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Anesthetic management for emergency cesarean section in a patient with severe valvular disease and preeclampsia
International Journal of Obstetric Anesthesia (2006) 15, 250–253 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2005.10.016
CASE REPORT
Anesthetic management for emergency cesarean section in a patient with severe valvular disease and preeclampsia S. Dua, M. A. Maurtua, J. B. Cywinski, A. Deogaonkar, J. H. Waters, J. A. Dolak Division of Anesthesiology & Critical Care Medicine, Cleveland Clinic Foundation, Cleveland OH, USA SUMMARY. Wider selection of young patients for prosthetic valve replacement for valvular heart disease has resulted in an increase in number of women with heart disease reaching childbearing age. Such patients presenting in labor for emergency cesarean section require special consideration. We present a report of a parturient who presented at 36 weeks of gestation with severe aortic and mitral stenosis, pulmonary edema and severe preeclampsia. The goals of our anesthetic management included (1) careful airway management (2) maintaining stable hemodynamics (3) optimizing fluid status, and (4) preventing seizures. Issues related to management of patients with severe valvular disease, prosthetic valves and complications due to anticoagulant therapy during pregnancy are discussed. 2005 Elsevier Ltd. All rights reserved. Keywords: Valvular heart disease; Cesarean section; Preeclampsia
of breath, peripheral edema and increasing blood pressure suggestive of preeclampsia. Her past medical history was significant for an aortic valve replacement with a Carbomedics supra-annular aortic valve prosthesis #21 and a mitral valve repair with a Cosgrove annuloplasty ring #26, following an episode of bacterial endocarditis three years before this admission. She also had a prophylactic inferior vena cava filter that was placed at the time of this surgery, because of deep vein thrombosis. Her surgical history also included a patent ductus arteriosus repair as a 9-month-old child. During her pregnancy she was followed closely by the High Risk Obstetrics Service and her history was significant for a transient ischemic attack (TIA) at 12 weeks, with sudden onset of right-sided weakness involving the right upper extremity with facial droop, aphasia and speech impediment. On admission she was short of breath at rest. Her blood pressure was 170/100 mmHg and her heart rate 90 beats/min and regular; her oxygen saturation was 98-100% on room air and she had 2+ peripheral edema. Chest auscultation revealed a prosthetic click, S4 gallop, a grade III/VI systolic ejection murmur with a diastolic rumble and bibasilar rales. Examination revealed a Mallampati grade 4 airway, a thyromental distance greater than three fingers’ breath and a full range of neck movement. An electrocardiogram showed normal sinus rhythm. A chest X-ray showed bilateral pulmonary infiltrates suggestive of pulmonary edema. Laboratory findings included hematocrit 36%, platelet
INTRODUCTION The presence of clinically significant maternal heart disease during pregnancy increases the risk of adverse maternal, fetal and neonatal outcomes.1 In this case, a 21-year-old parturient with severe aortic and mitral stenosis, pulmonary edema and severe preeclampsia underwent an emergent cesarean section with an excellent outcome. The anesthetic management of this patient is discussed.
