Ofcial reprint from UpToDate

www.uptodate.com 2017 UpToDate

Anesthesia for labor and delivery in high-risk heart disease: General considerations

Author: Katherine W Arendt, MD

Section Editors: David L Hepner, MD, Susan M Ramin, MD, Heidi M Connolly, MD, FASE, Jonathan B Mark, MD
Deputy Editor: Nancy A Nussmeier, MD, FAHA

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through:Jan 2017.|This topic last updated:Sep 26, 2016.

INTRODUCTIONCardiovascular disease is now the leadingcause of maternal mortality in the developed world [1-
3]. Although the incidence of pregnancy among women with congenital heart disease is increasing, the main causes
of cardiac death in pregnancy are acquired heart disease: myocardial infarction, aortic dissection, and
cardiomyopathy [2].

Anesthetic management of the pregnant woman with high-risk cardiovascular disease requires an understanding of
the individual patient's cardiac anatomy and pathophysiology; how the physiologic changes associated with
pregnancy, labor, and delivery have affected the patient; and the hemodynamic alter ations that may be induced by
the choices of analgesic or anesthetic techniques. Ideally , an individualized management plan is developed in the
antepartum period by a team of providers (cardiologist, obstetrician, and anesthesiologist)4].
[ Interdisciplinary
communication and preparation are critically important since peripartum obstetric and cardiac complications may
require rapid intervention.

This topic will discuss general considerations in the anesthetic management of the obstetric patient with high-risk
acquired or congenital cardiovascular disease, emphasizing methods ot minimize peripartum risk while providing
optimal anesthetic care. All other aspectsof management of heart disease during pregnancy, including specic
cardiac pathology, are discussed separately (see "Acquired heart disease and pregnancy" and "Pregnancy in women
with congenital heart disease: General principles"). Basic anesthetic considerations for obstetric patients also apply
to those with cardiovascular disease. (See"Adverse effects of neuraxial analgesia and anesthesia for obstetrics"
and "Pharmacologic management of pain during labor and deliv ery" and "Neuraxial analgesia for labor and delivery
(including instrumented delivery)".)

HEMODYNAMIC CHANGES DURING PREGNANCY, LABOR, AND DELIVERYUnderstanding the hemodynamic

changes related to pregnancy, labor, and delivery is essential so clinicians can anticipate which cardiac conditions
predispose to decompensation in the peripartum period and select appropriate anesthetic monitoring and
techniques to minimize this risk.

AntepartumCardiovascular and hemodynamic changes begin as early as the fourth week of gestation and persist
for several months postpartum. Systemic vascular resistance (SVR) decreases, heart rate (HR) increases by 15 to
20 beats/minute, and preload increases due to an increase in blood volume. These changes result in a 30 to 50
percent increase in cardiac output (CO) above baseline. A physiologic dilutional anemia also develops.
Cardiovascular and hemodynamic adaptations to normal pregnancy are summarized in the gures (gure 1A-C) and
discussed in detail separately. (See "Maternal cardiovascular and hemodynamic adaptations to pregnancy".)

LaborDuring labor, CO progressively increases due to pain, anxiety, and autotransfusion during contractions.
Stroke volume (SV) and HR rise and fall with each contraction, with peaks as high as 50 percent above prelabor
values.
DeliveryImmediately after either vaginal or cesarean delivery, CO peaks as the evacuated uterus contracts and
blood from myometrial veins is autotransfused into the systemic venous system. Also, the contracted uterus lifts off
the vena cava, resulting in greater venous blood return to the heart, which increases SV. In fact, within the rst 10
minutes following a term vaginal delivery, CO and SV increase by 59 and 71 percent, respectively [5]. However,
unusual or ongoing blood loss during and immediately after deliv ery can counteract these effects.

After vaginal delivery, increases in CO and SV persist for at least one hour,while HR decreases and blood pressure
(BP) remains unchanged [6]. These factors, in combination, typically er sult in unchanged mean arterial pressure
(MAP) in the early postpartum period. However, patients with heart failure are at increased risk of developing
pulmonary edema.

After cesarean delivery, MAP remains stable, but CO increases by approximately 30 to 50 percent, compared with
predelivery values [7-9]. This is an acute change that occurs within two minutes of deliv
ery of the fetus and persists
for about 10 minutes 7 [ ].

In patients with cardiovascular disease, other factors that affect hemodynamic status during and immediately after
delivery include the underlying cardiac pathology; gestational age; anesthetic agents; intr
avascular uid status;
positioning of the patient; and the oute,
r dose, and choice of uterotonic agents. (See'Effects of drugs commonly
used in the labor unit'below.)

PRENATAL ANESTHESIA EVALUATION

Risk straticationRisk stratication schemes help identify pregnant women with only mild cardiovascular
disease who may safely deliver in a community hospital versus those who should be transferred to a tertiary care
center [10-16]. The healthcare team, including the community-based anesthesiologist, will determine the optimum
location for delivery. A system with an obstetric anesthesiologistot help identify and evaluate such patients prior ot
their arrival for delivery is ideal. Risk stratication also helps in planning appropriate monitoring, intravascular
access, and anesthetic techniques.

The American Heart Association, the American College of Car diology, and the European Society of Cardiology have
classied the following lesions as high maternal oretal
f risk:

Congenital and genetic heart disease

[4,17]

Prior Fontan procedure

Severe pulmonary arterial hypertension

Cyanotic congenital heart disease

Complex congenital heart disease with sequelae such as heart failure, valve disease, or the need for
anticoagulation

Congenital heart disease with malignant arrhythmias

Marfan syndrome

Valvular heart disease

[4,14,18]

Severe aortic stenosis (valve area <1 cm2, mean transvalvular gradient >40 mmHg)with or without symptoms
 Mitral stenosis with New York Heart Association (NYHA) class II to IV symptoms (table 1)

Aortic or mitral regurgitation with NYHA class III to IV symptoms (table 1)

Aortic and/or mitral valve disease with severe left ventricular dysfunction (dened as a left ventricular ejection
fraction less than 40 percent) or severe pulmonary hypertension (dened as pulmonary artery pressure >75
percent of systemic pressure)

Mechanical prosthetic valve

Since severe morbidity or mortality during pregnancy, labor, and delivery is more common in patients with congenital
or valvular lesions, it is suggested that obstetrical car
e be obtained at institutions with maximal esources.
r For
example, peripartum nitric oxide administration or more aggressive "rescue" therapies such as cardiopulmonary
bypass, extracorporeal membrane oxygenation, ventricular assist devices, and even heart-lung transplantation have
been described in patients at extreme risk [19-22]. (See "Acquired heart disease and pregnancy" and "Pregnancy in
women with mitral stenosis" and "Pregnancy in women with a bicuspid aortic valve" and "Management of pregnant
women with prosthetic heart valves" and "Pregnancy in women with congenital heart disease: General principles"
and "Pregnancy in women with congenital heart disease: Specic lesions".)

