MITRAL STENOSIS WITH

PREGNANCY

- DR. ANKITA PATNI

- ANAESTHESIOLOGY
 INTRODUCTION
Rheumatic mitral stenosis forms 88% of the heart
diseases complicating pregnancy in the tertiary
referral centre in India.
Rheumatic mitral stenosis complicating
pregnancy is still a frequent cause of maternal
death.
A better understanding of the physiological
changes in pregnancy and the pathological
impact of mitral stenosis over pregnancy and a
multidisciplinary approach; where the
anaesthesiologist plays a major role, in diagnosis
and management, reduce the mortality and
morbidity.
 CARDIOVASCULAR CHANGES DURING
PREGNANCY
Parameter Percentage of change
Cardiac output 4050% Increase
Stroke volume 30% Increase
Heart rate 1525% Increase
Intravascular volume 45% Increase
Systemic vascular resistance 20% Decrease
Systolic BP Minimal
Diastolic BP 20% Decrease at mid-pregnancy
Pre-pregnant values at term
CVP Unchanged
O2 consumption 3040% Increase
 HEMODYNAMICS DURING LABOUR

Parameter Stage of labour Percentage of change

Cardiac output Latent phase 10% Increase

Active phase 25% Increase

Expulsive phase 40% Increase

Immediate post-partum 7580% Increase

Heart rate All stages Increase

CVP All stages Increase

HEMODYNAMICS DURING PUERPERIUM

Parameter Post-partum Percentage of Change

Cardiac output Within 1 h 30% above pre-labour values
2448 h Just below pre-labour values
2 weeks 10% above pre-pregnant values
1224 weeks Baseline pre-pregnancy values
Heart rate Immediate Decrease
2 weeks Pre-pregnant values
Stroke volume 48 h Remains above pre-labour values
24 weeks 10% above pre-pregnant values
 MS PREGNANCY

DECREA DECREA INCREASE

SE LA SE LV HR
emptying Filling

DECREASE
SV

DECREASE Fixed CO state; Heart

LA Dilates CO cannot cope up with
increased demand.

Pressure Irreversible
Long-
LA pressure At gradient PULMONARY standin chronic
INCREASESDIASTO develop CONGESTION g
LE s Pulmonary
betwee Hypertension
n LA AUTOTRANSFUSION from
Hemodyna
and LV uterus
mic
Hallmark of DELIVERY
MS
 MS- impairs left ventricular
filling- decrease in EDV (pre-
load)- decrease in SV- fall in
CO.
Reduced ventricular filling-
decrease ventricular wall
stress (after-load)- decrease
in ESV
Decrease in EDV > Decrease
in ESV = Decrease in SV
 SEVERITY GRADING OF MS

Measurem Normal Mild Moderate Severe

ent
Mitral valve area 4.06.0 1.52.5 1.01.5 <1.0
(cm2)

Mean pressure <2 26 612 >12

gradient (mmHg)

Pulmonary artery 1020 <30 3050 >50

mean pressure
(mmHg)
 Normal Orifice: 4 6 Cms2

Symptoms start < 2.5

< 2.5 cms2 Cms2
Mild MS 1.5 2.5
1.0 1.5 cms2 Cms2 (Dyspnea on
1.5- 2.5 cms2
severe exertion)
< 1.0 cms2
4-6 cms2 Moderate MS 1.0 1.5
Cms2 (PND pulmonary
oedema)
Severe/ Critical- < 1.0
Cms2 (Orthopnea
Class IV)
 MODIFIED NEW YORK HEART ASSOCIATION
FUNCTIONAL CLASSIFICATION (NYHA)
Class I No functional Asymptomatic
limitation of activity except during severe
exertion.
Class II Mild limitation of Symptomatic with
physical activity moderate activity
Class III Marked limitation of Symptomatic with
physical activity minimal activity
Class IV Severe limitation of Symptomatic at rest
physical activity
PREDICTORS OF MORTALITY AND
MORBIDITY
Severity of MS NYHA Class