CASE REPORT A 21-year-old primigravida at 36 weeks’ gestation was admitted to the labor suite with progressive shortness Accepted October 2005 S. Dua, Resident, Division of Anesthesiology & Critical Care Medicine, M.A. Maurtua and J.B. Cywinski, Staff, Department of Anesthesiology, A. Deogaonkar, Fellow, Division of Anesthesiology & Critical Care Medicine, J.A. Dolak, Head, Section of Anesthesia for Obstetrics & Gynecology, Department of Anesthesiology, Division of Anesthesiology & Critical Care Medicine, Cleveland Clinic Foundation, Cleveland OH; J.H. Waters, Chief, Department of Anesthesiology, Magee Women’s Hospital, University of Pittsburgh, Pennsylvania, USA. Correspondence to: Marco A. Maurtua, M.D., Department of General Anesthesiology, The Cleveland Clinic Foundation, 9500 Euclid Avenue, E31, Cleveland OH 44195, USA, Tel.: +216 445 1151; fax: +216 444 9247. E-mail: [email protected]. 250
Anesthetic management in valvular heart disease 251 count 175 · 109/L, prothrombin time 10.6 s, international normalized ratio (INR) of 0.94, plasma thromboplastin time 69.9 s, serum sodium 142 mmol/L, serum potassium 4.3 mmol/L, blood urea nitrogen (BUN) 15 mg/dL, serum creatinine 0.8 mg/dL and 4+ proteinuria. Arterial blood gas analysis on an FiO2 of 26% revealed a pH of 7.45, PaO2 12.8 kPa (96 mmHg), PaCO2 3.73 kPa (28 mmHg), HCO3 19 mmol/L and base excess 5 mEq/L. A bedside transthoracic echocardiogram (Figs. 1 and 2) demonstrated severe aortic stenosis (peak/mean gradients of 80/45 mmHg) mitral stenosis (peak/mean gradients of 28/14 mmHg) and a left ventricular ejection fraction of 55%. There was mild tricuspid and mitral regurgitation. Following cardiology consultation, mitral valve balloon valvuloplasty was recommended, to improve forward blood flow. The fetal heart rate tracing was in 140s with excellent long term variability. As the patient’s condition was rapidly deteriorating and given the complications of balloon valvuloplasty itself, it was decided to proceed with cesarean section under general anesthesia with the cardiology team standing by. Our decision was also motivated by the undesirability of performing a cesarean section for fetal distress in an unprepared location such as an interventional cardiology suite. The patient was taken to the operating room and placed supine with left uterine displacement to place a pulmonary artery catheter (PAC). An arterial line had been placed in the labor room. After a few seconds in this position she became severely dyspneic, her oxygen saturation dropped to 70% while receiving oxygen by a non-rebreathing face mask, her blood pressure increased to >190/100 mmHg and her heart rate increased to >110 beats/min. Attempts to place the PAC were abandoned and an awake fiberoptic intubation was performed in the sitting position. No upper airway edema or bleeding from the nasal mucosa was seen. General anesthesia was
Fig. 2 Continuous Flow Doppler tracing of flow across aortic valve.
induced with etomidate and a balanced anesthetic was provided with midazolam, fentanyl, atracurium and sevoflurane. A magnesium sulfate infusion was administered preoperatively at the rate of 1.5 g/h for seizure prophylaxis and was continued in the postoperative period. An esmolol infusion was also given at the rate of 20 lgÆkg 1min 1. Her intraoperative blood pressure remained stable in the range of 140-160 mmHg systolic and 70-80 mmHg diastolic. A viable female baby was delivered 7 min after the incision with Apgar scores of 8 and 9 at 1 and 5 min respectively and umbilical artery pH 7.25 and venous 7.26. The rest of the intraoperative course was uneventful. On completion of the procedure, the patient was transferred intubated and sedated to the cardiac intensive care unit for further management. A PAC was placed, which demonstrated a pulmonary artery pressure (PAP) of 66/29 mmHg, pulmonary capillary wedge pressure (PCWP) 26 mmHg, cardiac output (CO) 3.8 L/min and a cardiac index (CI) 1.75. After 6 h her PAP was 47/33 mmHg, PCWP 24 mmHg, CO 4.25 L/min and CI 2.19. By the next day her PAP was 41/29 mmHg, PCWP 19 mmHg, CO 6.51 L/min and CI 2.93. She was extubated on postoperative day (POD) 1. Anticoagulation was reestablished and diuresis was started with furosemide. A valvuloplasty was never performed because of the major hemodynamic improvement that occurred after delivery, as confirmed by a significant decrease in PAP and PCWP and improved CO and CI without the need of inotropes. On POD 3 she was transferred to the postpartum ward and was discharged on POD 6.
DISCUSSION
Fig. 1 Continuous Flow Doppler tracing of flow across mitral valve.
