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Journal of Obstrectic Anaesthesia and Critical Care
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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 46-49

Anesthetic management of cesarean section in parturients with severe mitral stenosis: A case series


Department of Anesthesiology, Maulana Azad Medical College and Associated Hospitals, New Delhi, India

Date of Web Publication11-Apr-2019

Correspondence Address:
Dr. Kirti N Saxena
B-302, Geetanjali Apartments, Vikas Marg Extension, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_6_18

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  Abstract 


Mitral stenosis (MS) is the most common valvular heart disease associated with pregnancy. The increase in cardiac output during pregnancy results in deterioration of the patient's condition with progress to higher New York Heart Association class. Both general and regional anesthesias have been described for cesarean section in these patients. Anesthetic management of these patients depends upon the severity of the disease. General anesthesia has traditionally been preferred for cesarean section in patients with severe MS. Regional anesthesia has become popular as a safe choice in the recent past for cesarean section in all parturients including those with heart disease. We report three parturients with severe MS who underwent cesarean delivery under graded epidural block successfully. The parturients and the neonates were fine after the procedure.

Keywords: Cesarean section, severe mitral stenosis, valvular heart disease


How to cite this article:
Saxena KN, Wadhwa B, Mishra D. Anesthetic management of cesarean section in parturients with severe mitral stenosis: A case series. J Obstet Anaesth Crit Care 2019;9:46-9

How to cite this URL:
Saxena KN, Wadhwa B, Mishra D. Anesthetic management of cesarean section in parturients with severe mitral stenosis: A case series. J Obstet Anaesth Crit Care [serial online] 2019 [cited 2019 Dec 5];9:46-9. Available from: http://www.joacc.com/text.asp?2019/9/1/46/255895




  Introduction Top


Mitral stenosis (MS) is the most common valvular heart disease associated with pregnancy. The area of the mitral valve is 4–6 cm2. The patient becomes symptomatic when this reduces to 2 cm2 and mitral valve area (MVA) of less than 1.0 cm2 is considered severe.[1] The increase in cardiac output during pregnancy results in deterioration of the patient's condition with progress to higher New York Heart Association (NYHA) class. Tachycardia reduces left ventricular filling time resulting in increased left atrial and pulmonary pressures, which may result in pulmonary edema. Atrial fibrillation is a known complication of MS and may further aggravate the situation with onset of systemic emboli.[1] It is well-known that valvular heart disease often manifests for the first time during pregnancy because of the physiological cardiovascular changes of pregnancy. Cardiac output starts increasing at 5 weeks of pregnancy and continues to increase until at term it becomes 50% more than normal. Patients with diagnosed heart disease may worsen during pregnancy for the same reason. The management of the disease needs to be individualized and requires multidisciplinary care from the time of diagnosis of the disease.[1]

We present three cases with severe MS who were presented to us for cesarean delivery. We used graded epidural anesthesia to conduct these cases successfully.


  Case Reports Top


Case 1

A 26-year-old primigravida with 38 weeks of gestation was posted for elective cesarean delivery following failed induction of labor the previous day. The patient was diagnosed as a case of rheumatic heart disease (RHD) with severe MS during her antenatal check up when she developed breathlessness during walking in the second trimester. The 2D echocardiography revealed MVA = 0.8 cm2. She was started on digoxin 0.25 mg once daily and tablet metoprolol 25 mg twice daily by the cardiologist, and tablet furosemide 20 mg twice daily was added during her third trimester as her condition had worsened. On fresh evaluation, she was classified as belonging to NHYA class II.

She had been planned for labor analgesia, but because induction of labor failed the previous day, she was planned for elective cesarean section under epidural anesthesia During the pre-anesthetic evaluation, her blood pressure was 96/60 mm Hg and heart rate was 96/min. All laboratory investigations including serum electrolytes were normal.

After taking written informed high-risk consent, the patient was wheeled inside the operation theater. All routine monitors were attached and two large bore intravenous cannulae were inserted. Coloading with lactated Ringer's solution was started. Under all aseptic precautions, epidural block was given by using a 16 G Tuohy's needle at L3-L4 space in lateral decubitus position. An 18G epidural catheter was threaded through it and was fixed at 9 cm to skin. Patient was repositioned giving a slight lateral tilt. A urinary catheter was inserted and urine output monitoring started. A test dose of 3 ml of 2% xylocaine with 1:200000 adrenaline was administered. After confirming the correct placement of the epidural catheter, it was activated with 11 ml of 2% xylocaine with 1:200000 adrenaline in aliquots within 15 min. After 15 min of administration of drug, a sensory block of thoracic 6 was achieved and the surgeons proceeded with the surgery.

