|Year : 2016 | Volume
| Issue : 1 | Page : 28-30
Emergency mitral valve replacement and cesarean section in parturients: Two case reports
PS Nagaraja1, Naveen G Singh1, Gaurav Pandey2, Pranav J Adoni1, CG Prabhushankar1, Vijayakumar M Heggeri1, Ravikumar Nagashetty3, TH Krishnaprasad4
1 Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
2 Department of Cardiac Anaesthesiology, Apollo Hospital, Bengaluru, Karnataka, India
3 Department of Cardio Thoracic Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
4 Department of Perfusion Sciences, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
|Date of Web Publication||22-Apr-2016|
Dr. Naveen G Singh
Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru - 560 069, Karnataka
Source of Support: None, Conflict of Interest: None
Cardiac surgery during pregnancy using cardiopulmonary bypass has a maternal mortality rate (MMR) of about 3-15%. Cardiopulmonary bypass, in addition, alters placental perfusion, which can increase infant mortality. Here, we report two cases of parturients with severe mitral stenosis, who developed acute mitral regurgitation (MR) after percutaneous transluminal mitral commissurotomy (PTMC) due to anterior mitral leaflet tear. They were posted for emergency mitral valve replacement (MVR) followed by cesarean section. Altering the routine cardiopulmonary bypass and anesthesia protocol resulted in a favorable maternal and fetal outcome.
Keywords: Cesarean section, cardiopulmonary bypass, mitral valve replacement (MVR)
|How to cite this article:|
Nagaraja P S, Singh NG, Pandey G, Adoni PJ, Prabhushankar C G, Heggeri VM, Nagashetty R, Krishnaprasad T H. Emergency mitral valve replacement and cesarean section in parturients: Two case reports. J Obstet Anaesth Crit Care 2016;6:28-30
|How to cite this URL:|
Nagaraja P S, Singh NG, Pandey G, Adoni PJ, Prabhushankar C G, Heggeri VM, Nagashetty R, Krishnaprasad T H. Emergency mitral valve replacement and cesarean section in parturients: Two case reports. J Obstet Anaesth Crit Care [serial online] 2016 [cited 2018 Dec 19];6:28-30. Available from: http://www.joacc.com/text.asp?2016/6/1/28/181075
| Introduction|| |
Rheumatic heart disease is the most common cause (60-80%) of heart disease during pregnancy in developing countries.  Incidence of heart disease among parturients being 1-4%,  if left untreated, it can lead to increased maternal mortality rate (MMR). Physiological changes in pregnancy demand an increase in cardiac output that can adversely result in life-threatening complications among parturients with heart disease. Cardiac surgery during pregnancy, using cardiopulmonary bypass (CPB), has resulted in MMR of about 3-15%,  and is reserved only for those with failed medical management. Here, we report two cases who underwent successful emergency mitral valve replacement (MVR), followed by lower segment cesarean section (LSCS) by altering the routine CPB and anesthesia protocol for a favorable maternal and fetal outcome.
| Case Report|| |
A 23-year-old primigravida diagnosed with moderate mitral stenosis (MS), trivial mitral regurgitation (MR), and mild aortic regurgitation (AR), with 32 weeks of gestation underwent percutaneous transluminal mitral commissurotomy (PTMC). Echocardiography done after PTMC showed acute severe MR due to a tear in the anterior mitral valve leaflet (AML). The patient developed respiratory distress with a rate of 44/min, tachycardia, blood pressure (B.P.) of 90/40 mmHg, SpO 2 90% with 8 L/min of oxygen, and bilateral basal crepitations.
A 24-year-old multigravida with a previous history of two abortions, diagnosed with severe MS, grade 2 tricuspid regurgitation (TR), ostium secundum atrial septal defect (ASD) with severe pulmonary hypertension (Lutembacher's syndrome), with 30 weeks of gestation underwent PTMC, following which she also developed acute severe MR due to AML tear. In addition, she presented with respiratory distress, tachycardia, B.P. of 80/40 mmHg, SpO 2 92% with 8 L/min of oxygen, and bilateral basal crepitations.