The pregnant patient with heart disease poses a unique challenge because of the increased burden that pregnancy places on an already compromised cardiovascular
252 International Journal of Obstetric Anesthesia system. Prosthetic valve replacement has improved overall outcomes in both the mother with poorly tolerated valvular heart disease and the fetus.2 In patients with prosthetic valves, the need for anticoagulation presents a dilemma. Insufficient anticoagulation may lead to thromboembolic phenomena while overdose poses hemorrhagic risks to the mother and, if oral therapy is used, to the fetus also. There is a general consensus that warfarin should be avoided during the first trimester, when it should be replaced by heparin. However, due to its narrow therapeutic margin it is difficult to maintain a constant level of anticoagulation with subcutaneous heparin. 3 In a systematic review of 40 studies,4 it was reported that thromboembolic prophylaxis in women with mechanical heart valves during pregnancy was best achieved with oral anticoagulation. The practice of substituting heparin for oral anticoagulation in the first trimester potentially eliminates the risk of fetal embryopathy, but appears to increase the risk of thromboembolism, as was seen in our patient. Our patient had been on warfarin until 7 weeks’ gestation after which she was switched to a subcutaneous heparin pump. Her TIA was thought to result from microemboli because of subtherapeutic doses of heparin, so she was transferred back to warfarin at 12 weeks and again to heparin at 33 weeks. The use of heparin requires aggressive monitoring and appropriate dose adjustment. The American Heart Association/American College of Cardiology Task Force report in 1998 recommended the use of warfarin, especially in high-risk women, through week 35, when unfractionated heparin (UFH) should be substituted in anticipation of labor.5 The recommendations of the Seventh American College of Chest Physicians consensus conference on antithrombotic therapy for prophylaxis in patients with mechanical heart valves6 include substituting unfractionated or low molecular weight heparin (LMWH) for warfarin when pregnancy is achieved in patients on oral anticoagulation. In women with prosthetic heart valves, careful dose adjustment of UFH throughout pregnancy, or UFH/LMWH until the thirteenth week and then warfarin until the middle of the third trimester before restarting UFH or LMWH, is strongly recommended. Furthermore, in high-risk women with prosthetic heart valves, addition of low-dose aspirin has been suggested. Most recently, a combination of aforementioned recommendations based on the type of prosthetic valve and the level of risk has been suggested, with an emphasis on the aggressive monitoring of trough level of heparin in addition to peak levels.7 Anticoagulant treatment should be discussed in detail with the patient and her partner throughout pregnancy. If the patient prefers to change to heparin for the first trimester, she should be made aware that heparin carries a higher risk of
both thrombosis and bleeding and that any risk to the mother also jeopardizes the fetus.5 Severe preeclampsia alone can cause pulmonary edema due to increased sympathetic tone, decreased colloid oncotic pressure, increased capillary permeability and an elevated afterload. In our patient, ‘the concomitant presence of severe mitral stenosis leading to congestion in the pulmonary circulation, severe aortic stenosis leading to an increase in an already elevated afterload due to preeclampsia and the physiologic increase in intravascular volume and cardiac output during pregnancy, were the triggering factors for the dramatic worsening seen in her hemodynamic status.8 Percutaneous mitral balloon valvuloplasty is currently recommended as a safe and viable procedure in patients with prosthetic valves when pharmacological therapy is ineffective during pregnancy.9,10 The decision to proceed with cesarean section rather than mitral valvuloplasty was made because of the concern that the patient might acutely decompensate during this procedure. If this occurred, then emergency delivery of the fetus might have been difficult and lengthy. This decision proved especially fortunate because shortly after completion of the cesarean section, the largest electrical blackout in American history occurred resulting in a hospital fire and evacuation of our labor and delivery suite. Reported results with mitral balloon valvuloplasty in pregnancy have been excellent, with few maternal and/ or fetal complications. This report, however, involved only a few patients.11 Interestingly, our patient’s hemodynamic instability completely resolved after delivery, eliminating the need for valvuloplasty. This outcome strongly supports the contention that the physiologic changes of pregnancy and preeclampsia resulted in acute hemodynamic decompensation, hence delivery could be considered as a therapeutic intervention in this circumstance. Our anesthetic goals were to secure our patient’s airway and keep her circulation stable by avoiding hypotension and tachycardia. Hypotension in this patient would have produced myocardial ischemia and tachycardia, not only increasing myocardial oxygen consumption, but also decreasing left ventricular filling time, which is a critical factor in severe mitral stenosis. Our goal in fluid management was normovolemia since hypervolemia would have worsened her pulmonary edema and hypovolemia would have decreased her preload. This case describes the management of a pregnant patient with severe aortic and mitral valve stenosis, compounded by the presence of preeclampsia. From the experience gained, we believe that rapid delivery of the fetus played a crucial part in the management of progressive maternal hemodynamic deterioration and was certainly therapeutic in the correction of preeclampsia.