Severe- 67% Class I and II- <1%

Class III and IV- Between 5 and

Moderate- 38%
15%

Class III and IV- Perinatal

Mild- 26%
mortality- 20-30%
 CARPREG SCORE
THE CARDIAC DISEASE IN PREGNANCY (CARPREG) RISKSCORE(TABLE I)
CAN BE CALCULATED TO ESTIMATE A WOMAN'S CARDIAC RISK DURING
PREGNANCY. IT IS IS BASED ON 4 RISK PREDICTORS:

Mortalit
y:
0 point-5%,
1 point-
27%,
>1 point-
75%
 AETIOLOGY OF MS

1. RHEUMATIC HEART DISEASE 8. MITRAL ANNULAR CALCIFICATION

2. CONGENITAL PARACHUTE MITRAL 9. RHEUMATOID ARTHRITIS
VALVE 10. SYSTEMIC LUPUS ERYTHEMATOSIS
3. HUNTERS SYNDROME 11. INFECTIVE ENDOCARDITIS WITH
4. HURLERS SYNDROME LARGE VEGETATIONS.

5. DRUGS METHYSERGIDE 12. LUTEMBACHERS SYNDROME:

ATRIAL SEPTAL DEFECT (ASD) + MITRAL
6. CARCINOID SYNDROME STENOSIS (MS) RHEUMATIC ORIGIN
7. AMYLOIDOSIS
 SYMPTOMS OF MS

1. DYSPNOEA 6. HAEMOPTYSIS

2. ORTHOPNEA 7. RECURRENT BRONCHITIS

3. PAROXYSMAL NOCTURNAL 8. COUGH

DYSPNEA 9. CHEST PAIN
4. PALPITATION 10. RIGHT HYPOCHONDRIAL PAIN
5. FATIGUABILITY (HEPATOMEGALY)
 DIAGNOSIS OF MS
Clini
cal
Exa
Diagnostic cardiac min
catheterization is necessary Cardi atio
ac n
only when Cath ECG
eteriz
echocardiography is non- ation
DIAGNO
diagnostic or results are STIC
discordant with clinical Doppl TOOLS
er
findings. exam
Chest
X-Ray
inatio
n Echo
cardi
Doppler examination provides ograp Echocardiography provides
hy
information about the severity information regarding the area
of the stenosis, the presence of of the mitral valve, size of the
other associated valve lesions left atrium, presence of
and the degree of pulmonary thrombus and the size and
hypertension function of the left ventricle
 GENERAL PHYSICAL EXAMINATION

OEDEMA MITRAL FACIES

SEVERE MITRAL LOW CARDIAC OUTPUT IN MITRAL
STENOSIS STENOSIS CAUSES PERIPHERAL
ULTIMATELY VASOCONSTRICTION PRODUCING
LEADS TO RIGHT
PINKISH PURPLE PATCHES ON CHEEKS.
HEART FAILURE.

MITRAL FLUSH DUE TO VASODILATATION

HEPATOMEGALY (VASCULAR STASIS) IS SEEN

SEEN IN RIGHT
VENTRICULAR SEEN IN FAIR SKINNED INDIVIDUALS
FAILURE AND
PULMONARY
HYPERTENSION.
 CARDIOVASCULAR EXAMINATION-
INSPECTION
PRECORDIAL BULGE INDICATES EARLY ONSET AND LONGER
DURATION OF CARDIAC DISEASE.

SCAR MARKS REVEAL PREVIOUS SURGERIES

ENGORGED NECK VEINS INDICATE HIGH RIGHT HEART

PRESSURES
 CARDIOVASCULAR EXAMINATION-
PALPATION
TAPPING CHARACTER OF THE APEX BEAT (PALPABLE S1) IS TYPICAL.
PALPABLE DIASTOLIC THRILL IN MITRAL AREA BEST FELT IN LEFT LATERAL
POSITION IN FULL EXPIRATION.

