Anaesthetic management of obstetric patient with MS.

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Anaesthetic management of obstetric patient with
MS.

• SPEAKER DR. AMANDEEP SINGH
• MODERATOR DR. S CHAWLA.

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
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Heart disease in pregnancy.

• INCIDENCE, 3.6 to 1.6.
• Rheumatic 75 - 90 mitral stenosis.
• Congenital-25.
• Maternal mortality lt1 in asymptomatic pt.
• 17 in MS with
  AF.
• 0.4 in NYHA class 1 and 2.
• 6.8 in NYHA class 3 and 4.

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Rheumatic fever.

• Gp. A beta haemolytic streptococci.
• Autoimmune attack on heart and connective tissue.
• Inflammation of all 3 layers of heart, mainly
  endocardium- valve leaflet thickens, calcify and
  become funnel shaped.
• RF equal among M/F. MS 2-3 times common in
  females.

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Jones criteria for diagnosis of RF.

• Major criteria
• 1. carditis
• 2.artharitis
• 3.subcutaneous nodules
• 4.chorea
• 5.erythema marginatum
• Minor criteria clinical
  1.fever
• 2. arthralgia
• 3. previous RF or rheumatic heart disease.

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• Lab.
• 1. increased acute phase reactants ? ESR.
• 
  ? CRP
• 
  Leucocytosis.
• Essential criteria evidence of recent
  streptoccocal infection.
• 1. ? antistreptolysin o titer.
• 2. positive throat culture.
• 3. recent scarlet fever.
• DIAGNOSIS 2 major or 1 major and 2 minor
  criteria in presence of essential criteria.

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Pathophisiology of MS.
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EFFECT OF PREGNANCY

• Anatomically moderate stenosis becomes
  functionally severe.
• Progressive stress on CVS leads to advancement of
  pt. from one NYHA class to another.
• Cardiac output ?es by 30 -40 till 28wks.
• HR ?es by 15 and SV by 30.

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• Each uterine contraction in 1st stage of labour
  ?es CO by 10-15
• In second stage by-45.
• Immediately after delivery by 80-150 .
• BP usually remains constant because of decrease
  in SVR.
• Pregnancy being a hypercoagulable state adds to
  thromboembolism associated with AF.

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SYMPTOMS

• Can be precipitated by
• Exertion
• Excitement
• Fever
• Severe anemia
• Paroxysmal tachycardia
• pregnancy

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symptoms

• fatigue
• Dyspnea on exertion
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Dyspnea at rest
• Hemoptysis
• Pulmonary or systemic embolization

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Physical examination

• Inspection and palpation
• Sev MS malar flush and pinched and blue facies
• Sinus rhythm JVP with prominent a waves
• AF JVP with c-v waves
• Systemic BP is normal or low
• RV tap along L sternal border enlarged RV
• Diastolic thrill at cardiac apex
• Tapping apex beat palpable S1 displacement of
  LV by enlarged RV

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auscultation

• S1 accentuated and snapping, and slightly
  delayed
• S2 split with P2 accentuated
• Opening snap heard best in expiration
• at or just medial to cardiac apex,
• L sternal edge,
• base of heart.

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auscultation

• Low pitched , rumbling diastolic murmur, heard
  best at apex with bell of stetho with pt. in L
  lat position in expiration. Aacentuated with mild
  exercise
• Presystolic accentuation in pts. with sinus rhythm

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MANAGEMENT OF PATIENT

• INVESTIGATIONS
• 1.Complete haemogram, coagulation profile, serum
  electrolytes, RFT, urine C/E.
• 2. ECG P mitale, AF , RAD, RAH .

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X-ray findings

• straightening of left heart
• Prominence of main pulmonary arteries
• Dilation of upper lobe pulmonary veins
• Double atrial shadow.
• Kerly B lines.
• Pulmonary edema.
• Backward displacement of esophagus by enlarges LA

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ECHOCARDIOGRAPHY

• Diagnostic mainstay
• Severity of stenosis
• Mitral orifice size
• Anatomy of mitral valve
• Estimate of transvalvular gradient
• pressure gradient 8 4v²
• Presence and severity of MR
• Size of cardiac chambers
• Estimation of PA pressures
• suitability of BMV

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Grades of MS severity
Severity MVA, cm2 Gradient, mm Hg PAP
Mild gt1.8 24 Normal
Moderate 1.21.6 49 Normal
Moderate to severe 1.01.2 1015 Mild pulmonary HTN
Severe lt1.0 15 Mild to severe Pulmonary HTN Mild to severe Pulmonary HTN
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Severity of MS
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MEDICAL MANAGEMENT

• 1. DIURETICS ? preload ,decongest lungs.
• 2. DIGOXIN therapy needs to be continued through
  pregnancy (aim to control HR lt 110)
• 4.Anticoagulants for AF to be continued.
• Heparin 5000 u BD S/C till 12 wk.
  Warfarin 3mg OD Upto 36 wk.
  Heparin ..7 days postpartum.
• 5.IM penidura/3wk throughout pregnancy.