Patients with pre-existing cardiovascular disease are at particularly high risk if their pregnancy is complicated (eg,
multiple gestation, preeclampsia, venous thromboembolism) [10]. An example is twin gestation in a patient with
mitral stenosis, who has increased risk of developing pulmonary congestion or edema due to the greater blood
volume expansion that occurs with multiple gestations.

Prepartum anesthesia consultationPrepartum evaluation includes review of the patient's cardiovascular lesions
prior reparative procedures, and pertinent cardiac testing to determine disorders that may impact peripartum care.
In high-risk cases, the decision er garding transfer to a tertiary care center is nalized during the anesthesiologist's
and other consultants' prepartum evaluations [10-16]. (See 'Risk stratication' above.)

Although the majority of pregnant women with cardiovascular disease have favorable outcomes [23,24], some may
experience deterioration in cardiopulmonary status during labor and delivery [25]. Thus, anesthetic management
should include contingency plans for obstetric complications such as the need for emer gency cesarean delivery or
postpartum hemorrhage, as well as plans for car diopulmonary complications.

When the antepartum maternal condition is tenuous or potentially terminal, it is impor

tant to document the patient's
resuscitative wishes in the event of cardiopulmonary arrest.

OBSTETRIC ISSUES

Induction of laborIn women at high risk of maternal morbidity or mor tality during labor or delivery, scheduling
induction rather than waiting for spontaneous labor ot begin may ensure that appropriate specialists are readily
available (eg, cardiologist, maternal-fetal medicine specialist, obstetric anesthesiolo gist, and neonatologist). High-
risk patients are identied on a case-by-case basis using risk stratication guidelines (see'Risk stratication' above),
and the clinical decision to schedule induction of labor versus allowing spontaneous onset of labor is
multidisciplinary.

Induction of labor, if required, is generally safe and usually performed in a conventional manner (eg, cervical ripening
with Foley catheter or misoprostol, amniotomy, oxytocin) (see "Induction of labor"). Placement of appropriate
maternal monitoring devices (discussed below), intravascular access, and other preparations for analgesia and
anesthesia should take place before contractions begin. If an epidural catheter is in place, pain control can be
implemented promptly when needed, thus mitigating hemodynamic instabilityelated r to the pain and stress of labor.
Women with signicant cardiovascular disease should be placed in a semir ecumbent position with a lateral tilt
during the intrapartum period. Vital signs should be assessed fr
equently between uterine contractions. Cardiac
decompensation may mandate initiation of intensive medical management.

Route of deliveryVaginal delivery is generally preferred unless there is an obstetric indication for cesarean
delivery. In high-risk cardiac patients, obstetric management of labor and delivery may be modied to accommodate
the limitations imposed by cardiac dysfunction. Neuraxial analgesia is generally required; if neuraxial analgesia is
not an option, then the advisability of vaginal delivery may need to be reconsidered.

Cesarean delivery is rarely performed solely for a maternal cardiac indication. Exceptions may include aortopathy
(eg, aortic dissection, dilated aorta >4.5 cm, or progressive aortic enlargement during gestation), in which epetitive
r
increases in cardiac output (CO) related to contractions and pushing may increase the risk of aortic dissection
(gure 2A-B). Other cardiovascular disorders that may be managed with cesarean delivery are severe pulmonary
hypertension or Eisenmenger syndrome, as these patients may develop right ventricular failure with cardiogenic
shock. The appropriate route for delivery, determined on a case-by-case basis, is discussed in ot pics addressing
each specic cardiovascular lesion.

Maternal warfarin anticoagulation one to two weeks before delivery is a possible indication for cesarean delivery
because fetal anticoagulation occurs withmaternal warfarin therapy and increases the risk of fetal intracranial
hemorrhage [26,27], and this risk is likely increased during vaginal birth.

Vaginal "cardiac delivery"In a maternal "cardiac delivery" with epidural analgesia, fetal descent during the
majority of the second stage is accomplished ex clusively by uterine contractions without the aid of maternal
expulsive efforts. When the fetal head reaches the pelvic oor, a low or outlet operative vaginal delivery (either
forceps or vacuum extraction) is performed. This avoids the physiologic changes associated with maternal pushing
(eg, Valsalva maneuver or increased intrathoracic pressure resulting in decreased venous return, decreased preload,
and decreased CO). Although the appropriateness of "cardiac delivery" is controversial, the maternal and fetal risks
of operative vaginal delivery relative to the maternal cardiac risk associated with Valsalva maneuvers are
individually determined for each patient. (See"Operative vaginal delivery".)

The anesthesiologist may evaluate maternal hemodynamic ot lerance of pushing including pulse oximetry waveform
and saturation. This is especially helpful in patients with intr
acardiac shunts because of the concern for right-t
o-left
shunt with increased intrathoracic pressure. The resultant decrease in oxygen saturation may stress the fetus. For
optimal monitoring, it may be necessary to position the pulse oximetry probe on an earlobe or other area since many
women use a handgrip during pushing.

Endocarditis prophylaxis(See "Antimicrobial prophylaxis for bacterial endocarditis", section on 'Vaginal or

cesarean delivery'.)

Effects of drugs commonly used in the labor unitThe following medications are often or routinely used during
labor or postpartum. Possible implications in women with high-risk car
diovascular disease are discussed.

Oxytocin for labor induction/augmentationor prevention/treatment of postpartum hemorrhage Oxytocin

decreases mean arterial pressure and total peripheral vascular resistance, and possibly slightly increases
pulmonary artery pressure [28,29]. These changes need to be considered and oxytocin must be administered
cautiously to patients with certain cardiovascular lesions (eg, aortic stenosis, hypertrophic obstructive
cardiomyopathy, ischemic heart disease, or aortopathy with risk of dissection), since sudden decompensation
can occur when afterload is er duced or heart rate is elevated.

Oxytocin should be administered as a dilute solution by continuous intravenous (IV) infusion. For postpartum
hemorrhage, an intramuscular (IM) injection of 10 USP units is alsoeasonable.
r Importantly, oxytocin should
not be administered IV as a large bolus.
 Misoprostol for cervical ripening or treatment of postpartum hemorrhage Misoprostol does not affect
maternal cardiac function, even at high doses [30].

Carboprost tromethamine for treatment of postpartum hemorrhage Side effects of carboprost tromethamine
include bronchospasm [31] and alterations in the ventilation/perfusion ratio, resulting in increased
intrapulmonary shunt fraction and hypoxemia [32]. Carboprost tromethamine may also induce hypertension at
high doses. Carboprost tromethamine should be avoided in patients with an intracardiac shunt because the
administration may increase shunting. It should also be avoided in patients with single-ventricle physiology as it
may signicantly decrease CO, which could potentially result in signicant morbidity or mortality [33].

