation

to high pressure due to L-R shunt

Obliterative changes in pulmonary circulation

Fixed increases in PVR

RV pressure

R – L shunt

cyanosis



Eisenmenger’s Syndrome • A delicate balance between PVR and SVR

must be maintained

PVR SVR

Acidosis

Hypercarbia

PPV

R >>>> L Shunt



Eisenmenger’s Syndrome • Definitions

Pulmonary hypertension at systemic level due to

high pulmonary vascular resistance, with

reversed or bidirectional shunt at

aortopulmonary, atrial or ventricular level



• Pregnant women with low risk cardiaclesions :

regional or general --- no difference in

morbidity or mortality rate• Pregnant women that cannot tolerate

supine position, e.g. severe MI, MS, and

CTR > 70%; Eisenmenger’s syndrome :

general anethesia with controlled respiration

Technique



Monitoring

• Pregnant women with low risk cardiac lesionand can tolerate supine position : noninvasive monitoring (NIBP, ECG, and pulseoxymetry)

• Pregnant women with moderate to high riskcardiac lesion :invasive monitoring

– Arterial line

– CVP

– Swan Ganz catheter



Anesthetic Management

• Depends on condition of the patient : – Hemodynamic status

– Respiratory status

– Position best tolerated by patient at rest

• Determines :

– Anesthetic technique – Monitoring



Drugs

• Vasodilators• Vasoconstrictors

• Inotropes

• Anti arrhythmias



Case Illustration

• Pregnant women 32 yrs old, G4A2P1, 34weeks pregnant, with Eisenmenger’s

syndrome caused by ASD II

• Termination of pregnancy with SC becausematernal deterioration

• Preop visit :

– Difficulty in breathing, with nasal O2,

– Can only tolerate sitting position

– Sometimes O2 desaturation




• General anesthesia• Arterial line, CVP, and SG side port insertion

before induction of anesthesia

• Surgeon and surgical team in sterile gownbefore induction of anesthesia

• Induction of anesthesia with IV Sufentanyl

0.5 – 1 g/kg/bw and Midazolam andappropriate muscle relaxant for intubation




• As soon as the patient loosesconsciousness, she is put into supine

position, and surgical team immediately

begins incision while the patient is being

intubated

• After intubation a PA catheter is inserted

• NTG, Vasopressor, and Inotropes given if

needed to control hemodynamics



S



Summary

• Good team work between cardiologist,surgeon, and anesthesiologist is needed inthe proper management of delivery/termination of pregnancy in women with

heart disease• The surgeon has to be informed of the

anesthetic procedure prior to the operation

• Pediatricians has to be ready in the OR andcapable of resuscitation / intubation of baby

anesthesia for termination of pregnancy in patient with eisenmenger’s syndrome

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