|Year : 2015 | Volume
| Issue : 1 | Page : 1-2
LSCS for a patient with Eisenmenger syndrome; lessons to be learnt
Department of Anaesthesia, Rainbow Hospitals, Hyderabad, Telangana, India
|Date of Web Publication||15-Apr-2015|
Dr. M Subrahmanyam
72, Nagarjuna Hills, Punjagutta, Hyderabad - 500 082, Telangana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Subrahmanyam M. LSCS for a patient with Eisenmenger syndrome; lessons to be learnt. J Obstet Anaesth Crit Care 2015;5:1-2
|How to cite this URL:|
Subrahmanyam M. LSCS for a patient with Eisenmenger syndrome; lessons to be learnt. J Obstet Anaesth Crit Care [serial online] 2015 [cited 2019 Dec 8];5:1-2. Available from: http://www.joacc.com/text.asp?2015/5/1/1/155190
A case report on the management of a patient in labor with Eisenmenger syndrome is reported in this issue of JOACC.  The outcome of this case was maternal death, which could have been avoided with better planning and coordination. India and many other developing countries are full of contrasts and paradoxes. Every major Indian city has gleaming skyscrapers along with sprawling slums. This contrast is most evident in the medical field across the developing world. The best of institutions with cutting edge technology and equipment co-exist with hospitals without basic monitoring, equipment or personnel! Such contrasts would probably be acceptable while dealing with simple cases of hernia or appendix in otherwise healthy individuals. When it comes to the care of sick patients or those with preexisting problems, the differences in equipment, infrastructure and personnel lead to tangible differences in outcome for the patient.
While a delivery is supposed be a natural phenomenon and even without medical assistance most women can normally deliver, it is recommended to deliver in hospitals to reduce maternal mortality rate (MMR). MMR is defined as the number of mothers dying per 100,000 live births. India had continued to have an appallingly high MMR. As part of the "millennium development goals," many "developing" countries aimed at bringing several developmental indices to more acceptable limits. One of the parameters targeted was MMR. From a MMR of 560/100,000 live births in 1990-91, India was required to reduce MMR to 109/100,000 live births by 2015.  Between 1990 and 2013, improvements were seen in the MMR, which has declined to 460 in 1995, 370 in 2000, 280 in 2005 and 190 in 2013.  Despite this progress, India is expected to fall short of the 2015 MMR goal of 109. Safe motherhood depends on the delivery being conducted by trained personnel, particularly through institutional facilities. However, delivery in institutional facilities in India was only 26% in 1992-93 and increased to 47% in 2007-08. Consequently, deliveries by skilled personnel have increased at the same pace, from 33% to 52% in the same period. , By 2015, it is expected that India will be able to ensure only 62% of births in institutional facilities with trained personnel.  Let us not forget the inherent contradiction that "institutional delivery" includes a rural primary health care as well as a gleaming corporate hospital.
Globally, there were an estimated 289,000 maternal deaths in 2013, a decline of 45% from 1990.  The Sub-Saharan Africa region alone accounted for 62% (179,000) of global deaths followed by Southern Asia at 24%. At the country level, the two countries that accounted for one-third of all global maternal deaths are India at 17% (50,000) and Nigeria at 14% (40,000). The MMR in India (190) is still 12 times higher than in developed regions (16). Apart from Sub-Saharan Africa, which has the highest MMR (510), every other region in the world has a lower MMR than India: Eastern Asia (33); Caucasus and Central Asia (39); Northern Africa (69); Western Asia (74); and Latin America and the Caribbean (85). 
We as physicians involved in the care of pregnant women have a huge role to play in decreasing this ugly rate of MMR in India and strive to bring it on par with the developed nations. This can only be achieved by all of us (Obstetricians, Gynecologists and Anesthesiologists) working together and striving to change the system. It is time for Anesthesiologists to say that we will not work in sub-standard conditions which actually endanger the life of the mother. The authors in this case report  conclude that the outcome would have been better if they could have managed this patient in a "higher center." What prevented them from shifting the mother after delivery (as shifting in labor was not considered appropriate)?
It is a real pity that even in this day and age; we are constrained by resources and equipment to manage our patients. One of the reasons this situation is persisting is because we as physicians in developing countries have accepted what the "system" is providing for us. In the case report by (Dr. Rodrigues),  the patient was screened by a cardiologist using a color Doppler echo machine. This machine costs upward of Rs. 3,000,000 ($ 50,000). Whereas, the authors could not lobby for an invasive monitor in their hospital, which would cost < Rs. 100,000 or $ 1600 (as an upgrade on existing monitors)! We can only blame ourselves in not representing our case adequately to the authorities and constantly compromising on the quality of care being provided. It is no virtue to claim that such and such a case was managed well "even in a low resource center." It is time we eliminated the concept of a low resource center.
Among all the specialties mentioned in the care of mothers, the role of our specialty is unique as we are the default "peri-operative physicians" especially in the maternity wing of any hospital. Whatever may be the cause of the disease or illness; all patients who are sick and unstable are eventually managed by anesthesiologists.
Anesthesiologists who are involved in maternal care (Obstetric Anesthesiologists) should take a more active role in the care of pregnant patients. We are any way involved in the management of delivery by caesarean section in a significant number of women. Why not start this care early and extend it to all the 100% of pregnant patients to ensure better outcomes?  We need to be involved right from the first trimester in screening high-risk pregnancies and taking part in discussions about the risks and benefits of continuing a particular pregnancy. For instance, had the patient quoted in the case report been counselled about the enormous risk this pregnancy has placed on her life, she may have opted for a termination. We should also encourage our obstetric colleagues to refer all cases with medical co-morbidities to anesthesiologists early in pregnancy. These would include patients with heart disease, preeclampsia, obesity, difficult airway, muscular dystrophies, antiphospholipid antibody syndrome, liver or kidney disease, etc. This way, a plan action is available rather than be stuck with the decision making in an "emergency" situation.
Postoperative care is another huge area often neglected by anesthesiologists. The general tendency is to let the obstetricians deal with postoperative issues and pain relief. The thought process of most anesthesiologists is that our job is done if the patient comes out safely from the operation theatre. This is an area where better coordination and our active involvement will make a real difference in outcomes. We are all aware that the majority of peri-operative deaths occur not during surgery but in the postoperative period. This is because we are very vigilant during surgery in the operating rooms and ensure minute to minute monitoring and correct any increase or decrease in hemodynamic, oxygenation and other vital parameters. Whereas, in the postoperative wards, it is primarily the nurses and surgeons who care for the patients. Which is what has happened in the case reported.  Had there been an active role of the anesthesia department, the patient's deterioration could have been picked up earlier, and she could have been shifted to a referral hospital.
Anesthesiologists practicing the sub-specialty of obstetric anesthesia have a huge role and responsibility in the care of pregnant patients and if all of us rise up to the challenge, we can certainly bring down the unfortunate deaths of mothers.
| References|| |
Rodrigues JS, Shenoy T, Acharya M. Anesthetic management of a patient with Eisenmenger′s syndrome for an emergency caesarean section in an under resourced area. J Obstet Anesth Cri Care 2015;5:27-9.
Trends in Maternal Mortality: 1990-2013. Estimates by WHO, UNICEF, UNFPA, the World Bank and the United Nations Population Division. Executive Summary. WHO/RHR/14.13. ©World Health Organization; 2014. Available from: http://www.who.int
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