Anesthetic management in valvular heart disease 253 REFERENCES 1. Siu S C, Colman J M, Sorensen S, et al. Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease. Circulation 2002; 105: 2179–2184. 2. Angeles-Valdes J, Uruchurtu C E, Gomez C A. Mitral valvuloplasty. the double balloon technique compared with the “nucleus single balloon technique. Arch Cardiol Mex 2002; 72: 290–296. 3. Al Lawati A A, Venkitraman M, Al Delaime T, Valliathu J. Pregnancy and mechanical heart valves replacement; dilemma of anticoagulation. Eur J Cardiothorac Surg 2002; 22: 223–227. 4. Chan W S, Anand S, Ginsberg J S. Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature. Arch Intern Med 2000; 160: 191–196. 5. Bonow R O, Carabello B, De Leon A C, et al. ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease. Executive Summary. A Report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on management of patients with valvular heart disease). J Heart Valve Dis 1998; 7: 672–707.
6. Bates S M, Greer I A, Hirsh J, Ginsberg J S. Use of antithrombotic agents during pregnancy: The seventh ACCP Conference on antithrombotic and thrombolytic therapy. Chest 2004; 126: 627s–644s. 7. Elkayam U, Bitar F. Valvular heart disease and pregnancy: Part II: prosthetic valves. J Am Coll Cardiol 2005; 46: 403–410. 8. Desai D J, Golwala M P, Dhimar A A, Swadia V N. Emergency LSCS in a patient with severe mitral stenosis with pulmonary hypertension with aortic regurgitation (NYHA-III). Indian Journal of Anaesthesia 2002; 46: 483–485. 9. Martinez-Reding J, Cordero A, Kuri J, Martinez-Rios M A, Salazar E. Treatment of severe mitral stenosis with percutaneous balloon valvotomy in pregnant patients. Clin Cardiol 1998; 21: 659–663. 10. Poirier P, Champagne J, Alain P, et al. Mitral balloon valvuloplasty in pregnancy: limiting radiation and procedure time by using transesophageal echocardiography. Can J Cardiol 1997; 13: 843–845. 11. Pavankumar P, Venugopal P, Kaul U, et al. Closed mitral valvotomy during pregnancy. A 20-year experience. Scand J Thorac Cardiovasc Surg 1988; 22: 11–15.
CASE REPORT
Anesthetic management for emergency cesarean section in a patient with severe valvular disease and preeclampsia S. Dua, M. A. Maurtua, J. B. Cywinski, A. Deogaonkar, J. H. Waters, J. A. Dolak Division of Anesthesiology & Critical Care Medicine, Cleveland Clinic Foundation, Cleveland OH, USA SUMMARY. Wider selection of young patients for prosthetic valve replacement for valvular heart disease has resulted in an increase in number of women with heart disease reaching childbearing age. Such patients presenting in labor for emergency cesarean section require special consideration. We present a report of a parturient who presented at 36 weeks of gestation with severe aortic and mitral stenosis, pulmonary edema and severe preeclampsia. The goals of our anesthetic management included (1) careful airway management (2) maintaining stable hemodynamics (3) optimizing fluid status, and (4) preventing seizures. Issues related to management of patients with severe valvular disease, prosthetic valves and complications due to anticoagulant therapy during pregnancy are discussed. 2005 Elsevier Ltd. All rights reserved. Keywords: Valvular heart disease; Cesarean section; Preeclampsia
of breath, peripheral edema and increasing blood pressure suggestive of preeclampsia. Her past medical history was significant for an aortic valve replacement with a Carbomedics supra-annular aortic valve prosthesis #21 and a mitral valve repair with a Cosgrove annuloplasty ring #26, following an episode of bacterial endocarditis three years before this admission. She also had a prophylactic inferior vena cava filter that was placed at the time of this surgery, because of deep vein thrombosis. Her surgical history also included a patent ductus arteriosus repair as a 9-month-old child. During her pregnancy she was followed closely by the High Risk Obstetrics Service and her history was significant for a transient ischemic attack (TIA) at 12 weeks, with sudden onset of right-sided weakness involving the right upper extremity with facial droop, aphasia and speech impediment. On admission she was short of breath at rest. Her blood pressure was 170/100 mmHg and her heart rate 90 beats/min and regular; her oxygen saturation was 98-100% on room air and she had 2+ peripheral edema. Chest auscultation revealed a prosthetic click, S4 gallop, a grade III/VI systolic ejection murmur with a diastolic rumble and bibasilar rales. Examination revealed a Mallampati grade 4 airway, a thyromental distance greater than three fingers’ breath and a full range of neck movement. An electrocardiogram showed normal sinus rhythm. A chest X-ray showed bilateral pulmonary infiltrates suggestive of pulmonary edema. Laboratory findings included hematocrit 36%, platelet
INTRODUCTION The presence of clinically significant maternal heart disease during pregnancy increases the risk of adverse maternal, fetal and neonatal outcomes.1 In this case, a 21-year-old parturient with severe aortic and mitral stenosis, pulmonary edema and severe preeclampsia underwent an emergent cesarean section with an excellent outcome. The anesthetic management of this patient is discussed.