PARASTERNAL HEAVE

IF ONE FINDS ENGORGED SUPERFICIAL VEINS LOOK FOR DIRECTION OF

FLOW.
 CARDIOVASCULAR EXAMINATION-
AUSCULTATION

S1 IS SHARP, SHORT, ACCENTUATED

OPENING SNAP AFTER S2

LOW PITCHED MID-DIASTOLIC RUMBLING MURMUR WITH
PRESYSTOLIC ACCENTUATION IN MITRAL AREA.
MURMUR BEST HEARD AT CARDIAC APEX WITH BELL OF
STETHOSCOPE IN LEFT LATERAL POSITION AT HEIGHT OF
EXPIRATION
 ECG FINDINGS
1. BROAD NOTCHED P WAVES SIGNIFYING ATRIAL ENLARGEMENT.

2. ATRIAL FIBRILLATION (F- WAVES REPLACING P-WAVES)

3. RIGHT VENTRICULAR ENLARGEMENT

 CXR
1. LEFT ATRIAL ENLARGEMENT
MITRALISATION OF HEART

2. STRAIGHTENING OF LEFT HEART

BORDER

3. ELEVATION OF LEFT MAINSTEM

BRONCHUS

4. EVIDENCE OF MITRAL CALCIFICATION,

EVIDENCE OF PULMONARY EDEMA,
PULMONARY VASCULAR CONGESTION.

5. KERLEYS B LINES

6. DOUBLE CONTOUR OF THE RIGHT

BORDER OF HEART
CHEST X-RAY

Kerley
b lines
ECHOCARDIOGRAPHY
 MANAGEMENT

MEDICAL SURGICAL OBSTETRICAL

DIURETICS, -
VALVULOPLASTY VAGINAL
BLOCKERS

AF- DIGOXIN,
VALVE CAESAREAN
ANTI-
REPLACEMENT SECTION
COAGULANTS
 MEDICAL MANAGEMENT
ASSOCIATED WITH ATRIAL
FIRST LINE OF TREATMENT IN FIBRILLATION
SYMPTOMATICS
BED REST DIGOXIN AND BETA BLOCKERS TO REVERT
OXYGEN THERAPY
IT TO SINUS RHYTHM.
DIURETICS
BETA-ADRENERGIC RECEPTOR BLOCKADE- USEFUL TO
ANTICOAGULATION TO PREVENT
PREVENT TACHYCARDIA DURING PREGNANCY. PROPRANOLOL SYSTEMIC EMBOLIZATION.
OR ATENOLOL DECREASES THE INCIDENCE OF MATERNAL
PULMONARY OEDEMA WITHOUT ADVERSE EFFECTS ON THE CARDIOVERSION SHOULD BE PERFORMED
FOETUS OR NEONATE.
IF PHARMACOLOGIC THERAPY FAILS TO
ANTIBIOTIC PROPHYLAXIS FOR ENDOCARDITIS IS RESERVED
CONTROL THE VENTRICULAR RESPONSE.
ONLY FOR PATIENTS WITH A PREVIOUS HISTORY OF
ENDOCARDITIS OR PRESENCE OF ESTABLISHED INFECTION.
 ANTICOAGULATION DURING PREGNANCY

SC/IV HEPARIN FOR UP TO 12 WEEKS ANTEPARTUM (APTT 1.52.5-TIMES OF

NORMAL)
WARFARIN FROM 12 TO 36 WEEKS (MAINTAIN INR 2.5 3.0)
SC/IV HEPARIN AFTER 36 WEEKS
THERAPY WITH LOW-MOLECULAR WEIGHT HEPARIN (LMWH) INSTEAD OF
UNFRACTIONATED HEPARIN IS GAINING POPULARITY. ALTHOUGH AN ANTI XA
ACTIVITY IS USED TO MONITOR LMWH, NO ANTI-XA ACTIVITY-BASED
GUIDELINES HAVE BEEN ISSUED TILL DATE.
 SURGICAL MANAGEMENT

PERCUTANEOUS (success
rate is nearly 100%. It increases the
valve area to >1.5 cm2 without a
substantial increase in mitral
regurgitation.)