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Definitive therpy

• Mechanical relief of obstruction.
• BMV, Open comissurotomy, mitral valve
  replacement.
• Indications
  1.symptomatic pt., NYHA gr2,
  2.PHT,
  
• 3.medical therapy has failed to relieve
  symptoms.
• BMV is preferred option , in 16 -24 wk.

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Management of pregnancy.

• Admission
• NYHA gr.1- 2wk prior to EDOD.
• NYHA gr 2- at 28 wk.
• NYHA gr3/4 - throughout pregnancy.Management
  of 1st stage
• Bed rest, lt.lateral position, 02 by side.
• No role of induction.
• Cautious fluid 75 ml/hr.
• Antibiotic prophylaxis ampicillin 2g iv and
  Gentamycin 1.5mg/kg iv on onset of labour and
  after 8 hr.

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• Hemodynamic goals

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Avoid tachycardia

• AF with fast rate Not tolerated
• Acute AF
• Cardioversion starting with 25J
• Or ß-blocker (propranolol 0.2-0.5 mg iv every 3
  mins, maximum 0.1 mg/kg)
• Or digoxin
• 0.5mg iv over 10 mins followed by 0.25 mg iv
  every 2 hrs to achieve full digitalisation
• Each dose has an effect in 15 mins with full
  effect in 1 2 hrs

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• avoid Sinus tachycardia
• HRgt140, or decrease in CO, increase in PCWP
• Reverse the precipitating event
• Pain
• Light anesthesia
• Hypercarbia
• Acidosis
• Or administer ß-blocker

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• Avoid marked increase in central blood volume
• Overtransfusion
• Trendelenburg position
• Auto transfusion
• Monitered by CVP or PCWP
• Marked decrease in SVR may not be tolerated

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• Avoid increase in PVR
• Hypercarbia
• Hypoxia
• Acidosis
• Lung hyperinflation
• Volume overload
• Prostaglandins for uterine atony caution
• Pulmonary vasodilators
• Prolonged mechanical ventilation may be reqiured

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Vaginal delivery

• Epidural analgesiaprevents increase in CO to
  higher extents. ?es pain and tachycardia,
  prevents fatigue and exertion.
• Second stage delay is to be curtailed using
  ventouse or forceps.
• IV ergometrine is to be withheld.
• Third stage slight blood loss is benificial.
• Oxytocin infusion only if exessive blood loss.
• IV frusemide can be given.

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Elective LSCS

• Premedication tab ranitidine 150 mg
• tab perinorm 10 mg
• Endocarditis
  prophylaxis.
• MONITORING
• NYHA Gr1/2 - ECG, NIBP, Pulse oximeter, EtCO2,
  Temparature, Esophageal stethoscope, Foley's
  catheter for UO.
• NYHA Gr.3/4- IABP,CVP/Swan ganz cather
  PAP,PCWP,CO

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Regional v/s GA.

• For mitral valve disease regional anaesthesia is
  benifecial since it decreases both preload and
  afterload and decongests lungs.
• GA is prefered if PHT, AF , assosiated AS,
  emergency or patient is haemodynamically unstable.

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Technique for GA

• Anaesthesia machine and intubation trolley are
  checked.
• Patient supine ,wedge under right hip.
• Monitors applied.
• Large bore IV cannula.
• Preoxygenation for 3 min.
• RSI with preset doses of Thiopentone and
  Succinylcholine. Cricoid pressure maintained till
  cuff is inflated.

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• Drugs that produce tachycardia are to be avoided
• Atropine
• Pancuronium
• Pethidine
• Ketamine

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• Maintanence O2 N2O 50 each.
  
  Halothane preferred ?HR,
  least vasodialating Atracurium 0.5mg/kg.
• Maintain sinus rythum. In presence of AF, control
  ventricular rate with Digoxin or Diltiazam.
• If sudden SVT develops DC Cardioversion.
• Maitain SVR. Phenylephrine can be used.
• After delivery of baby, Morphine 0.15mg/kg.
• Oxytocin cautiously if exessive blood loss.
• Smooth Extubation.

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• Post op care in ICU
• If ventilated post op
• ABG
• Pulmonary mechanics and
• CXR
• Should be monitored

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THANK YOU.
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om