Methergine for treatment of postpartum hemorrhage Methergine is contraindicated in patients with

cardiovascular disease, especially those with systemic, pulmonary, or pregnancy-induced hypertension,
because of the following side effects:

Vasoconstriction (potentially causing sudden systemic hypertension and resultant stroke, seizure, or
myocardial ischemia in patients with hypertension, especially preeclampsia) [34]

Coronary vasospasm (potentially causing myocardial infarction in patients with ischemic heart disease)

Increased pulmonary artery pressure (potentially causing shunt reversal and cyanosis in patients with
intracardiac shunts)

Magnesium sulfatefor seizure prophylaxis and neonatal neuroprotection Cardiac dysfunction is associated
with very high magnesium levels and appears to be secondary to respiratory arrest and hypoxia [35]. Toxicity
can be avoided by standard maternal monitoring during magnesium administration.

Beta-agonists for treatment of preterm labor or prolonged or frequent uterine contractions Adverse
reactions seen in 1 to 10 percent of patients include tachycardia, hypertension, and palpitations. In <1 percent,
side effects include arrhythmia, cardiac arrest, chest pain, hypotension, myocardial infarction, myocardial
ischemia, pulmonary edema, and paradoxical bronchospasm. Beta-agonists should be used cautiously in
women with cardiac lesions sensitive to these effects and generally should be avoided in women with heart
failure. Alternative tocolytics are available (see "Inhibition of acute preterm labor"). Patients with hypertrophic
cardiomyopathy (HCM) are especially at risk for left ventricular outow obstruction and decompensation with
beta-agonist administration.

Antihypertensive drugs Labetalol and nifedipine are the most common antihypertensive drugs used in the
labor unit; occasionally, hydralazine is selected. The safety of these drugs depends on the patient's underlying
cardiovascular physiology. For example, the reex tachycardia that may occur with hydralazine administration
may be undesirable in patients with mitral stenosis. Also, nifedipine should be avoided in women with aortic
stenosis or HCM because decreasing systemic vascular resistance (SVR) decreases coronary perfusion to the
thickened myocardium in aortic stenosis and can worsen outow obstruction in HCM. Beta blockade, howe ver,
is useful for patients with HCM because it helps pr event infundibular spasm. In general, antihypertensive
agents should be used cautiously in women with car diac lesions sensitive to hypotension by employing low
doses, gradual titration, and more intensive monitoring. (See 'Preparation of vasoactive agents' below and
'Monitoring' below.)

GENERAL PRINCIPLES OF ANESTHETIC MANAGEMENT

MonitoringStandard labor monitoring includes noninvasive blood pressure (NIBP) measurement,

tocodynamometry, and fetal heart rate (HR) monitoring. In patients with high-risk cardiovascular disease, additional
continuous maternal monitoring is recommended throughout labor and delivery or cesarean delivery in order to
detect development of complications such as myocardial ischemia, arterial hemoglobin desaturation, or pulmonary
edema.

ElectrocardiogramIn all high-risk cardiac patients, a continuous electrocardiogram (ECG) is monitored for
development of arrhythmias, as well as detection of my ocardial ischemia in patients with aortic stenosis, ischemic
heart disease, or hypertrophic cardiomyopathy. A ve-lead ECG with computerized ST-segment trending is superior
to visual clinical interpretation for identifying ST-segment changes [36-38], and multiple-lead monitoring is more
sensitive than single-lead monitoring for detection of ischemia 39].
[ However, many obstetric nurses are not
qualied to interpret ECG monitoring (ie, telemetry). Therefore, it may be necessary to coordinate specialized
nursing care for patients at risk during labor.

External debrillator padsIn patients with a history of poorly-tolerated tachyarrhythmias, we place external
debrillator pads to achieve rapid cardioversion or debrillation.

Pulse oximetryA continuous pulse oximetry monitor with both audible and visible waveform display should be
used. This is particularly important for patients with cyanotic congenital heart disease or right-to-left intracardiac or
extracardiac shunts.

Intravenous catheter ltersFilters on all intravenous (IV) catheters are necessary to prevent paradoxical air
embolism in patients with intracardiac or extracardiac shunts.

Intra-arterial catheterSystemic blood pressure (BP) is monitored with an intra-arterial catheter so that
hypotension can be detected and treated immediately. During labor, moment-to-moment monitoring of arterial BP
allows analysis of the effects of uterine contractions and maternal expulsive efforts on overall hemodynamics

In high-risk or unstable patients undergoing cesarean delivery, the intra-arterial catheter should be inserted prior to
induction of either regional or general anesthesia. This also facilitates management of avsoactive drug
administration and measurement of arterial blood gases.

Central venous catheterIn unstable patients (eg, hypotension, pulmonar y edema, or peripartum hemorrhage)
with high-risk cardiovascular disease, a central venous catheter (CVC) may be inserted for vasoactive drug
administration, as well as for monitoring central venous pressure (CVP). Although the latter measurement should
not be used as a sole guide for uid management, it ma y be helpful when CVP values are either high or low.

Pulmonary artery catheterA pulmonary artery catheter (PAC) is rarely indicated in parturients with high-risk
cardiac disease. The risk of complications(eg, arrhythmias, incorrect interpretation of data, pulmonary artery
rupture) during catheter placement and management is high in this population because of conduction and anat omic
abnormalities. However, a PAC may be helpful in selected patients (eg, severe pulmonary hypertension requiring
titration of pulmonary vasodilatory agents such as nitric oxide). In this situation, the patient may undergo labor and
delivery in an intensive care unit (ICU) setting, rather than on a regular obstetric ward. (See "Pulmonary artery
catheterization: Indications, contraindications, and complications in adults" .)

Transesophageal or transthoracic echocardiographyPerioperative transesophageal echocardiography (TEE)

or transthoracic echocardiography (TTE) is indicated to determine the cause of anyunexplained persistent or life-
threatening circulatory instability (ie, "rescue echo"). During general anesthesia, TEE monitoring is the best method
to assess volume status (eg, hypovolemia), as well as regional and global cardiac function.

Preparation of vasoactive agentsVasoactive drugs should be prepared in advance, including syringes for bolus
administration and infusions for continuous administr ation. Bolus IV doses of bothphenylephrine and ephedrine
should be immediately available, as well as a phenylephrine infusionot be administered at 0.1 to 2 mcg/kg/minute if
necessary. Depending on the specic cardiac lesion, other vasodilator, inodilator, inotropic, and/or vasopressor drug
infusions should also be readily available (table 2). Notably, nitroprusside and nitroglycerin are myometrial relaxants;
these agents should be used with caution immediately after deliv
ery since they may lead to uterine atony and
postpartum hemorrhage. (See"Anesthesia for noncardiac surgery in patients with heart failure", section on
'Administration of vasoactive agents'.)