Valvuloplasty
OPEN (foetal loss is high
in open commissurotomy
as compared to
II Trimester percutaneous, at a ratio of
1:8)
Reserved for severe
cases with calcified
Valve Replacement
valve and in mural
thrombus.
 OBSTETRIC MANAGEMENT
VAGINAL VAGINAL
DELIVERY DELIVERY
Tachycardia, secondary to The second stage of delivery should be cut short by
labour pain, increases flow instrumentation.
across the mitral valve, Maintenance of left uterine displacement for good venous return.
producing sudden rises in Supplemental oxygen administration with pulse oximetry
left atrial pressure, leading monitoring to minimize increases in pulmonary vascular resistance,
to acute pulmonary fetal heart rate monitoring should be carried out.
oedema. Invasive cardiac monitoring like radial artery cannulation and
pulmonary catheter are beneficial in assessing the cardiac output,
pulmonary artery pressure and for guiding fluid and drug therapy,
Good LABOUR
especially in NYHA III and IV patients.
ANALGESIA is
Sudden drops in systemic vascular resistance (SVR) in the
must.
presence of a fixed cardiac output can be prevented by small bolus
doses of phenylephrine, with volume expansion when necessary.

Epidura
CS
l
E
 OBSTETRIC MANAGEMENT
Caesarean
section Technique of choice. CSE
offers rapid onset and
Only for improved analgesia It
obstetric offers ability to use low
reasons dose spinal with room for
post operative analgesia
Combined
Epidural/Spi General
Spinal
nal Anaesthesia
Epidural

Epidural anaesthesia might not be

an ideal technique as it requires
slow induction, delay in the onset of
action which may not be possible in
an emergency situation. Moreover
large volume of local anesthetic is
needed for adequate blockade.
Subarachnoid causes rapid onset
of extensive sympathetic
blockade with intense
vasodilatation, sudden
hypotension and severe
tachycardia.
OBSTETRIC MANAGEMENT
Category 1 -
Immediate threat Category 2 -
to life of woman or Maternal or fetal
fetus (baby needs compromise, not
to be removed in immediately life
30 min. of making threatening(some
the decision to do time can be spent
LSCS) for resuscitation)

Category 4- At a Category 3 -
time to suit the Needing early
woman and delivery but no
maternity team maternal or fetal
compromise
 GOALS FOR ANAESTHETIC MANAGEMENT

MAINTENANCE OF AN ACCEPTABLE SLOW HEART RATE

IMMEDIATE TREATMENT OF ACUTE ATRIAL FIBRILLATION AND REVERSION TO
SINUS RHYTHM
AVOIDANCE OF AORTOCAVAL COMPRESSION
MAINTENANCE OF ADEQUATE VENOUS RETURN
MAINTENANCE OF ADEQUATE SVR
PREVENTION OF PAIN, HYPOXAEMIA, HYPERCARBIA AND ACIDOSIS, WHICH
MAY INCREASE PULMONARY VASCULAR RESISTANCE.
 EPIDURAL ANALGESIA
ONE OF THE MAJOR ADVANTAGES OF EPIDURAL ANALGESIA IS THAT IT CAN BE
ADMINISTERED IN INCREMENTAL DOSES AND THAT THE TOTAL DOSE COULD BE
Allows the maternal cardiovascular
TITRATED TO THE DESIRED SENSORY LEVEL.
system to compensate for the occurrence
SLOWER ONSET OF ANAESTHESIA of sympathetic blockade, resulting in a
lower risk of hypotension and decreased
uteroplacental perfusion.
THE SEGMENTAL BLOCKADE SPARES THE LOWER EXTREMITY MUSCLE PUMP,
AIDING IN VENOUS RETURN, AND ALSO DECREASES THE INCIDENCE OF
THROMBOEMBOLIC EVENTS.
INVASIVE HAEMODYNAMIC MONITORING, JUDICIOUS INTRAVENOUS
ADMINISTRATION OF CRYSTALLOID AND ADMINISTRATION OF SMALL BOLUS
DOSES OF PHENYLEPHRINE MAINTAIN MATERNAL HAEMODYNAMIC STABILITY.
NEURAXIAL BLOCK IN AN ANTICOAGULATED PATIENT HAS THE RISK OF
EPIDURAL HAEMATOMA.
 COMBINED SPINAL-EPIDURAL
PROCEDURE PER SE