After delivery of baby, oxytocin infusion was started at 10 units/h. Injection esmolol 30 mg intravenous was administered to control the heart rate, which increased to 160 beats/min after the delivery of baby, but there was no drop in blood pressure.

No other complications occurred during the intraoperative period. Oxygen was supplemented throughout the surgery using an oxygen mask. Post-operative analgesia was maintained with epidural morphine and intravenous paracetamol round the clock. The patient was kept in the high dependency obstetric unit for the next 2 days and continued to do well postoperatively.

Case 2

A 24-year-old female, primigravida with 37 weeks of gestation pregnancy with severe MS (MVA = 0.6 cm2) in congestive heart failure was posted for an elective lower segment cesarean section.

The patient came to the obstetric casualty with complains of severe breathlessness, orthopnea, and generalized edema. She was having breathlessness even during talking. On auscultation, bilateral crepts were heard all over the lung fields. A diastolic murmur was auscultated over the cardiac area, and generalized pitting edema was observed. She was admitted in the high dependency unit. The 2D Echocardiography was done and was suggestive of RHD with severe MS having MVA = 0.6 cm2, with severe tricuspid regurgitation (TR) and severe pulmonary artery hypertension (PAH). The patient was diagnosed to be in congestive heart failure and was classified as NYHA class IV by the cardiologist. A 12 lead ECG revealed sinus tachycardia.

She was initially administered furosemide infusion at 5 mg/h with strict urine output monitoring (urine collected in graduated jar 6 hourly), which was changed to oral furosemide 20 mg thrice daily, digoxin 0.25 mg once daily, and metoprolol 50 mg twice daily after 2 days. As per the cardiologist advice a plan was made for an elective caserean section the following day.

During the pre-anesthetic evaluation, she was found to be still in failure with pedal edema. We advised for continuation of all drugs till the morning of surgery. Encouraged by our success with the previous patient, we planned epidural anesthesia for her even though the patient continued to be in congestive cardiac failure on arrival in the operation suite. Her blood pressure was 100/64 mm Hg, and pulse rate was 142/min.

Epidural block was given under all aseptic precautions to the patient in the sitting position using a 16G Tuohy's needle at L3- 4 interspace and the epidural catheter threaded. She was then repositioned with a slight head–up, and a left lateral tilt as the patient was getting dyspnoeic in the supine position. A test dose of 3 ml of 2% xylocaine with 1:200000 adrenaline was given. After confirming the correct placement of the epidural catheter, it was activated with 10 ml of 2% xylocaine with 1:200000 adrenaline given in aliquots in a period of 15 min. The sensory block level of T6 was achieved 20 min after administering the drug, and the patient was handed to the surgeons. Oxygen was supplemented to the patient with a venturi mask with FiO2 of 50%, and her hemoglobin saturation was maintained at above 98%. After delivery of baby, oxytocin infusion was given at 5 units/h. The patient developed a sudden episode of breathlessness after delivery of the baby, which was managed by giving 100% oxygen and 3 mg of intravenous morphine. There were no other complications occurred during the course of surgery. Total fluid administered was 500 ml of crystalloid and 500 ml of colloid with minute to minute urine output monitoring and auscultation of chest. Postoperatively, the patient was shifted to the intensive care unit (ICU) for monitoring. Postoperative analgesia was maintained with epidural 0.0625% bupivacaine 6ml and 1 mg morphine 8 hourly. The patient was discharged from the ICU after 48 h and continued to improve following the delivery.

Case 3

A 22-year-old female patient diagnosed as RHD with severe MS, severe TR, and trivial mitral regurgitation with PAH was posted for elective cesarean section with indication of breech presentation with oligohydramnios.