CASE REPORT A 21-year-old primigravida at 36 weeks’ gestation was admitted to the labor suite with progressive shortness Accepted October 2005 S. Dua, Resident, Division of Anesthesiology & Critical Care Medicine, M.A. Maurtua and J.B. Cywinski, Staff, Department of Anesthesiology, A. Deogaonkar, Fellow, Division of Anesthesiology & Critical Care Medicine, J.A. Dolak, Head, Section of Anesthesia for Obstetrics & Gynecology, Department of Anesthesiology, Division of Anesthesiology & Critical Care Medicine, Cleveland Clinic Foundation, Cleveland OH; J.H. Waters, Chief, Department of Anesthesiology, Magee Women’s Hospital, University of Pittsburgh, Pennsylvania, USA. Correspondence to: Marco A. Maurtua, M.D., Department of General Anesthesiology, The Cleveland Clinic Foundation, 9500 Euclid Avenue, E31, Cleveland OH 44195, USA, Tel.: +216 445 1151; fax: +216 444 9247. E-mail: [email protected]. 250
Anesthetic management in valvular heart disease 251 count 175 · 109/L, prothrombin time 10.6 s, international normalized ratio (INR) of 0.94, plasma thromboplastin time 69.9 s, serum sodium 142 mmol/L, serum potassium 4.3 mmol/L, blood urea nitrogen (BUN) 15 mg/dL, serum creatinine 0.8 mg/dL and 4+ proteinuria. Arterial blood gas analysis on an FiO2 of 26% revealed a pH of 7.45, PaO2 12.8 kPa (96 mmHg), PaCO2 3.73 kPa (28 mmHg), HCO3 19 mmol/L and base excess 5 mEq/L. A bedside transthoracic echocardiogram (Figs. 1 and 2) demonstrated severe aortic stenosis (peak/mean gradients of 80/45 mmHg) mitral stenosis (peak/mean gradients of 28/14 mmHg) and a left ventricular ejection fraction of 55%. There was mild tricuspid and mitral regurgitation. Following cardiology consultation, mitral valve balloon valvuloplasty was recommended, to improve forward blood flow. The fetal heart rate tracing was in 140s with excellent long term variability. As the patient’s condition was rapidly deteriorating and given the complications of balloon valvuloplasty itself, it was decided to proceed with cesarean section under general anesthesia with the cardiology team standing by. Our decision was also motivated by the undesirability of performing a cesarean section for fetal distress in an unprepared location such as an interventional cardiology suite. The patient was taken to the operating room and placed supine with left uterine displacement to place a pulmonary artery catheter (PAC). An arterial line had been placed in the labor room. After a few seconds in this position she became severely dyspneic, her oxygen saturation dropped to 70% while receiving oxygen by a non-rebreathing face mask, her blood pressure increased to >190/100 mmHg and her heart rate increased to >110 beats/min. Attempts to place the PAC were abandoned and an awake fiberoptic intubation was performed in the sitting position. No upper airway edema or bleeding from the nasal mucosa was seen. General anesthesia was
Fig. 2 Continuous Flow Doppler tracing of flow across aortic valve.