Neuraxial analgesia for laborWe suggest a labor epidural or a low-dose combined spinalepidural (CSE) for most
parturients with high-risk cardiovascular disease.

A major physiologic benet of neuraxial labor analgesia in high-risk cardiac patients is reduction in cardiac output
(CO) peaks throughout labor since these increases are largely mediated by catecholamine release due to pain and
anxiety. Thus, the epidural should be placed early in labor. Ideally, the epidural block is dense enough to minimize
any subsequent pain.

Either an epidural or a low-dose CSE can be safely performed in most cases. However, close monitoring of systemic
BP is necessary.

For patients in active labor with severe pain, CSE using intrathecal opioid without local anesthetic in the intrathecal
space may be preferable to an epidural technique alone because of faster onset ofanalgesia with minimal
hemodynamic effects. For patients in early labor who are relatively comfortable, this difference is less important.

In general, neuraxial approaches are desirable because:

Excellent analgesia is provided.

Continuous infusion of local anesthetic and opioid in the epidur

al catheter may be titrated to meet the needs of
the patient as labor progresses. Dense analgesia can be achieved, thus minimizing catecholamine elease.
r

A passive second stage of labor is possible because the ur

ge to push is diminished. (See'Vaginal "cardiac
delivery"' above.)

If urgent cesarean delivery becomes necessary, a surgical block can be established with minimal hemodynamic
changes by "dosing up" the epidural catheter with more concentrated local anesthetic (typically 2%lidocaine).

Epidural technique for labor

Perform loss-of-resistance technique withsaline (rather than air) to avoid paradoxical air embolism, which can
occur if the epidural needle is unintentionally placed into an epidural vein in a patient with an intra- or
extracardiac shunt.

Evaluate the risks and benets of administering a test dose via the epidural catheter. (See 'Test dose
administration' below.)

Administer a 5-mL dose of the labor epidur al solution (eg, 0.04 to 0.125% bupivacaine with 1 to 2 mcg/mL
fentanyl) incrementally every ve minutes, up to 15 mL. Close monitoring is important to assure adequate labor
analgesia.

If the block remains below T10, and therefore provides inadequate labor analgesia, it is easonable
r to
administer another 5 to 10 mL of the labor epidural solution.

If signicant labor pain persists 30 minutes after this bolus, it is lik

ely that the position of the epidural catheter
is suboptimal and it should be er placed.

Administer a continuous infusion of the labor epidur

al solution at a rate of 6 to 12 mL/hour, titrated to maintain
adequate analgesia and avoid hypotension.
 It is reasonable to allow a patient-controlled epidural analgesia button for an additional dose of 4 o
t 6 mL of the
infusion as frequently as every 15 minutes, or an epidural pump equipped with programmed intermittent bolus
settings.

CSE technique for labor

Administer 15 to 25 mcg of fentanyl into the intrathecal space. Consider eliminating local anesthetic fr
om the
intrathecal dose to decrease the likelihood of hypotension.

If intrathecal local anesthetic is utilized, 1.5 to 2.5 mg of intrathecal isobaric bupivacaine is a reasonable dose.
An example of a patient who would benet fr om intrathecal local anesthetic is a multiparous patient rapidly
progressing into the second stage of labor.

Initiate administration of a continuous infusion of the labor epidural solution (eg, 0.04 to 0.125% bupivacaine
with 1 to 2 mcg/mL of fentanyl) at a rate of 6 to 12 mL/hour, titrated to maintain adequate analgesia and avoid
hypotension.

If labor pain begins to return as the intrathecal fentanyl (with or without local anesthetic) wears off, administer
5 to 10 mL of 0.04 to 0.125% bupivacaine with 1 to 2 mcg/mL of fentanyl in the epidural catheter every ve
minutes, up to 15 mL total.

Test dose administrationIn patients with cardiovascular disease, the risks and benets of administering a
test dose of local anesthetic withepinephrine into the epidural catheter are evaluated on a case-by-case basis.

Because aspiration of an epidural catheter may be negative even if the catheter is located intravascularly or
intrathecally, a test dose is administered into the epidural catheter prior to full dosing. This detects catheter
misplacement without causing the harm that couldesult r from a full epidural labor analgesia or surgical anesthesia
dose of local anesthetic injected into the intravascular space (eg, seizure or local anesthetic toxicity) or the
intrathecal space (eg, a high spinal with anesthetic block inv olving the cervical nerves or higher). A traditional
epidural test dose contains a local anesthetic dose that causes centr al nervous system (CNS) excitation (eg, ear
ringing) if given intravascularly or a dense block and hypotension if giv en intrathecally. Epinephrine is usually
included in the test dose, causing hypertension and/or tachycardia if given intravascularly. For example, 3 mL of
1.5% lidocaine with 1:200,000 epinephrine is a typical test dose.

However, obstetric patients with certain cardiovascular lesions would respond poorly to administration of alpha and
beta sympathomimetic agonists (eg, aortic aneurysm or dissection, hypertrophic obstructive cardiomyopathy, or
severe mitral or aortic stenosis). Even a small IV dose ofepinephrine in these patients may result in catastrophic
events (eg, marked tachyarrhythmia or hypertension with resultant cardiovascular deterioration). In these patients,
epinephrine is avoided and only a local anesthetic and an opioid are administered to assess for intravascular or
intrathecal placement, using one of the following appr oaches:

We suggest administering an initial test dose of 3 mL of 1.5%lidocaine with 100 mcg fentanyl in order to test
for potentially disastrous intravascular or intrathecal placement of the catheter. Intravascular placement would
be determined by the rapid onset of sleepiness (due to the fentanyl blood concentration), while intrathecal
placement would be determined by the onset of a spinal block (which would be evident after approximately ve
minutes).

Alternatively, the rst dose of the labor epidural solution can be the "test dose." In this practice, the rst 5 mL of
the labor epidural solution (eg, 0.04 to 0.125% bupivacaine with 1 to 2 mcg/mL fentanyl) is administered, and
the patient is immediately assessed for CNS ex citation symptoms (intravascular placement), then
subsequently assessed (ve minutes later) for motor block (intrathecal placement).
Whichever technique is chosen, it is important to note that failure to recognize an intravascular injection prior to fully
dosing an epidural could result in bupivacaine toxicity and resultant arrhythmias, circulatory collapse, and cardiac
arrest. Equally important, failure to recognize an intrathecal injection prior to fully dosing an epidural could result in a
high spinal and resultant hypotension, bradycardia, respiratory insufciency or apnea, loss of consciousness, and
cardiac arrest.

