Management of Labor and Delivery in Cardiovascular Disease: Cardiologist Perspective - PowerPoint PPT Presentation


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Management of Labor and Delivery in Cardiovascular Disease: Cardiologist Perspective


Management of Labor and Delivery in Cardiovascular Disease: Cardiologist Perspective Niloufar Samiei MD, FACC Associate Professor in Cardiology Rajaei Cardiovascular ... – PowerPoint PPT presentation

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Title: Management of Labor and Delivery in Cardiovascular Disease: Cardiologist Perspective

Management of Labor and Delivery in
Cardiovascular DiseaseCardiologist Perspective
Niloufar Samiei MD, FACC Associate Professor in
Cardiology Rajaei Cardiovascular Medical and
Research Center
  • Introduction
  • Hemodynamics of Labor
  • General Principles
  • Specific lesions

  • Leading cause of maternal mortality in the
    developed world
  • Over a half of all maternal death can be
  • Increase the incidence of pregnancy in CHD
  • Acquired heart disease as the main cause of death
  • Team working( Obstetrician, Cardiologist,
    Anesthesiologist, Neonatalogist)
  • Individualized plan
  • Interdisciplinary communication and preparation

Hemodynamic changes of labor as unique time
  • Anxiety, fear and apprehension
  • Progressive increase in CO
  • Rise of CO 3-3.5 l/min during 2nd stage
  • Autotransfuison 300-500 ml/contraction
  • Autotransfusion postpartum 1000ml
  • Average blood loss 500cc/ NVD for a singleton,
    100cc/ CS and vaginal twins
  • Other factors anemia, preeclampsia, infection
  • Fluctuation of HR and SV
  • Early post partum increased CO and SV, decrease
    of HR , stable mean arterial pressure

Hemodynamic changes of labor
  • NVD within 10 min after delivery CO and SV
    increase 59 and 71 respectively
  • Persist for at least 1 hour
  • C/S CO increase by 30-50 within 2 minutes
  • Persist for 10 minutes

General Principles
  • Risk stratification choice of delivery, location
  • Pain control
  • Strict input/output
  • Continuous ECG monitoring
  • Oxygen supplementation
  • Intravenous filters if shunt is present
  • Arterial line
  • Patient positioning (semi recumbent/lateral tilt)
  • Fetal monitoring
  • Thrombosis/ endocarditis prophylaxis
  • Invasive monitoring

Risk Stratification
  • Prior Fontan procedure
  • Severe PAH
  • Cyanotic CHD
  • Complex repair CHD with residua
  • CHD with malignant arrhythmia
  • Severe AS
  • MS with NYHA class II to IV symptoms
  • AI or MR with NYHA class III or IV symptoms
  • AV or MV disease with severe LV dysfunction
  • Marfan syndrome
  • Prosthetic valves

  • Vaginal delivery is generally preferred
  • Scheduling labor instead of spontaneous form in
    women at high risk
  • Placement of monitoring devices, IV access and
    other preparation for analgesia and anesthesia
    before starting of contractions
  • Check of vital sign between contractions
  • Any sign or symptom of cardiac decompensation
    indication for intensive medical care
  • If neuroaxial analgesia is not an option route
    for delivery should be reconsidered

Vaginal Cardiac Delivery
  • Epidural analgesia
  • Fetal descent during the majority of the 2nd
    stage is accomplished exclusively by uterine
    contractions without the aid of maternal
    expulsive effort
  • Low or outlet operative delivery
  • Still controversial

  • Trial of pushing
  • Pulse oximetry waveform
  • Mostly on earlobe

  • Continuous ECG
  • Arrhythmias
  • Myocardial ischemia
  • A 5 lead ECG with computerized St segment
  • Specialized nursing care

External Defibrillator or Pacemaker Pads
  • Patients with history of poorly tolerated tachy
  • Patients with CIED reprogrammed for operation or
    deactivated in detection of tachy/ bradycardia by

Pulse Oximetry
  • Continuous
  • Audible and visible waveform
  • Particularly in cyanotic CHD or right to left
    vascular shunt

Intra Venous Catheter Filters
  • Prevent paradoxical air emboli
  • Intracardiac shunts
  • Extracardiac shunts

Intra arterial catheter
  • Invasive monitoring of arterial BP
  • Hypotension can be detected promptly and treated
  • Analysis of uterine contractions and maternal
    expulsive effort on overall hemodynamics
  • Should be inserted before induction of anesthesia
    in unstable high risk patients undergoing CS
  • Also facilitates ABG and vasoactive drug

Central Venous Catheter
  • In unstable patients with high risk
    cardiovascular disease
  • For administration of vasoactive drugs
  • For monitoring of CVP
  • Should not be used as a sole guide for fluid
  • Helpful when CVP values are either high or low

Pulmonary Artery Catheter
  • Rarely indicated
  • High risk for complication
  • Helpful in some situations
  • PAH requiring titration of pulmonary vasodilatory
    agents such as nitric oxide

  • TTE or TEE
  • Determine the cause of any unexplained persistent
    or life threatening circulatory instability
  • During GA, TEE is the best method to assess
    volume status, regional and global cardiac

Vasoactive Drugs
  • Should be prepared in advance
  • Syringes and infusions
  • Phenylephrine
  • Efedrine
  • Norepinefrine

Neuroaxial Analgesia
  • Reduction in CO peaks throughout labor
  • Should be placed early in labor
  • Epidural or low dose combined epidural-spinal
  • monitoring of systemic BP is necessary
  • Excellent analgesia
  • Dense analgesia can be achieved
  • Titration is possible
  • A passive 2nd stage
  • In case of urgent CS , surgical block can be

Specific Lesions
  • Aortic rupture or disection risk
  • Fixed cardiac output lesions
  • -avoid hypotension
  • -avoid pulmonary edema
  • Shunts/ Eisenmenger syndrome/PH
  • IHD

Endocarditis Prophylaxis
  • Prosthetic cardiac valve or prosthetic material
    used for cardiac valve repair
  • Previous infective endocarditis
  • Congenital heart disease (CHD)
  • Unrepaired cyanotic CHD, including those with
    palliative shunts and conduits
  • Completely repaired CHD with prosthetic material
    or device either by surgery or catheter
    intervention during the first 6 months after the
  • Repaired CHD with residual defects
  • Cardiac transplantation recipients who develop
    cardiac valvulopathy

Post Partum Period
  • Care should be given with bolus of oxytocine
  • Controlled intravenous infusion
  • Several days of close monitoring in patients with
    diminished LV function
  • Prophylactic diuretics and ACEI
  • Routine post delivery echo
  • Risk of thromboembolism
  • A short observation period (48Hours) for low risk
  • Lactation

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