induced with etomidate and a balanced anesthetic was provided with midazolam, fentanyl, atracurium and sevoflurane. A magnesium sulfate infusion was administered preoperatively at the rate of 1.5 g/h for seizure prophylaxis and was continued in the postoperative period. An esmolol infusion was also given at the rate of 20 lgÆkg 1min 1. Her intraoperative blood pressure remained stable in the range of 140-160 mmHg systolic and 70-80 mmHg diastolic. A viable female baby was delivered 7 min after the incision with Apgar scores of 8 and 9 at 1 and 5 min respectively and umbilical artery pH 7.25 and venous 7.26. The rest of the intraoperative course was uneventful. On completion of the procedure, the patient was transferred intubated and sedated to the cardiac intensive care unit for further management. A PAC was placed, which demonstrated a pulmonary artery pressure (PAP) of 66/29 mmHg, pulmonary capillary wedge pressure (PCWP) 26 mmHg, cardiac output (CO) 3.8 L/min and a cardiac index (CI) 1.75. After 6 h her PAP was 47/33 mmHg, PCWP 24 mmHg, CO 4.25 L/min and CI 2.19. By the next day her PAP was 41/29 mmHg, PCWP 19 mmHg, CO 6.51 L/min and CI 2.93. She was extubated on postoperative day (POD) 1. Anticoagulation was reestablished and diuresis was started with furosemide. A valvuloplasty was never performed because of the major hemodynamic improvement that occurred after delivery, as confirmed by a significant decrease in PAP and PCWP and improved CO and CI without the need of inotropes. On POD 3 she was transferred to the postpartum ward and was discharged on POD 6.
DISCUSSION
Fig. 1 Continuous Flow Doppler tracing of flow across mitral valve.
The pregnant patient with heart disease poses a unique challenge because of the increased burden that pregnancy places on an already compromised cardiovascular
252 International Journal of Obstetric Anesthesia system. Prosthetic valve replacement has improved overall outcomes in both the mother with poorly tolerated valvular heart disease and the fetus.2 In patients with prosthetic valves, the need for anticoagulation presents a dilemma. Insufficient anticoagulation may lead to thromboembolic phenomena while overdose poses hemorrhagic risks to the mother and, if oral therapy is used, to the fetus also. There is a general consensus that warfarin should be avoided during the first trimester, when it should be replaced by heparin. However, due to its narrow therapeutic margin it is difficult to maintain a constant level of anticoagulation with subcutaneous heparin. 3 In a systematic review of 40 studies,4 it was reported that thromboembolic prophylaxis in women with mechanical heart valves during pregnancy was best achieved with oral anticoagulation. The practice of substituting heparin for oral anticoagulation in the first trimester potentially eliminates the risk of fetal embryopathy, but appears to increase the risk of thromboembolism, as was seen in our patient. Our patient had been on warfarin until 7 weeks’ gestation after which she was switched to a subcutaneous heparin pump. Her TIA was thought to result from microemboli because of subtherapeutic doses of heparin, so she was transferred back to warfarin at 12 weeks and again to heparin at 33 weeks. The use of heparin requires aggressive monitoring and appropriate dose adjustment. The American Heart Association/American College of Cardiology Task Force report in 1998 recommended the use of warfarin, especially in high-risk women, through week 35, when unfractionated heparin (UFH) should be substituted in anticipation of labor.5 The recommendations of the Seventh American College of Chest Physicians consensus conference on antithrombotic therapy for prophylaxis in patients with mechanical heart valves6 include substituting unfractionated or low molecular weight heparin (LMWH) for warfarin when pregnancy is achieved in patients on oral anticoagulation. In women with prosthetic heart valves, careful dose adjustment of UFH throughout pregnancy, or UFH/LMWH until the thirteenth week and then warfarin until the middle of the third trimester before restarting UFH or LMWH, is strongly recommended. Furthermore, in high-risk women with prosthetic heart valves, addition of low-dose aspirin has been suggested. Most recently, a combination of aforementioned recommendations based on the type of prosthetic valve and the level of risk has been suggested, with an emphasis on the aggressive monitoring of trough level of heparin in addition to peak levels.7 Anticoagulant treatment should be discussed in detail with the patient and her partner throughout pregnancy. If the patient prefers to change to heparin for the first trimester, she should be made aware that heparin carries a higher risk of