Either scenario could be catastrophic for any patient, but this is especially true for patients ha
ving limited cardiac
reserve. Certainly, proceeding with cautionwith initial dosing of the epidural in cardiac patients is of paramount
importance. In fact, it is reasonable to consider each subsequent dose of epidural local anesthetic solution o t be a
"test dose." Thus, doses are administered in 3- to 5-mL increments every ve minutes, while asking the patient for
signs and symptoms of an intravascular or intrathecal injection. However, if there is no evidence of sensory block
after a full 15-mL epidural dose has been administered, then the epidural should be replaced.

Parenteral analgesia for laborPatient-controlled analgesia (PCA) via intravascular opioid infusion with
remifentanil or fentanyl may not be a good alternative in a high-risk cardiac patient because pain control is often
suboptimal and catecholamine er lease is not adequately mitigated. Furthermore, achieving even moderately
effective analgesia may require an opioid dose that suppresses ventilation. The resultant carbon dioxide (CO2)
retention can cause respiratory acidosis as well as further catecholamine release. Either catecholamine er lease or
respiratory acidosis can lead to exacerbation of pulmonary hypertension, arrhythmias, ischemia, or decompensated
heart failure in patients at risk.

Neuraxial anesthesia for cesarean deliveryNeuraxial anesthetic techniques are preferred in most patients having
cesarean delivery, including those with cardiovascular pathology (see"Anesthesia for cesarean delivery"). For most
high-risk cardiac patients, a low-dose CSEor a very slowly titrated epidural anesthetic is reasonable if an intra-
arterial catheter has been previously inserted for continuous arterial BP monitoring.

A purported benet of the low-dose CSE technique includes a slower onset of the neur axial block, allowing the
anesthesiologist to adequately maintain preload and afterload while still achieving the reliability of an intrathecal
local anesthetic block. Although data on utilization for delivery in high-risk cardiac patients are limited, we prefer this
technique because of the greater reliability of intrathecal (versus solely epidural) local anesthetics for surgical
anesthesia. In a case report including four patients with high-risk cardiovascular disease, CSE performed with an
intrathecal dose of bupivacaine 4 to 5 mg plus fentanyl 20 to 25 mcg was safe and effective [40]. Administration of
this low intrathecal dose is followed by slow loading of the epidural catheter with local anesthetic (eg, 2%lidocaine
without epinephrine) to achieve a T6 surgical level.

In contrast, the sympathectomy induced by a spinal dose appropriate for abdominal surgery that is administered
rapidly in a single intrathecal injection may result in profound hypotension. This would be particularly harmful in
patients with cardiac lesions where sudden decreases in preload or afterload can be disastrous (eg, aortic stenosis,
aortic coarctation, hypertrophic cardiomyopathy, mitral stenosis, or congenital heart disease with right-to-left
shunting).

Some anesthesiologists avoid any neuraxial technique in patients with left ventricular outow tract obstruction [41].
However, careful and well-monitored epidural anesthesia for cesarean delivery has been reported to be well
tolerated, even in severe aortic stenosis or hypertrophic cardiomyopathy [42,43]. Of note, patients with Marfan
syndrome and related disorders may have lumbosacral dural ectasia with an increased risk of dural puncture or
inadequate spinal anesthesia. (See"Anesthesia for labor and delivery in high-risk heart disease: Specic lesions",
section on A' ortic aneurysm or dissection (Marfan syndrome)'.)

Epidural technique for cesarean deliveryWith or without CSE, placement of the epidur al catheter is followed
by slow dosing (3 to 5 mL every ve minutes) of an agent such as 2%lidocaine. With such slow dosing, as well as
appropriate monitoring and vigilance, severe cardiovascular instability is unlikely [42,44]. In patients who may not
tolerate sympathomimetic activity,it is important to avoid epinephrine as an additive to the epidural local
anesthetic. (See 'Test dose administration' above.)

In high-risk cardiac patients, especially those with any sort of outow tract obstruction, we place an intra-
arterial catheter prior to administration of epidural anesthesia.

In cardiac lesions where any sudden decrease in preload or afterload can be disastrous, prepare a
phenylephrine infusion so that titrated phenylephrine administration can be immediately initiated ot treat
hypotension. Other vasopressors (eg, ephedrine) should be readily available.

Perform loss of resistance with saline, rather than air, to avoid paradoxical air embolism, which could er sult in
stroke in a patient with an intracardiac shunt.

Evaluate the risks and benets of administering an epinephrine-containing test dose via the epidural catheter.
(See 'Test dose administration' above.)

Perform left uterine displacement immediately after placement of the epidur

al. Exaggerating the tilt may be
necessary.

Dose the epidural catheter slowly with a local anesthetic withoutepinephrine (3 to 5 mL every ve minutes)
until a T6 level is achieved.

Fentanyl 50 to 100 mcg via the epidural catheter is often used as an adjunct ot reduce intraoperative
discomfort. It is reasonable to administer 100 mcg of epidural fentanyl after the newborn is delivered, or before
delivery if there is no fetal compromise.

Preservative-free morphine 2 to 3 mg or hydromorphone 1 mg via the epidural catheter provides postoperative

analgesia. It is reasonable to administer this dose of opioid after the newborn is delivered. We monitor patients
receiving long-acting neuraxial opioids for adequacy of ventilation (eg, respiratory rate and depth of respiration),
oxygenation (eg, pulse oximetry when appropriate), and level of consciousness for 24 hours after
administration [45]. (See "Management of acute perioperative pain", section on 'Monitoring the patient who has
received neuraxial analgesia'.)

During onset of the block, crystalloid is administered to prevent hypotension. However, overhydration and rapid
preloading (eg, 1000 mL of crystalloid) should be avoided in patients with heart failure. In these patients,
reduced volumes of crystalloid and slower administration are appropriate (eg, 250-mL increments with
monitoring of the patient's hemodynamic and clinical er sponses to each increment), and a vasopressor agent
may be necessary.

If BP begins to fall, gentle titration of a phenylephrine infusion (0.1 to 2 mcg/kg/minute), phenylephrine boluses
(40 to 100 mcg), or ephedrine boluses (5 to 20 mg) are options to counteract the hemodynamic effects of the
surgical neuraxial block. Selection depends upon the patient's HR and the specic cardiovascular lesion,
although phenylephrine is usually preferred because of lesser potential for ef tal acidosis [46].

If surgery progresses beyond an hour, additional 3- to 5-mL epidural doses of 2% lidocaine will likely be
necessary.

CSE technique for cesarean deliveryWe often select a low-dose sequential CSE for hemodynamically
stable, well-hydrated women with high-risk cardiovascular disease undergoing cesarean delivery.