She developed breathlessness (NYHA 4) and anasarca at 7 months of pregnancy, and she was then diagnosed as a case of RHD with MS with a MVA of 0.8 cm2. She had sinus tachycardia on ECG. She was started on treatment for right heart failure with injectable furosemide 20 mg twice daily, oral ramipril 5 mg, and ivabradine 5 mg both once daily.

She was posted for elective cesarean section after 1 week of treatment as this time was required for optimization. When patient presented herself for PAC, she was NYHA III, with no edema or signs of right heart failure present. Chest was clear on auscultation, and diastolic murmur was present with a heart rate of 90 beats/minute and a BP of 100/67 mmHg. The plan of anesthesia was graded epidural anesthesia and a similar technique as in previous patients was followed. A total of 14 ml drug was administered, a sensory level of T6 was achieved in 20 min, and left lateral tilt of 15 degrees was given to the operating table. After delivery of baby, oxytocin infusion was started. One episode of hypotension occurred, which was treated with 3 mg of injection mephentermine. There were no other complications occurred. Injection dexamethasone 4 mg was given epidurally for postoperative analgesia, catheter was removed, and the patient was shifted to ICU for further monitoring.


  Discussion Top


All our patients had severe MS, and the second patient was in failure at the time of performing cesarean section. Because epidural block results in increase in venous capacity and thereby reduces preload, it is likely to be beneficial in these patients provided hypotension is treated. Because we had successfully used epidural anesthesia delivered with titrated doses of local anesthetic in the first patient uneventfully, we decided to use the same technique in the second and third patient also. Other authors have used bupivacaine and ropivacaine for epidural anesthesia;[2],[3] however, Mishra et al. used a combination of lignocaine and adrenaline for both test dose and establishment of block followed by use of bupivacaine and fentanyl in a parturient with Eisenmenger's syndrome.[4] We have used the same combination of lignocaine and adrenaline as it results in quick onset of blockade and adequate duration of block.[5] The use of adrenaline in epidural test dose in patients with heart disease has been questioned but not found unacceptable.[6] Adrenaline may help in preserving blood pressure as small amounts are systemically absorbed and would have the same effect as ephedrine.[7] Presently, designed epidural catheters in use have multiple orifices and are likely to detect intravascular placement easily. The use of graded epidural further prevents any other complication from occurring. The use of pulmonary catheters in parturients with heart disease undergoing cesarean delivery has been considered unnecessary.[8] Invasive monitoring was not used because in all these patients the disease had worsened after onset of pregnancy. Invasive monitoring is definitely indicated in patients with severe heart disease before onset of pregnancy but its role in such patients is not so well established as complications of invasive monitoring are serious as well as the fact that cesarean delivery is a short surgical procedure in experienced hands.[9] Mephentermine was kept standby and used as and when hypotension occurred. Mephentermine and phenylephrine have similar effect on blood pressure, but phenylephrine causes more bradycardia, which requires treatment with glycopyrrolate.[10]

Vaginal delivery is preferred in parturients with severe MS unless they develop obstetric complications or there is deterioration in the general condition of the patient. This results in a higher incidence of cesarean section in these patients.[11] Both general and regional anesthesia have been described for cesarean section in these patients. The anesthetic management of these patients depend upon the severity of the disease. General anesthesia has traditionally been preferred for cesarean section in patients with severe MS. However, tachycardia, at laryngoscopy and extubation must be avoided.[7] The use of opioids during induction may result in respiratory depression in the neonate, whereas at extubation they may lead to delayed awakening from anesthesia and increased chances of postoperative mechanical ventilation in the parturient. Increase in preload because of autotransfusion following uterine contraction at delivery can result in pulmonary edema, which manifests only after extubation because of positive pressure ventilation introperatively, which prevents it from occurring.[12]

Regional anesthesia has become popular as a safe choice in the recent past for cesarean section in all parturients including those with heart disease. The problems associated with neuraxial blockade is mainly the hemodynamic alterations associated with it. Epidural anesthesia is generally preferred over spinal anesthesia. The use of vasoconstrictors such as phenylephrine to prevent hypotension and tachycardia and judicious administration of intravenous fluids make this a safe technique for both mother and baby. However, there has been controversy over the use of neuraxial blockade in patients with severe MS as this is a fixed cardiac output state, and the patient may not tolerate the associated decreased systemic vascular resistance.[13] Further, these patients may be on drugs such as diuretics and beta-blockers that may compromise the compensatory cardiovascular mechanisms present in normal parturients. Inspite of these drawbacks of epidural anesthesia, it is increasingly being preferred for cesarean delivery in patients with severe heart disease because the increased venous capacity takes the load of the volume of blood pumped into the system during autotransfusion. In case of hypotension, drugs such as phenylephrine cause systemic vasoconstriction and help in preserving the blood pressure.[14] There are several recent case reports of successful use of epidural anesthesia in parturients with severe heart disease.[3],[4],[5]