CSE IS PERFORMED IN LATERAL DECUBITUS POSITION UNDER STRICT ASEPTIC PRECAUTIONS

EPIDURAL SPACE IS IDENTIFIED WITH 18 G TUOHY NEEDLE USING LOR WITH SALINE. SPINAL
NEEDLE IS INTRODUCED THROUGH THE TUOHY NEEDLE AND SUBARACHNOID BLOCK IS
PERFORMED.20-30 G OF FENTANYL ALONG WITH 2.5 -5MG OF 0.5% BUPIVACAINE IS GIVEN.
THIS IS FOLLOWED BY INSERTION OF EPIDURAL CATHETER THROUGH WHICH 3 ML OF 2%
XYLOCAINE WITH EPINEPHRINE IS GIVEN.

POST OPERATIVE ANALGESIA IS MAINTAINED AS SHOWN IN THE TABLE BELOW

DRUG INITIAL INJECTION CONTINUOUS INFUSION
BUPIVACAINE 10-15 ML OF A 0.25%-0.125% SOLUTION 0.0625%-0.125% SOLUTION AT 8-15 ML/HR

ROPIVACAINE 10-15 ML OF A 0.1%-0.2% SOLUTION 0.5%-0.2% SOLUTION AT 8-15 ML/HR

FENTANYL 50-100 MICROGRAM IN A 10-ML VOLUME 1-4 MICROGRAM/ML

 MYTHS AND WORRIES ABOUT REGIONAL
ANAESTHESIA
1. PRELOADING IS MANDATORY AND HAZARDOUS--CVP GUIDED FLUID MANAGEMENT
NEGATES OVERLOADING AND MAINTAINS ADEQUATE CARDIAC OUTPUT

2. REGIONAL ANAESTHESIA IS ASSOCIATED WITH SUDDEN FALL IN BP. LOCAL

ANAESTHETIC WITH OPIOID COMBINATION INTRATHECALLY FOLLOWED BY EPIDURAL
TO TITRATE THE DESIRED LEVEL OF BLOCK DOES NOT PRODUCE RAPID FALL IN BP.

3. DELAY IN PERFORMING THE ACTUAL PROCEDURE: THIS DOESNT HAPPEN WITH

EXPERT HANDS

4. THE COMPLICATIONS OF CSE-LIKE TOTAL SPINAL, LA TOXICITY, EPIDURAL

HEMATOMA AND ABSCESS ARE NEGLIGIBLE WITH SENIOR ANESTHESIOLOGISTS.
 REGIONAL ANAESTHESIA
CONTROVERSIES ABOUT
CSE: CONTRAINDICATIONS TO
REGIONAL ANAESTHESIA
ACTIVE HEAVY BLEEDING
RISK OF EPIDURAL CATHETER UNCORRECTED COAGULOPATHY (E.G. HELLP

THROUGH THE DURAL HOLE SYNDROME (HEMOLYSIS, ELEVATED LIVER ENZYMES,

LOW PLATELETS) ASSOCIATED WITH PRE-
PERCEIVED INCREASE IN ECLAMPSIA)

NEUROTRAUMA THROMBOCYTOPENIA

SYSTEMIC SEPSIS

LOCAL SEPSIS AT SITE OF INSERTION

PATIENT REFUSAL
 ANAESTHETIC GOALS:

1. MAINTAIN THE HEART RATE AROUND 80-100 B/MIN .

GUIDELINES FOR
2. MAINTAIN LEFT ATRIAL PRESSURE HIGH ENOUGH TO
GENERAL TAKE ADVANTAGE OF THE INCREASED PRELOAD
ANAESTHESIA RESERVE.