Administer 3 mg isobaricbupivacaine combined with 15 mcgfentanyl and 0.15 mg preservative-free morphine

(or 50 to 100 mcg hydromorphone) into the intrathecal space.
 Subsequently, dose the epidural catheter very slowly with a local anesthetic withoutepinephrine (eg, 3 to 5 mL
of 2% lidocaine every ve minutes), titrated to a T6 level over approximately 20 minutes.

With this option, aphenylephrine infusion should be initiated immediately priorot intrathecal injection at 0.5
mcg/kg/minute, and subsequently titrated to keep the patient's BP as close to baseline as possible (the usual
range is 0.1 to 2 mcg/kg/minute). Other vasopressors (eg, ephedrine [5- to 20-mg boluses]) should be er adily
available if phenylephrine is ineffective.

General anesthesia technique for cesarean deliveryGeneral anesthetic techniques are occasionally needed for
cesarean delivery in patients with high-riskcardiovascular disease (see"Anesthesia for cesarean delivery"). The
pathophysiology and the desired hemodynamic goals for a specic cardiovascular lesion are taken into account in
selection of anesthetic agents.

All patients are preoxygenated with 100 percent oxygen, and a rapid sequence intubation is typically performed for
cesarean delivery. If a very slowly titrated induction is indicated to maintain hemodynamic stability in a patient with
high-risk cardiovascular disease, hemodynamic stability should be prioritized above concerns for aspiration, and the
induction should proceed slowly. Although the value of cricoid pressure is debatable, we use it in all inductions for
cesarean deliveries.

A reasonable approach for induction in many patients with cardiovascular disease is use of a short-acting hypnotic
(eg, etomidate [0.2 to 0.3 mg/kg], ketamine [1 to 2.5 mg/kg], or propofol [1.5 to 2.5 mg/kg, in divided doses, titrated
to effect] with phenylephrine boluses [50 to 100 mcg] or phenylephrine infusion [0.1 ot 2 mcg/kg/minute]). However,
considerations in choosing induction agents vary based on the individual cardiovascular lesion and pregnancy
complications (eg, ketamine should be avoided in preeclamptic patients because of the sympathetic stimulation).
Succinylcholine 1 to 1.5 mg/kg is administered for paralysis.

Although preinduction treatment with lidocaine (50 to 100 mg) and narcotic agents (eg, fentanyl, 1 to 2 mcg/kg) is
typically avoided in cesarean delivery in order to maximize neonatal respiratory drive at birth, patients with
cardiovascular disease may benet from administration of these agents to blunt the sympathetic response to
laryngoscopy and intubation. Maternal hemodynamic stability is the priority,rather than the usual obstetric
anesthesia concerns regarding neonatal sedation. If fentanyl and lidocaine are administered, the neonatal team
should be notied so that preparations are made for possible respiratory support of the newborn.

For maintenance of general anesthesia, sevourane or desurane is administered at approximately 1 minimum

alveolar concentration (MAC) value (concentration of inhalation anesthetic agent inthe alveoli required to prevent
movement in response to a surgical stimulus in 50 percent of patients (table 3)), as tolerated. If desurane is
selected, rapid increases in concentration are avoided, as this may cause tachycardia and pulmonary hypertension.
Nitrous oxide (N2O) is avoided in patients with elevated pulmonary artery pressures and in patients with intracardiac
shunts. (See "General anesthesia: Maintenance and emergence", section on 'Inhalation anesthesia'.)

MANAGEMENT OF IMPLANTABLE CARDIOVERTER DEFIBRILLATORS AND PACEMAKERSPatients with

cardiovascular disease may have a pacemaker (PM), biventricular PM, and/or implantable cardioverter debrillator
(ICD). For women who are laboring with an ICD, we leave the ICD function on during labor,and then disable anti-
tachyarrhythmia therapy if a cesarean delivery is necessary [47,48]. Appropriate perioperative management of
patients with a PM or ICD is discussed separ ately. (See "Perioperative management of patients with a pacemaker or
implantable cardioverter-debrillator", section on 'Intraoperative management'.)

For emergency cesarean delivery, immediate reprogramming of an ICD by the institutional cardiac implantable
electronic device (CIED) care team or magnet placement over the device will be necessary to disable anti-
tachyarrhythmia therapy prior to electrocautery use. (See "Perioperative management of patients with a pacemak
er
or implantable cardioverter-debrillator", section on 'Emergency surgery'.)
MANAGEMENT OF ARRHYTHMIASArrhythmias in the peripartum period are not uncommon in patients with
ischemic heart disease or structural heart disease. It is important to note that cardioversion or debrillation is not
contraindicated in pregnancy, and fetal intolerance of an arrhythmia, as indicated by fetal bradycardia, is an
indication for rapid cardioversion. Management of specic arrhythmias is discussed separ ately:

(See "Supraventricular arrhythmias during pregnancy".)

(See "Ventricular arrhythmias during pregnancy".)
(See "Maternal conduction disorders and bradycardia during pregnancy".)
(See "Cardioversion for specic arrhythmias", section on 'Cardioversion during pregnancy'.)

POSTPARTUM CAREThe intensity of postpartum monitoring is determined by the patient's underlying

cardiovascular disease and any obstetricor cardiac events that occurred during labor and delivery. Women with
lesions such as pulmonary hypertension related to Eisenmenger syndrome, peripartum cardiomyopathy, or a dilated
aorta due to Marfan syndrome are at particularly high risk for morbidity and mortality during the postpartum period
[49,50]. Management of postpartum care in patients with cardiovascular disease is covered elsewhere. (See
"Overview of postpartum care" and "Pregnancy in women with congenital heart disease: General principles", section
on 'Postpartum care' and "Acquired heart disease and pregnancy", section on 'Postpartum care'.)

SUMMARY AND RECOMMENDATIONS

Understanding the hemodynamic changes elated

r to pregnancy, labor, and delivery allows the anesthesiologist
to anticipate decompensation in the peripar
tum period in patients with cardiovascular lesions, and to select
appropriate anesthetic monitoring and techniques to minimize this risk. (See 'Hemodynamic changes during
pregnancy, labor, and delivery' above.)

The healthcare team, including the anesthesiologist, will determine the optimum location for deliv ery in patients
with high-risk cardiovascular lesions. High-risk patients can be identied using risk str
atication schemes
developed by national and international cardiology societies. (See'Risk stratication' above.)

During labor and delivery, we suggest the following monitors (see 'Monitoring' above):

Continuous pulse oximetry throughout active labor. A visible and audible waveform is especially important
for patients with cyanotic congenital heart disease or right-to-left vascular shunting.

Telemetry for patients at increased risk of developing arrhythmias and a ve-lead monitor with
computerized ST-segment trending capability in patients at risk for my
ocardial ischemia.