  Conclusion Top


The use of graded epidural for cesarean delivery in parturients with severe MS is safe for both the mother and the baby.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vidovich MI. Cardiovascular disease. In: Chestnut DH, Polley LS, Tsen LC, editors. Chestnut's Obstetric Anaesthesia: Principles and Practice. 5th ed. Philadelphia (PA): Mosby Elsevier; 2014. pp. 960-1002.  Back to cited text no. 1
    
2.
Gupta M, Gurjar SS, Suthar OP, Karnawat R. Anesthesia for cesarean section in patients with severe mitral stenosis with congestive heart failure. Anaesth Pain Intensive Care 2016;20:330-33.  Back to cited text no. 2
    
3.
Naz A, Dasgupta S, Bandhopadhyay BK, Shirazee HH. Graded epidural anaesthesia for Caesarean section in a parturient with Shone's syndrome: A case study. S Afr J Anaesth Analg 2016;22.  Back to cited text no. 3
    
4.
Mishra L, Pani N, Samantaray R, Nayak K. Eisenmenger's syndrome in pregnancy: Use of epidural anesthesia and analgesia for elective cesarean section. J Anaesthesiol Clin Pharmacol 2014;30:425-6.  Back to cited text no. 4
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Hillyard SG, Bate TE, Corcoran T, Paech MJ, O'Sullivan G. Extending epidural analgesia for emergency Caesarean section-a meta-analysis. BJA 2011;107:668-78.  Back to cited text no. 5
    
6.
Gogarten W, Strümper D, Buerkle H, Van Aken H, Marcus MAE. Testing an epidural catheter in obstetrics: Epinephrine or isoproterenol? Int J Obst Anesth 2001;10:40-5.  Back to cited text no. 6
    
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Kuczkowski KM, van Zundert A. Anesthesia for pregnant women with valvular heart disease: The state of the art. J Anesth 2007;21:252-7.  Back to cited text no. 7
    
8.
Leibowitz AB, Oropello JM. The pulmonary artery catheter in anesthesia practice in 2007: An historical overview with emphasis on the past 6 years. Semin Cardiothorac Vasc Anesth 2007;11:162-76.  Back to cited text no. 8
    
9.
Vidovich MI. Cardiovascular disease. In Chestnut's Obstetric Anesthesia: Principles and practice. 5th ed. Elsevier Saunders; 2014.  Back to cited text no. 9
    
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Kannan M, Vijayanand G. Mitral stenosis and pregnancy: Current concepts in anaesthetic practice. Indian J Anaesth 2010;54:439-44.  Back to cited text no. 10
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11.
Mohta M, Janani SS, Sethi AK, Agarwal D, Tyagi A. Comparison of phenylephrine hydrochloride and mephenterminesulphate for prevention of post spinal hypotension. Anaesthesia 2010;65:1200-05.  Back to cited text no. 11
    
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Shimoyama Y, Sawai T, Umegaki O, Agui T, KadonoN, Nakahira J,et al. Sudden onset of severe pulmonary edema after emergency cesarean section. JA Clin Rep 2016;2:23.  Back to cited text no. 12
    
13.
Langesaeter E, Dragsund M, Rosseland LA. Regional anaesthesia for a Caesarean section in women with cardiac disease: A prospective study. Acta Anaesthesiol Scand 2010;54:46-54.  Back to cited text no. 13
    
14.
Dyer RA, Reed AR, Van Dyk D, Arcache MJ, Hodges O, Lombard CJ, et al. Hemodynamic effects of ephedrine, phenylephrine, and the coadministration of phenylephrine with oxytocin during spinal anesthesia for elective cesarean delivery. Anesthesiology 2009;111:753-65.  Back to cited text no. 14
    




 

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Introduction
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