Anesthesia for Termination of Pregnancy in Patient with Eisenmengers Syndrome Erwin Siregar

Background
Pregnant woman with cardiac disease >>> High risk !!!!

Hemodynamic Changes
Normal pregnancy: Changes begin during 2nd-7th weeks of pregnancy, and peaks in the late 2nd trimester
Blood volume 40-50 % due to activation of Renin Aldosterone axis Anemia of pregnancy CO 30 -50 % : preload afterload maternal HR 10-15 /minute BP decrease by 10 mmHg SVR Addition of utero-placental bed of low-resistance

Normal pregnancy :
Fatigue Dyspnoe Poor exercise tolerance

How about pregnant women with heart disease ????

Pregnant Pt with Cardiac Disease

Several points to ponder
Basic characteristics of each cardiac disease Present status of cardiac disease?
Hemodynamic fluctuations ? Pulmonary complications ?

Regional ? General ? What appropriate monitors ?

KISS (Keep it Simple, Stupid)

If the patient is comfortable in the supine position regional or general If the patient is comfortable only in the semi or sitting position with/ out difficulty in breathing : General anesthesia Monitors :
Potential for hemodynamic fluctuations : Invasive :
AL CVP PA catheters (Pulmonary Hypertension)

Pregnant women with heart disease

NYHA predictor of outcome NYHA class III atau IV :

Mortality rate 7 % Morbidity rate 30 % No pregnancy please !!!!!

Risk Factor
Siu et al (1997)
Prior cardiac events (heart failure, transient ischemic attack, stroke prior to pregnancy) Cyanosis or poor functional class Left heart obstruction Systemic ventricular dysfunction

Classification
Three classification
Low risk lesions Moderate risk lesions High risk lesions

Low risk lesions

Atrial Septal defect Ventricular septal defect Patent ductus arteriosus Asymptomatic AS with low mean gradient (<50 mmHg), and normal LV function AR with normal LV function and NYHA class I or II MVP (isolated or with mild / moderate MR and normal LV function) MR with normal LV function and NYHA class I or II Mild /moderate MS (MVA > 1.5 cm2, mean gradient< 5 mmHg) without severe pulmonary hypertension Mild/ moderate PS Repaired acyanotic congenital heart disease without residual cardiac dysfunction

Moderate risk lesions

Large left to right shunt Coarctation of the aorta Marfans syndrome with a normal aortic root Moderate/ severe MS Mild/ moderate AS Severe PS History of prior peripartum cardiomyopathy with no residual ventricular dysfunction

High risk lesions

Eisenmengers syndrome Severe PH Complex cyanotic heart disease (TOF, Ebsteins anomaly, Tr Art, TGA, tricuspid atresia) Marfans syndrome with aortic root or valve involvement Severe AS with or without symptoms Aortic and / or mitral valve disease with moderate/ severe LV dysfunction (EF < 40 %) NYHA class III to IV symptoms associated with any valvular disease or with cardiomyopathy of any etiology History of peripartum cardiomyopathy with persistent LV dysfunction

Eisenmengers Syndrome
Caused by continuous exposure of the pulmonary circulation to high pressure due to L-R shunt Obliterative changes in pulmonary circulation Fixed increases in PVR RV pressure R L shunt cyanosis

Eisenmengers Syndrome
A delicate balance between PVR and SVR must be maintained

PVR

SVR

Acidosis Hypercarbia PPV

>>>> L Shunt

Eisenmengers Syndrome
Definitions
Pulmonary hypertension at systemic level due to high pulmonary vascular resistance, with reversed or bidirectional shunt at aortopulmonary, atrial or ventricular level

Technique
Pregnant women with low risk cardiac lesions : regional or general --- no difference in morbidity or mortality rate Pregnant women that cannot tolerate supine position, e.g. severe MI, MS, and CTR > 70%; Eisenmengers syndrome : general anethesia with controlled respiration

Monitoring
Pregnant women with low risk cardiac lesion and can tolerate supine position : non invasive monitoring (NIBP, ECG, and pulse oxymetry) Pregnant women with moderate to high risk cardiac lesion : invasive monitoring
Arterial line CVP Swan Ganz catheter

Anesthetic Management
Depends on condition of the patient :
Hemodynamic status Respiratory status Position best tolerated by patient at rest

Determines :
Anesthetic technique Monitoring

Drugs
Vasodilators Vasoconstrictors Inotropes Anti arrhythmias

Case Illustration
Pregnant women 32 yrs old, G4A2P1, 34 weeks pregnant, with Eisenmengers syndrome caused by ASD II Termination of pregnancy with SC because maternal deterioration Preop visit :
Difficulty in breathing, with nasal O2, Can only tolerate sitting position Sometimes O2 desaturation

Anesthetic Management
General anesthesia Arterial line, CVP, and SG side port insertion before induction of anesthesia Surgeon and surgical team in sterile gown before induction of anesthesia Induction of anesthesia with IV Sufentanyl 0.5 1 g/kg/bw and Midazolam and appropriate muscle relaxant for intubation

Anesthetic Management
As soon as the patient looses consciousness, she is put into supine position, and surgical team immediately begins incision while the patient is being intubated After intubation a PA catheter is inserted NTG, Vasopressor, and Inotropes given if needed to control hemodynamics

Summary
Good team work between cardiologist, surgeon, and anesthesiologist is needed in the proper management of delivery/ termination of pregnancy in women with heart disease The surgeon has to be informed of the anesthetic procedure prior to the operation Pediatricians has to be ready in the OR and capable of resuscitation / intubation of baby