External debrillator pads to achieve rapid cardioversion or debrillation in patientswith a history of poorly-
tolerated tachyarrhythmias.

Intra-arterial catheter to enable monitoring of moment-to-moment changes in blood pressure (BP) prior to
induction of either regional or general anesthesia for cesarian delivery in high-risk patients and in laboring
patients with hemodynamic instability .

Labor analgesia with epidural or combined spinalepidural (CSE) results in a benecial decrease in
sympathetic stimulation. For CSE, a dose of fentanyl 15 to 25 mcg administered into the intrathecal space
results in minimal hemodynamic effect, with a faster onset of analgesia compar ed with an epidural technique
alone (eg, for a patient in active labor with severe pain). If intrathecal local anesthetic is added for CSE (eg, for a
multiparous patient rapidly progressing into the second stage of labor), a er asonable intrathecal dose is 1.5 to
2.5 mg of isobaricbupivacaine.
 For the labor epidural, we use a continuous infusion of 0.04 to 0.125% bupivacaine with 1 to 2 mcg/mL of
fentanyl, administered at a rate of 6 to 12 mL/hour. (See 'Epidural technique for labor' above.)

Local anesthetic-containingepinephrine is avoided in patients with high-risk cardiovascular disease who would
respond poorly to administration of alpha and beta sympathomimetic agonists (see'Test dose administration'
above):

Administer an initial test dose of 3 mL of 1.5%lidocaine with 100 mcg fentanyl into the epidural catheter to
test for intravascular placement (rapid onset of sleepiness due o
t fentanyl blood concentration) or
intrathecal placement (onset of a spinal block in approximately ve minutes).

An alternative test dose is to administer the rst 5 mL of the labor epidur

al solution (eg, 0.04 to 0.125%
bupivacaine with 1 to 2 mcg/mL fentanyl) and immediately assess the patient for centr al nervous system
(CNS) excitation symptoms. After ve minutes, perform a further assessment for motor block.

For cesarean delivery in a hemodynamically stable, well-hydrated woman, we oftenselect a low-dose CSE
rather than epidural alone. We administer 3 mg isobaric bupivacaine with 15 mcg fentanyl and 0.15 mg
preservative-free morphine (or 50 to 100 mcg hydromorphone) into the intrathecal space. Subsequently, we
dose the epidural catheter very slowly with a local anesthetic withoutepinephrine (eg, 3 to 5 mL of 2% lidocaine
every ve minutes) to achieve a T6 level. (See 'Neuraxial anesthesia for cesarean delivery' above.)

In patients with signicant cardiovascular disease requiring general anesthesia, particularly unstable patients,
hemodynamic stability should be prioritized over concerns regarding maternal aspiration or newborn sedation.
A reasonable approach is a slowly titrated induction with intra-arterial BP monitoring, utilizing etomidate (0.2 to
0.3 mg/kg), ketamine (1 to 2.5 mg/kg), or propofol (1.5 to 2.5 mg/kg, in divided doses, titrated to effect) with
phenylephrine boluses or infusion, as well assuccinylcholine (1 to 1.5 mg/kg). The choice of drug depends on
the specic cardiovascular lesion. Use oflidocaine and fentanyl as adjunct agents during induction is
acceptable; however, the neonatal team should be alerted to this decision. (See'General anesthesia technique
for cesarean delivery' above.)

For maintenance of general anesthesia, a volatile anesthetic at approximately 1 minimum alveolar

concentration (MAC) is administered as tolerated in 100 percent oxygen. Nitrous oxide (N2O) is avoided in
patients with pulmonary hypertension or shunts. (See'General anesthesia technique for cesarean delivery'
above.)

If BP decreases with either a neuraxial technique or general anesthesia, gentle titration of a phenylephrine
infusion (0.1 to 2 mcg/kg/minute), phenylephrine boluses (40 o t 100 mcg), or ephedrine boluses (5 to 20 mg)
are options to maintain BP as close to baseline as possible. (See'Preparation of vasoactive agents' above.)

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Topic 4446 Version 31.0

GRAPHICS

Hemodynamic changes in normal pregnancy

Normal pr egnancy is char acteriz ed by an incr ease in car diac output, a r eduction in
systemic v ascular r esistance, andminimal changein mean blood pr essure. These
changes ar e associated with a 10- t o 15-beat/mi nute incr ease in hear t rate.

Graphic 54685 V ersion 5.0

Total blood volume, plasma volume, and red cell volume in normal
pregnancy

Data from Shnider SM, Le vinson G. Anesthesia for Obs tetrics, 3rd ed, Williams & Wilkins,
Baltimore, p. 8.

Graphic 61948 V ersion 4.0

Systemic hemodynamics during normal pr
egnancy

Data from: Bonica JJ, McDonald JS. Principles and Pr actice of Obstetric Analgesia and Anesthesia,
2nd ed, Williams & Wilkins, Baltimor e, 1994. p.60.

Graphic 55985 V ersion 3.0

NYHA and other classications of cardiovascular disability
New York Heart
Class Association functional
classication [1]
I Patients with car diac disease
but without resulting limitations
of physical activity . Ordinary
physical activity does not
cause undue fatigue,
palpitation, dyspnea, or anginal
pain.
II Patients with car diac disease
resulting in slight limitation of
physical activity. They are
comfortable at rest. Ordinary
physical activity r esults in
fatigue, palpitation, dyspnea, or
anginal pain.
III Patients with car diac disease
resulting in mark ed limitation of
physical activity. They are
comfortable at rest. Less than
ordinary physical activity
causes fatigue, palpitation,
dyspnea, or anginal pain.
IV Patients with car diac disease
resulting in inability t o carry on
any physical activity without
discomfor t. Symptoms of
cardiac insufciency or of the
anginal syndr ome may be
present even at rest. If any
physical activity is under taken,
discomfor t is increased.
NYHA: New York Heart Association.
References:
1. The Criteria Committee of the New Y ork Heart Association. Nomenclatur e and Criteria for Diagnosis of Diseases of the Hear t and Great
Vessels, 9th ed, Little, Br own & Co, Bost on, 1994. p.253.
2. Campeau L. Gr ading of angina pect oris. Circulation 1976 54:522.
3. Goldman L, Hashimot o B, Cook EF, Loscalzo A. Comparative reproducibility and v alidity of systems for assessing car diovascular
functional class: Adv antages of a new specic activity scale. Circulation 1981; 64:1227.
Graphic 52683 V ersion 13.0
Canadian Cardiovascular
Society functional
classication [2]
Ordinary physical activity, such
as walking and climbing stairs,
does not cause angina. Angina
with strenuous or rapid
prolonged exertion at work or
recreation.
Slight limitation of or dinary
activity. Walking or climbing
stairs rapidly, walking uphill,
walking or stair climbing after
meals, in cold, in wind, or when
under emotional str ess, or only
during the few hours after
awakening. Walking more than
two blocks on the le vel and
climbing mor e than one ight
of ordinary stairs at a normal
pace and in normal conditions.
Marked limitation of or dinary
physical activity. Walking one to
two blocks on the le vel and
climbing one ight in normal
conditions.
Inability to carry on any
physical activity without
discomfor t. Anginal syndr ome
may be present at rest.
Specic activity scale [3]
Patients can per form to
completion any activity
requiring 7 metabolic
equivalents, eg, can carr y 24 lb
up eight steps; do outdoor
work (shovel snow, spade soil);
do recreational activities
(skiing, basketball, squash,
handball, jog/walk 5 mph).
Patients can per form to
completion any activity
requiring 5 metabolic
equivalents, eg, ha ve sexual
intercourse without st opping,
garden, rake, weed, roller skate,
dance fox trot, walk at 4 mph
on level ground, but cannot and
do not perform to completion
activities requiring 7
metabolic equiv alents.
Patients can per form to
completion any activity
requiring 2 metabolic
equivalents, eg, shower without
stopping, strip and mak e bed,
clean windows, walk 2.5 mph,
bowl, play golf, dress without
stopping, but cannot and do
not perform to completion any
activities requiring >5
metabolic equiv alents.
Patients cannot or do not
perform to completion
activities requiring >2
metabolic equiv alents. Cannot
carry out activities listed abo ve
(specic activity scale III).
Cardiac output during normal labor,delivery, and postpartum