both thrombosis and bleeding and that any risk to the mother also jeopardizes the fetus.5 Severe preeclampsia alone can cause pulmonary edema due to increased sympathetic tone, decreased colloid oncotic pressure, increased capillary permeability and an elevated afterload. In our patient, ‘the concomitant presence of severe mitral stenosis leading to congestion in the pulmonary circulation, severe aortic stenosis leading to an increase in an already elevated afterload due to preeclampsia and the physiologic increase in intravascular volume and cardiac output during pregnancy, were the triggering factors for the dramatic worsening seen in her hemodynamic status.8 Percutaneous mitral balloon valvuloplasty is currently recommended as a safe and viable procedure in patients with prosthetic valves when pharmacological therapy is ineffective during pregnancy.9,10 The decision to proceed with cesarean section rather than mitral valvuloplasty was made because of the concern that the patient might acutely decompensate during this procedure. If this occurred, then emergency delivery of the fetus might have been difficult and lengthy. This decision proved especially fortunate because shortly after completion of the cesarean section, the largest electrical blackout in American history occurred resulting in a hospital fire and evacuation of our labor and delivery suite. Reported results with mitral balloon valvuloplasty in pregnancy have been excellent, with few maternal and/ or fetal complications. This report, however, involved only a few patients.11 Interestingly, our patient’s hemodynamic instability completely resolved after delivery, eliminating the need for valvuloplasty. This outcome strongly supports the contention that the physiologic changes of pregnancy and preeclampsia resulted in acute hemodynamic decompensation, hence delivery could be considered as a therapeutic intervention in this circumstance. Our anesthetic goals were to secure our patient’s airway and keep her circulation stable by avoiding hypotension and tachycardia. Hypotension in this patient would have produced myocardial ischemia and tachycardia, not only increasing myocardial oxygen consumption, but also decreasing left ventricular filling time, which is a critical factor in severe mitral stenosis. Our goal in fluid management was normovolemia since hypervolemia would have worsened her pulmonary edema and hypovolemia would have decreased her preload. This case describes the management of a pregnant patient with severe aortic and mitral valve stenosis, compounded by the presence of preeclampsia. From the experience gained, we believe that rapid delivery of the fetus played a crucial part in the management of progressive maternal hemodynamic deterioration and was certainly therapeutic in the correction of preeclampsia.
Anesthetic management in valvular heart disease 253 REFERENCES 1. Siu S C, Colman J M, Sorensen S, et al. Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease. Circulation 2002; 105: 2179–2184. 2. Angeles-Valdes J, Uruchurtu C E, Gomez C A. Mitral valvuloplasty. the double balloon technique compared with the “nucleus single balloon technique. Arch Cardiol Mex 2002; 72: 290–296. 3. Al Lawati A A, Venkitraman M, Al Delaime T, Valliathu J. Pregnancy and mechanical heart valves replacement; dilemma of anticoagulation. Eur J Cardiothorac Surg 2002; 22: 223–227. 4. Chan W S, Anand S, Ginsberg J S. Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature. Arch Intern Med 2000; 160: 191–196. 5. Bonow R O, Carabello B, De Leon A C, et al. ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease. Executive Summary. A Report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on management of patients with valvular heart disease). J Heart Valve Dis 1998; 7: 672–707.
6. Bates S M, Greer I A, Hirsh J, Ginsberg J S. Use of antithrombotic agents during pregnancy: The seventh ACCP Conference on antithrombotic and thrombolytic therapy. Chest 2004; 126: 627s–644s. 7. Elkayam U, Bitar F. Valvular heart disease and pregnancy: Part II: prosthetic valves. J Am Coll Cardiol 2005; 46: 403–410. 8. Desai D J, Golwala M P, Dhimar A A, Swadia V N. Emergency LSCS in a patient with severe mitral stenosis with pulmonary hypertension with aortic regurgitation (NYHA-III). Indian Journal of Anaesthesia 2002; 46: 483–485. 9. Martinez-Reding J, Cordero A, Kuri J, Martinez-Rios M A, Salazar E. Treatment of severe mitral stenosis with percutaneous balloon valvotomy in pregnant patients. Clin Cardiol 1998; 21: 659–663. 10. Poirier P, Champagne J, Alain P, et al. Mitral balloon valvuloplasty in pregnancy: limiting radiation and procedure time by using transesophageal echocardiography. Can J Cardiol 1997; 13: 843–845. 11. Pavankumar P, Venugopal P, Kaul U, et al. Closed mitral valvotomy during pregnancy. A 20-year experience. Scand J Thorac Cardiovasc Surg 1988; 22: 11–15.