3. AVOID PULMONARY ARTERY HYPERTENSION BY

TREATING HYPERCARBIA, HYPOXEMIA, AND ACIDEMIA.
GENERAL
4. AGGRESSIVELY TREAT PULMONARY ARTERY
ANAESTHESIA HAS THE
HYPERTENSION WITH VASODILATOR THERAPY TO AVOID
ADVANTAGES OF SPEED
RV FAILURE. IF RV FAILURE DOES OCCUR, INOTROPIC
OF INDUCTION,
SUPPORT OF THE RV AND PULMONARY VASODILATION
CONTROL OF THE
MAY BE NECESSARY. THE PRESENCE OF PAH IS THE
AIRWAY, AND SUPERIOR
MAJOR FACTOR THAT INCREASE THE MORTALITY.
HEMODYNAMICS.
 ANAESTHETIC GOALS
5. AVOID FACTORS WHICH DEPRESS THE MYOCARDIUM (INHALATION AGENTS AND DRUGS)

6. MAINTAIN AWARENESS OF POTENTIAL FOR LV RUPTURE.

7. AGGRESSIVE TREATMENT OF ARRHYTHMIAS IF THEY OCCUR

8. AVOID PROFOUND CHANGES IN SVR

9. ATTENUATE PRESSOR RESPONSE (INTUBATION, EXTUBATION, LIGHT PLANE OF ANESTHESIA)

10. ADEQUATE ANALGESIA AND ADEQUATE MUSCLE RELAXATION GUIDED BY NEURO

MUSCULAR MONITORING

11. ASPIRATION PROPHYLAXIS

12. BLOOD LOSS ASSESSMENT AND PROMPT REPLACEMENT

 GENERAL ANAESTHESIA
INDUCTION OF ANAESTHESIA

1. AVOID KETAMINE INCREASES HEART RATE, BLOOD PRESSURE

2. AVOID ATRACURIUM INCREASED HISTAMINE RELEASE CAUSES HYPOTENSION WHICH

MANIFESTS AS TACHYCARDIA.

. A BETA-ADRENERGIC RECEPTOR ANTAGONIST AND AN ADEQUATE DOSE OF OPIOID LIKE

FENTANYL SHOULD BE ADMINISTERED BEFORE OR DURING THE INDUCTION OF GENERAL
ANAESTHESIA.

. ESMOLOL HAS A RAPID ONSET AND SHORT DURATION OF ACTION, IT IS A BETTER CHOICE IN
CONTROLLING TACHYCARDIA. SINCE FOETAL BRADYCARDIA HAS BEEN REPORTED AFTER
ESMOLOL, FOETAL HEART RATE SHOULD BE MONITORED.
 GENERAL ANAESTHESIA
MAINTENANCE OF ANAESTHESIA

1. DRUGS SHOULD HAVE MINIMAL EFFECTS ON HEMODYNAMIC PATTERN

2. BALANCED ANAESTHESIA WITH N 2O/ NARCOTIC/ VOLATILE ANAESTHETIC

3. N2O CAUSES INSIGNIFICANT PULMONARY VASOCONSTRICTION. IT IS SIGNIFICANT ONLY IF PULMONARY

HYPERTENSION EXISTS. SO, ONE NEEDS TO TREAT PULMONARY HYPERTENSION PREOPERATIVELY.