Data from Bonica, JJ, McDonald, JS. Principles and Pr actice of Obstetric Analgesia and
Anesthesia, 2nd ed, Williams &Wilkins, Baltimor e, 1994. p. 62.

Graphic 79834 V ersion 2.0

Hemodynamics with contractions

Data from: Bonica JJ, McDonald JS. Principles and Pr actice of Obstetric Analgesia and Anesthesia, 2nd
ed, Williams & Wilkins, Baltimor e, 1994. p.66.

Graphic 69056 V ersion 3.0

Vasoactive infusions used in the operating room: Adult dosing*

Drug Class Predominant mechanism Infusion dose

Vasopressin Vasoconstrictor Vasopressin 1 and 1 to6 units/hour

vasopressin 2 receptors or
0.01 to 0.1 units/minute

Phenylephrine Vasoconstrictor Alpha receptors 10 to 200 mcg/minute

or
0.1 to 2 mcg/kg/minute

Norepinephrine Inotrope/vasoconstrictor Alpha and beta 1 receptors 1 to 30 mcg/minute

or
0.01 to 0.3 mcg/kg/minute

Dopamine Inotrope/vasoconstrictor Dopaminergic receptors <3 mcg/kg/minute (D)

Beta 1 and beta 2 receptors 3 to 10 mcg/kg/minute (1 and

2)

Alpha receptors >10 mcg/kg/minute ()

Dobutamine Inotrope/vasodilator Beta 1 and beta 2 receptors 1 to 20 mcg/kg/minute

Epinephrine Inotrope/vasoconstrictor Alpha receptors 1 to 100 mcg/minute

Beta 1 and beta 2 receptors or
0.01 to 1 mcg/kg/minute
1 to 2 mcg/minute (2)
2 to 10 mcg/minute (1, 2)
10 to 100 mcg/minute ()

Milrinone Inotrope/vasodilator Phosphodiester ase inhibitor Loading dose 50 mcg/k g over

(decrease in rate of cyclic 10 minutes (usually omitted),
adenosine monophosphate then 0.375 to 0.75
[cAMP] degradation) mcg/kg/minute

Isoproterenol Inotrope/vasodilator Beta 1 and beta 2 receptors 5 to 20 mcg/minute

or
0.05 to 0.2 mcg/kg/minute

Clevidipine Vasodilator Inhibits calcium ion inux; 1 to 16 mg/hour

selective arteriolar smooth or
musclerelaxation
0.02 to 0.27 mg/minute

Nicardipine Vasodilator Inhibits calcium ion inux; 5 to 15 mg/hour

selective arteriolar smooth or
muscle relaxation
0.08 to 0.25 mg/minute

Nitroglycerin Vasodilator Increase in cyclic GMP (cGMP) 10 to 400 mcg/minute

or
0.1 to 4 mcg/kg/minute

Nitroprusside Vasodilator Smooth muscle r elaxation 10 to 400 mcg/minute

or
0.1 to 4 mcg/kg/minute

Esmolol Adrenergic antagonist and anti- Beta 1 receptors 10 to 50 mg boluses,then 25

arrhythmic to300 mcg/kg/minute

Labetalol Adrenergicantagonist Beta 1 , beta 2 , and alpha 1 5 to 20 mg IV boluses, then 0.5

 receptors to 2 mg/minute

V: vasopressin; D: dopaminer gic; : alpha adr energic; : beta adrenergic.

* Dose ranges are based on adult patients of normal size.
Vasopressin doses >0.04 units/minute ar e reserved for salvage therapy (ie, failure to achieve adequate mean ar terial pressure goal with
other vasopressor agents).
At low doses, epinephrine infusion has benecial br onchodilatory effects and may cause ar terial vasodilation and decr eased blood
pressure. Dose-related effect ranges vary somewhat in clinical pr actice.
Nitroprusside doses >400 mcg/minute ar e not recommended due t o minimal added benet and incr eased risk for thiocy anate or cyanide
toxicity.

Graphic 96387 V ersion 10.0

Denition of minimum alveolar concentration (MAC) values

MAC level Effect

0.3 MAC MAC awake (MAC value below this will allow the patient t o become conscious)

1 MAC End-tidal concentr ation of anesthetic agent necessar y to prevent movement in response to a surgical
stimulus in 50% of patients

1.5 MAC MAC value where 90% of patients will not mo ve in response to a surgical stimulus

2.0 MAC MAC-BAR (MAC value required to block autonomic responses to a surgical stimulus in 50% of patients)

MAC: minimum alv eolar concentr ation; a value of 1.0 M AC is the concentration of an inhalation anesthetic agent in the alveoli required to
prevent movement to a surgical stimulus in 50% of patients.

Graphic 109424 V ersion 2.0

Contributor Disclosures
Katherine W Arendt, MD Nothing to disclose David L Hepner, MD Nothing to disclose Susan M Ramin,
MD Nothing to disclose Heidi M Connolly, MD, FASE Nothing to disclose Jonathan B Mark, MDNothing to
disclose Nancy A Nussmeier, MD, FAHA Nothing to disclose

Contributor disclosures are reviewed for conicts of interest by the editorial group. When found, these are
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