Anesthetic management of delivery in women with pregnancy associated myocardiopathy

By Dr. Schwartz Andrei, MD senior lecturer Ben Gurion University of the Negev Faculty of Health Sciences. Soroka Medical Center Division of Anesthesiology and Critical Care. Beer Sheva. Israel

Introduction

Heart disease is now the second commonest cause of maternal death in the U.K. ( 1 ) Death from cardiomyopathy accounts for rising proportion of maternal death . The situation is mirrored in USA where cardiomyopathy causing 7.7 % of pregnancy related death. In 1991 1997, 70% of death were due to peripartum cardiomyopathy. There are two main types of cardiomyopathy, dilated ( PPCM), and hypertrophic ( HOCM) .

A . Dilated peripartum cardiomyopathy ( PPCM) 1. Diagnostic criteria for PPCM

congestive heart failure developed in last month of pregnancy or first five months post partum, in a women with no history of cardiac disease, with no identificable cause. impared left ventricular function on echocardiography ejection fraction of less than 65 % end diastolic dimension of greater than 2.7 cm /m2 body surface area

2. Epidemiology

Elkayam and Et Al ( 8 ) described an identical clinical condition that apperead earlier in pregnancy at 17 36 weks of gestation and did not differ clinically from women with the usual presentation of PPCM. Is a rare form of cardiomyopathy. Recent raports suggest an estimated incidence of one case per 299 livebirth in Haiti, one case per 1000 livebirth in South Africa and one case per 2800 to 4000 livebirth in USA. ( 4 )

Risk factors associated with PPCM have included :

advanced age gravidity african origine toxaemia or hypertension of pregnancy use of tocolitics twin pregnancy (4)

3. Aetiology

The cause and mechanism of pathogenesis of PPCM remain unknown - autoimmune mechanism ? - inflamation ( miocarditis) ? - viral trigger for development of PPCM ? ( 12 ) - nutritional disorders,such as deficiencies in selenium ? ( 18 )

4. Clinical presentation

Symptoms and signs of systolic heart failure : - dependent edema - dyspnea on exertion - ortopnea - abdominal disconfort secondary to passive congestion of the liver - later : postural hypotension - ECG: left ventricular hypertrophy

Early signs and symptoms of heart failure can be obscured by pregnancy. Delayed diagnosis can be associated with increased morbidity and mortality ! Left ventricular thrombus is common in PCCM patients . Peripherial embolism then become possible to any part of body.

5. Management and prognosis

Treatment aims to reduce afterload, preload, increase of myocardial contractility - Angiotensin converting enzime - Hydralazin - Beta blockers - Diuretics - Heparin

PPCM have higher rate of spontaneous recovery of ventricular function however . In a single center prospective study of 100 South African patients, 15 % died and only 23 % recovered to normal left ventricular function after 6 months of treatment . ( 18 ) Lampert and Lang ( 19 ) pooled data from 13 studies comprising 419 cases of PPCM and reported that 50 % to 60 % of patients showed complete or near complete clinical recovery, usualy within the first 6 months post partum .

TK Misrhra,Swain S, in their study ( 3 ) on the 56 patients, showed that 23 % of the patients died . The mortality rate in the USA has ben reported to range from 25 50 %, the majority of death occuring within 3 months after delivery ( 2 )

Long term prognosis

One of the greatest concerns of PPCM patients is the safety of additional pregnancies ( 4 ) Elkayam and Et Al ( 8 ) have followed patients with PPCM ,who became pregnant again and reported during subsequent pregnancies that mortality was very high . In their series, 44 % of patients had symptomatic deterioration and 19 % died.

Anaesthetic management

There is scant information in the literature regarding the anesthetic management of peripartum cardiomyopathy. The main purpose of anaesthesia is to prevent further cardiac depression and uncontrolled changes in afterload and preload. ( 18 ) Delivery of fetus reduce the haemodynamic stress of the heart. The mode of delivery for patients with PPCM is generally based on obstetric indications (7)

Vaginal delivery

Slow induction of epidural analgesia is a safe and effective analgesic technique. ( 16 ) Effective pain management is a necessity to avoid further increase in cardiac output from pain and anxiety .

Caesarian section

The original anaesthetic management of woman with PPCM requiring caesarian section depend on its severity . Early refferal to an obstetric anesthesist is important, if PPCM is diagnosed in the last month of pregnancy . Close liasson with the patient cardiologist and obstetrician is essential. Early ( preoperative ) critical care referal is essential for unstable patients and critically ill patients.

Intraoperative monitoring may include : - AL - CVP - PWP - TTE - TEE There is not any consensus for the anaesthetic management of the peripartum cardiomyopathic pregnancies.