4. CARDIAC STABLE MUSCLE RELAXANTS ARE TO BE USED. (PREFERABLY AVOID PANCURONIUM )

5. AVOID LIGHTER PLANES OF ANAESTHESIA (TO AVOID TACHYCARDIA)

6. FLUID MANAGEMENT:

. AVOID HYPERVOLEMIA - -> WORSENS PULMONARY EDEMA

. AVOID HYPOVOLEMIA - -> SACRIFICES ALREADY DECREASED LEFT VENTRICULAR FILLING,

WHICH FURTHER DECREASES CARDIAC OUTPUT. HYPOVOLEMIA SECONDARY TO BLOOD LOSS
AND VASODILATORY EFFECTS OF ANAESTHESIA OUGHT TO BE AVOIDED.
 GENERAL ANAESTHESIA

AFTER DELIVERY OF THE FOETUS, OXYTOCIN 1020 U IN 1,000 ML OF CRYSTALLOID

SHOULD BE ADMINISTERED AT A RATE OF 40 80 MU/MIN. AN INFUSION OF OXYTOCIN
CAN LOWER THE SVR AS WELL AS ELEVATE THE PULMONARY VASCULAR RESISTANCE,
RESULTING IN A DROP IN CARDIAC OUTPUT. CARE MUST BE TAKEN DURING ITS
ADMINISTRATION.
METHYLERGOMETRINE, OR 15-METHYLPROSTAGLANDIN F2, PRODUCES SEVERE
HYPERTENSION, TACHYCARDIA AND INCREASED PULMONARY VASCULAR RESISTANCE.

POST-OPERATIVELY
AVOID PAIN AS PAIN BEGETS HYPOVENTILATION WHICH LEADS TO RESPIRATORY ACIDOSIS,
HYPOXEMIA WHICH MANIFESTS AS RAISED HEART RATE AND PULMONARY VASCULAR
RESISTANCE.
 ADVANTAGES OF GA

1. RAPIDLY ESTABLISHED 7. VENTILATION OF ATELECTATIC AREAS BETTER V/Q

2. BETTER HEMODYNAMIC STABILITY 8. SINUS RHYTHM CAN BE MAINTAINED. IN CASE OF

SVT AND VENTRICULAR ARRHYTHMIAS PROMPTLY
3. PREVENTION OF ASPIRATION AS THE AIRWAY
REVERTED BY CARDIOVERSION
IS ISOLATED
9. PEAK AIRWAY PRESSURE CAN BE KEPT <20 CMS H2O
4. HIGH FIO2 -WHICH WILL REDUCE PVR
10. ELECTIVE POST OPERATIVE VENTILATION TO TIDE
5. VENTILATION CONTROLLED TO AVOID OVER THE CCF THAT MAY BE POSSIBLE AFTER

HYPERCARBIA-WHICH WILL INCREASE PVR PARTURITION

11. EFFECTIVE MANAGEMENT OF PULMONARY OEDEMA -

6. FRC IS INCREASED BY CONTROLLED
IPPV WITH PEEP, LIBERAL USE OF HIGH DOSE
VENTILATION
MORPHINE
 COMPLICATIONS OF GA
1. FAILED INTUBATION 8. NEED FOR ADEQUATE POST OP.
2. ASPIRATION( MORE COMMON IN ANALGESIA
UNPREPARED CASE)
9. NEONATAL DEPRESSION
3. HYPERTENSIVE CRISIS
10. DELAYED RECOVERY
4. ARRHYTHMIA-HYPOXIA, HYPERCARBIA,
INHALATIONAL AGENTS, DRUGS 11. ANAESTHETIC DRUG
5. USE OF POLY PHARMACY AND INTERACTIONS
ANAPHYLAXIS
12. INCREASED INCIDENCE OF PONV
6. AWARENESS
13. PROLONGED STAY ICU
7. UTERINE ATONY WITH INHALATION
AGENTS
 OUTLINES OF MANAGEMENT
1. PRE-CONCEPTUAL COUNSELING- NYHA III AND IV ARE ADVISED CORRECTIVE
CARDIAC BEFORE PREGNANCY. IT IS ADVISABLE FOR CERTAIN CARDIAC
DISEASES WHERE PREGNANCY IS TO BE AVOIDED