Dobutamine intravenous (IV) injection 5 μg/kg/min, 0.05 mg/kg IV morphine injection, 40 mg IV lasix injection were administered for both the patients and were posted for emergency MVR followed by LSCS. Premedication with 40 mg pantoprazole injection and 4 mg ondansetron IV injection was given in both the cases. A 2 g magnesium sulphate injection was administered over 45 min and subcutaneous terbutaline was given before the induction of general anesthesia (GA) for tocolysis. Invasive femoral arterial line and central venous catheter in the right internal jugular vein was inserted under local anesthesia. Preoxygenation with 100% oxygen and placement of a wedge under the right hip were done for both the cases. ECG, invasive blood pressure, central venous pressure, temperature, pulse oximeter, end-tidal carbon-di-oxide (Etco2), Bispectral index (BIS), urine output, and fetal heart rate monitoring were done. In both the patients, GA was induced with fentanyl 2 μg/kg, titrated doses of etomidate, and vecuronium 0.1 mg/kg IV to facilitate muscle relaxation. The trachea was intubated with 7.0 size cuffed endotracheal tube and ventilated on a controlled mode with 100% oxygen. Anesthesia was maintained with isoflurane 0.5 MAC and propofol infusion of 1-2 mg/kg/h, maintaining a BIS of 40 to 60. Pre CPB, mean arterial pressure (MAP) was maintained at around 80 mmHg. Systemic heparinization was done to maintain activated clotting time (ACT) more than 480 s. After aortic and bicaval cannulation, the patient was subjected to CPB for MVR. Both the patients underwent normothermic CPB of 34-36°, crystalloid prime, pulsatile flow of 4-5 L/min with alpha-stat pH management, MAP of 70-90 mmHg, hematocrit of 30-35%, pCo 2 of 35-40 mmHg, and potassium of 4-4.5 mmol/L. Fetal heart rate was monitored throughout the CPB using a stethoscope which was plastered to the patient's lower abdomen. During initiation of CPB there was a drop in fetal heart rate which was corrected by increasing perfusion pressure and pump flow rates. Total CPB time was 64 min and 57 min with aortic cross clamp time of 54 min and 46 min in case 1 and case 2, respectively. In both the cases, 25 mm St. Jude mechanical heart valves were used. Both the patients were weaned from CPB with 5 μg/kg/min dobutamine injection to maintain a MAP around 70 mmHg and heparin was neutralized with protamine to normalize the ACT.
Case 1 underwent MVR, whereas case 2 underwent MVR with De vaga tricuspid valve plasty with ASD closure and then both the patients underwent LSCS. Both the babies born had an Apgar score of 3 at birth and hence, were intubated and mechanically ventilated. IV oxytocin 20 units infusion was given and intramuscular (IM) prostodin 0.2 mg was given to prevent uterine atony. In the first case, the patient was ventilated for 6 h and in the second case, the patient was ventilated for 7 h and later, their trachea was extubated. Dobutamine injection was subsequently weaned, maintaining a MAP of 70 mmHg. The first parturient's baby was ventilated for 12 h and the second parturient's baby was ventilated for 14 h and later extubated after good respiratory efforts and hemodynamic stability. Both the babies were reversed with IV naloxone 0.1 mg/kg before extubation. Invasive monitoring was continued till the 4 th postoperative day. After 5 days, both the mothers with their neonates were shifted from the intensive care unit and 5 days later were discharged from the hospital. At the end of a 2 year follow-up, both the mothers and their children are doing well.
| Discussion|| |
CPB in pregnant women is associated with high maternal mortality.  Determining whether cardiac surgery should precede cesarean section should be dealt on a case-by-case basis. Early intervention can decrease maternal risk but may result in fetal demise. Alternatively, delaying cardiac surgery until after delivery may result in maternal death. Previous articles have reported emergency valve replacement immediately following cesarean section. , Because the parturients had developed an acute severe MR with hemodynamic instability, the cardiac surgeon, obstetrician, pediatric cardiologist, and anesthesiologist decided to do MVR followed by LSCS, as saving the mother was of prime importance. In our cases, uterine atony and postpartum hemorrhage (PPH) were a major concern if cesarean section preceded MVR.