There are reports of anaesthetic management techniques that include:

- general anaestesia with inhalational agents ( 6 ) - general anaesthesia with remifentanil ( 2 ) - general anaesthesia with etomidate ( 13 ) - spinal anaesthesia ( 1 ) - combine epidural and spinal anaesthesia with continous epidural catheter.

The anesthesist main goal is to reduce preload and afterload and increase myocardial contractility ( 1 )

a. General anaesthesia ( GA)

May be necessary for urgent CS. The general anaesthesia carrie the advantage of secure airway, more predictable haemodynamic status, in case of necessity the oportunity of transesophageal echocardiography. ( 2, 15 ) Balanced anesthesia with inhalational agents may cause myocardial depression from mild to severe and intravenous agents can pass the fetoplacentar barrier, causing fetal depression. In literature it has been reported that there are cases of myocardial depression and cardiac arrest due to general anaesthesia. ( 15 )

CPMc Carrol et al ( 2 ) used succesfully the TIVA with a target controlled infusion of remifentanil, in a case of one women with PPCM and ejection fraction of 15 % . Remifentanil , a sinthetic opoid, has several distinctive pharmacokynetic properties . The autors concluded that with remifentanil could provide anaesthesia that significantly reduce the stress response and subsequent possible detrimental effect on SVR . The use of remifentanil would, in theory through its metabolism and short duration of action, avoid the neonatal depression.

Bilemjani E ( 13 ) published the case of one women with PPCM and EF of 10% , at 32 weeks of gestation, that GA for caesarian section was induced with etomidate and maintanend with remifentanil infusion safely, without any adverse outcome on mother or newborn.

b. Regional anaesthesia

A regional technique has the advantage of reducing afterload ,which may improve ventricular function ( 1 )

Epidural anaesthesia ( EA )

There has been a report of the succesful use of slow titrated epidural, where the sensory block was allowed to develop over 10 h. ( 20 )

Spinal anaesthesia ( SA )

Clearly a regional technique with a rapid onset of sensory and sympathetic block with associated hypotension is inappropiate. In the studies that compare the single shot spinal anaesthesia with continous spinal anaesthesia it has been concluded that continous spinal anaesthesia elicits better hemodynamic stability, ( 14, 15 ) even there is a study which report that this stability is equal to epidural anaesthetic management ( 16 )

Combined spinal & epidural anaesthesia ( CSE )

The administration of small intrathecal dose of local anaesthetic followed by epidural supplementation allows a controlled onset of sensory and sympathetic block and should avoid potential dangerous and dramatic falls in systemic vascular resistence and arterial pressure . Shnaider R, Ezri T. et al , preferred CSE to epidural anaesthesia because that has a lower failure rate, than EA. Some autors report a lower incidence of hypotensive episodes with CSE, compared to EA.(3)

Conclusions

PPCM can affect women of various ethnic background at any age; it is more common in women over 30 years of age. Strong association with gestational hypertension and twin pregnancy should raise the level of suspicion for development of cardiomyopathy in patients with these condition who develop symptoms of heart failure Left ventricular function is markedly depressed at the time of diagnosis and normalizes in more than half of the patients .

Early recognition of PPCM should allow a timely diagnosis and appropiate care of this life threatening condition. It is not idealy anaesthetic management ; the main purpose of anaesthesia is to prevent further cardiac depression and uncontrolled changes in afterload an and preload. Collaboration among obstetrician, cardiologist, anaesthesiologist is essential to optimize care .

B. Hyhertrophic miocardyopathy
Definition:

Hypertrophic obstructive cardiomyopathy ( HOCM ) is a myocardial disorder, caracterised by left ventricular hypertrophy. The diagnosis of HOCH is made by echocardiography, demonstrating unexplained asymetrical myocardial hypertrophy. ( 14 )

Incidence

The disorder has ben estimated to occur in 0.05 - 0.2 % of general population. ( 11 ) In a pregnant women is 1 in 500 to 1 - 1000 ( 1 ). In less than half the women, the condition is diagnosed before the first pregnancy .

Symptoms and diagnosis

Disease severity is in direct proportion to the degre of left ventricular outflow obstruction. Dyspnea, orthopnea, paroxismal nocturnal dyspnea are the result of congestive heart failure. Arrhythmia may occur causing syncope ,dizzines or even sudden cardiac death ( 11 ).

Prognosis and mortality

Majority of the woman make a good outcome with a much lower mortality than with PPCM, arround 4 %

Anaesthetic management

Collaboration with the obstetrician and cardiologist is essential. In the UK ( 11 ) most women with HOCM were delivered by caesarian section and received general anaesthesia. Drugs such inotropes, that can worsen the outflow gradient are relative contraindicated in HOCH . For cardio-vascular stability, small dose of phenylephrine is indicated. Pryn A., Bryden F. et al, used succesfuly combined spinal epidural anaesthesia in a case of pregnant women with HOCH. Epidural anaesthesia also have been reported in women with HOCH . ( 19 )