. THEY HAVE TO BE REGISTERED, INTERVIEWED REGARDING FUNCTIONAL DIFFICULTIES, REGULAR

FOLLOW UPS STARTING FROM EARLY PREGNANCY. IT IS ADVISABLE TO MANAGE THEM IN HIGHER
CENTERS WHERE MULTIDISCIPLINARY SUPPORT IS AVAILABLE(MULTIDISCIPLINARY APPROACH:
MANAGEMENT BY A TEAM OF SPECIALISTS APART FROM OBSTETRICIANS THAT INCLUDES THE
CARDIOLOGIST(FAILURE PREVENTION, ARRHYTHMIA MANAGEMENT), CT SURGEON(EMERGENT
CARDIAC SURGERY), NEONATOLOGIST(PRETERM BABY) ANESTHESIOLOGIST(PAIN RELIEF-
EPIDURAL, MECHANICAL VENTILATION IF NECESSARY)

2. CORRECT FACTORS WHICH WILL BURDEN THE CARDIAC LESION LIKE ANEMIA,
OBESITY, HYPERTENSION, ARRHYTHMIA

3. PREVENTION OF INFECTION
 OUTLINES OF MANAGEMENT
4. OPTIMIZATION OF HEART RATE WITH PHARMACOLOGICAL AGENTS

5. PREGNANCY IS A HYPERCOAGULABLE STATE, WHICH INCREASES THE RISK OF

THROMBOEMBOLIC EVENTS, ESPECIALLY IN THE CARDIAC PATIENT WITH A
PROSTHETIC HEART VALVE, VALVULAR HEART DISEASE, OR HEART FAILURE.
ANTICOAGULANT THERAPY SHOULD BE CONSIDERED IN THESE HIGH-RISK PATIENTS
TO PREVENT THROMBOEMBOLISM OR THROMBUS FORMATION.

6. IE PROPHYLAXIS -(AS PER THE ACOG GUIDELINES- SOME OF THE DRUGS

RECOMMENDED BY ACC/AHA ARE NOT RECOMMENDED FOR PREGNANT PATIENTS)

7. MONITORS- OTHER THAN THE ASA STANDARDS RECOMMENDATION- ADVANCED

MONITORS LIKE INVASIVE ARTERIAL PRESSURE, CVP -, PCWP AND TEE ARE
RECOMMENDED. THEY SHOULD BE CONTINUED IN THE POST PARTUM PERIOD UPTO
72 HRS AT LEAST
 OUTLINES OF MANAGEMENT
8. PLANNING THE MODE OF DELIVERY-VAGINAL DELIVERY IS BETTER TOLERATED(LESS BLOOD
LOSS, LESS CATECHOLAMINE), PAIN RELIEF DURING LABOR - RECOMMENDED, SHORTENING
THE SECOND STAGE- OUTLET FORCEPS, EPISIOTOMY.

9. LARGE BOLUSES OF OXYTOCICS SHOULD BE AVOIDED AS THEY CAUSE PROFOUND

HYPOTENSION. ERGOMETRINE BETTER AVOIDED. PGF 2 ALPHA AND MESOPROSTOL ARE USED
CAUTIOUSLY.

10. IF PLANNED FOR CESAREAN SECTION CHOICE OF ANESTHETIC SHOULD BE DIRECTED TO

KEEP THE HAEMODYNAMIC STABLE (AS NEAR NORMAL SYSTEMIC VASCULAR RESISTANCE,
PRELOAD, AFTERLOAD AS POSSIBLE)ADEQUATE REPLACEMENT OF BLOOD LOSS.

11. ALL PATIENTS WITH CARDIAC DISEASE SHOULD BE KEPT IN HIGH DEPENDENCY UNIT AND
MONITORED AFTER THE DELIVERY FOR A MINIMUM PERIOD OF 72HRS

12. PLAN AND ADVISE CARDIAC SURGERY IN THE SECOND TRIMESTER IF IS WARRANTED IN THE
INTEREST OF THE MOTHER'S WELL BEING.
THANK YOU