The use of CPB in early puerperium can be associated with major complications, as CPB would alter coagulation mechanism and possible decrease in platelet count, which is required for hemostasis after placental separation. This would result in massive PPH.  According to the American college of Obstetricians and Gynecologists, it is recommended to administer heparin only 6-12 h after cesarean section to prevent PPH  [Table 1].
CPB is associated with poor neonatal outcome as well. However, we had a favorable fetal outcome in both our cases. This was achieved by deviating from the routine CPB protocol  , maintaining maternal hematocrit >25%, high maternal oxygen saturation, normothermia, high perfusion flow rates >2.5 L/min/m 2 , high perfusion pressure more than 70 mmHg, minimal CPB time, pulsatile perfusion, and alpha-stat pH management [Table 2].
Before the induction of GA, tocolytics were administered to prevent uterine contractions and continuous fetal heart rate monitoring was done. Unfavorable maternal outcome was due to CPB or preoperative cardiac status and not due to the anesthetic drugs used.  Mechanical ventilation was done with a controlled mode to maintain high maternal oxygenation and pCo 2 between 35-40 mm Hg to maintain uterine blood flow and placental perfusion.
| Conclusion|| |
A multidisciplinary team comprising of cardiac anesthesiologists, cardiothoracic surgeons, obstetricians, pediatricians, perfusionists, and intensivists are desirable for successful management of such patients. Hence, in both our cases we had favorable maternal and fetal outcome by deviating from the routine anesthesia and CPB protocol.
The authors would like to acknowledge the help provided by Dr. C.N Manjunath, Director and HOD, professor, dept. of Cardiology, Dr. Manjunatha N, HOD, Dr. A M Jagadeesh, professor, dept. of Anaesthesiology, Dr Giridhar Kamalapurkar, HOD, Dr. P.S. Seetharma Bhat, professor, dept of cardio Thoracic Surgery, Dr. Nirmala Bhat, consultant Obstetrician, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bhatla N, Lal S, Behera G, Kriplani A, Mittal S, Agarwal N, et al
. Cardiac disease in pregnancy. Int J Gynaecol Obstet 2003;82:153-9.
Kapoor MC. Cardiopulmonary bypass in pregnancy. Ann Card Anaesth 2014;17:33-9.
Chambers CE, Clark SL. Cardiac surgery during pregnancy. Clin Obstet Gynecol 1994;37:316-23.
Shah AM, Ikram S, Kulatilake EN, Pearson JF, Hall RJ. Emergency mitral valve replacement immediately following caesarean section. Eur Heart J 1992;13:847-9.
Tzankis G, Morse DS. Cesarean section and reoperative aortic valve replacement in a 38-week parturient. J Cardiothorac Vasc Anesth 1996;10:516-8.
Lamarra M, Azzu AA, Kulatilake EN. Cardiopulmonary bypass in the early puerperium: Possible new role for aprotinin. Ann Thorac Surg 1992;54:361-3.
James A; Committee on Practice Bulletins - Obstetrics. Practice bulletin no. 123: Thromboembolism in pregnancy. Obstet Gynecol 2011;118:718-29.
John AS, Gurley F, Schaff HV, Warnes CA, Phillips SD, Arendt KW, et al
. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 2011;91:1191-6.
Chandrasekhar S, Cook CR, Collard CD. Cardiac surgery in the parturient. Anesth Analg 2009;108:777-85.
[Table 1], [Table 2]