|Year : 2020 | Volume
| Issue : 2 | Page : 135-137
Severe dilated cardiomyopathy undergoing emergency lower segment cesarean section: A case report
Sunil Thakur1, Vatika Bhardwaj1, Sushruti Kaushal2, Aman Thakur1
1 Department of Anaesthesia, Shri Lal Bahadur Shastri Government Medical College, Mandi, Himachal Pradesh, India
2 Department of Obstetrics and Gynaecology, Shri Lal Bahadur Shastri Government Medical College, Mandi, Himachal Pradesh, India
|Date of Submission||06-Sep-2019|
|Date of Acceptance||20-May-2020|
|Date of Web Publication||20-Aug-2020|
Dr. Vatika Bhardwaj
Department of Anaesthesia, Set Number- 602 , Type 4, Block-D, Shri Lal Bahadur Shastri Government Medical College Campus, Nerchowk, Mandi- 175 021, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Dilated cardiomyopathy (DCM) is a rare condition in pregnancy and has an established grave prognosis as such. Anesthetic management of pregnant patients with dilated cardiomyopathy is quite challenging either because of preexisting DCM or the risk of precipitating sudden cardiac failure. Pregnancy in patients with preexisting DCM can further flare-up disease and can be life- threatening, especially in patients who land up in an emergency when there is less time to optimize the patient's condition. The anesthesiologist thus must have knowledge of its causes, pathophysiology, clinical features, and various anesthetic modalities available. The present case report illustrates the successful management of a parturient with preexisting DCM undergoing emergency caesarean section. It is very important that patients with DCM should have regular follow-up so that timely intervention can be done about the mode of delivery for the safety of both mother and child.
Keywords: Emergency caesarean section, general anesthesia, preexisting dilated cardiomyopathy
|How to cite this article:|
Thakur S, Bhardwaj V, Kaushal S, Thakur A. Severe dilated cardiomyopathy undergoing emergency lower segment cesarean section: A case report. J Obstet Anaesth Crit Care 2020;10:135-7
|How to cite this URL:|
Thakur S, Bhardwaj V, Kaushal S, Thakur A. Severe dilated cardiomyopathy undergoing emergency lower segment cesarean section: A case report. J Obstet Anaesth Crit Care [serial online] 2020 [cited 2020 Oct 31];10:135-7. Available from: https://www.joacc.com/text.asp?2020/10/2/135/292738
| Introduction|| |
Maternal mortality is higher in patients with preexisting cardiac disease. Pregnancy with dilated cardiomyopathy carries a risk of heart failure, thromboembolism, maternal death, and associated fetal complications like intrauterine growth retardation, prematurity, and fetal death. Moreover, patients presenting for emergency lower segment cesarean section (LSCS) do not give us much time for cardiac optimization and stabilization especially when they come to the health facility for the first time without any antenatal check-up in that institution.
Though, there are ample reported cases,,,,, of perioperative management of patients with peripartum DCM, but case reports with already existing DCM are few [Table 1]. We hereby report a case of a 24-year-old primigravida (PGR), which is a diagnosed case of dilated cardiomyopathy for emergency cesarean section.
|Table 1: Anaesthetic management for caesarean section of patients with pre-existing dilated cardiomyopathy (DCM).|
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| Case Report|| |
A 24-year-old PGR at a period of gestation 39 weeks + 4 days with a regular antenatal check-up at a subcenter, presented with a history of labor pain for 3–4 h. Detailed history revealed hospital admission 2 years ago with features suggestive of congestive heart failure (CHF) and was diagnosed with DCM. She was on a twice daily dosage of oral furosemide 20 mg and once daily dosage of spironolactone 25 mg, digoxin 0.25 mg, ramipril 1.25 mg, and carvedilol 3.125 mg each. She was counseled against pregnancy by a cardiologist 10 months back when her echocardiography (ECHO) finding revealed DCM with severe eccentric mitral regurgitation, mild tricuspid regurgitation, moderate pulmonary artery hypertension, global hypokinesia, severe left ventricular systolic dysfunction, and ejection fraction (EF) 20%–25%. The patient did not go for further follow-up.
A quick, preanesthetic examination was conducted. General physical examination didn't reveal any significant findings. Her vital signs were as follows: Pulse 109/min, SpO295% on room air, and blood pressure (BP) 118/68 mmHg. She was New York Heart Association (NYHA) class II in 2nd trimester, but for the last one month she was NYHA class III. On examination of cardiovascular system S1 and S2 with a systolic murmur was present. There were no features suggestive of CHF.
The decision for immediate LSCS was taken in the view of acute fetal distress. High-risk consent was taken for perioperative cardiac event. General anesthesia was planned, and the patient was taken to operating room where electrocardiogram, pulse oximetry, and noninvasive BP monitors were attached. After securing two intravenous lines with 18 G cannula on the right forearm and external jugular vein, left radial artery cannulation was done for invasive BP. Rapid sequence induction was performed with inj. fentanyl 150 microgram (mcg), etomidate 10 mg, and succinylcholine 100 mg IV with cricoid pressure, and airway was secured with a cuffed endotracheal tube ( ETT). Anesthesia was maintained with oxygen/air (50:50), isoflurane [Minimum alveolar concentration (MAC) 1%–1.5%], and intermittent atracurium. After the delivery of an alive male baby, oxytocin 20 units/L infusion was started by using a micro-drip set and was titrated. Analgesia was achieved with additional doses of fentanyl 50 mcg and paracetamol 1 gm. Bupivacaine was infiltrated at the incision site and morphine 6 mg was given after surgery and continued 6 hourly for the first 24 h.
A single episode of hypotension (BP-72/40 mmHg) along with bradycardia (HR-35 bpm) happened in the intraoperative period after the delivery of baby, which was treated with intermittent boluses of ephedrine in doses of 3–6 mg and one dose of intravenous atropine 0.6 mg. Then, BP was maintained 100–130 mmHg systolic, 60–90 mmHg diastolic, and mean blood pressure 60–70 mmHg throughout the surgery. Estimated blood loss was around 600 mL and patient received 800 mL of crystalloids and 10 mg IV furosemide intraoperatively.
At the end of surgery tracheal extubation was done smoothly. Postoperatively BP was 120/72 mmHg, pulse rate was 100 beats/min, and SpO2 of 97%. Patient had no complaints of any chest pain, sweating, tachypnoea, or difficulty in breathing. Patient was then shifted to ICU for monitoring. Further course was uneventful, next day she was shifted to ward and discharged 5 days later.
| Discussion|| |
The option of regional anesthesia (RA) and general anesthesia (GA) involves the consideration of both merits and pitfalls of each technique and associated symptoms in patients with DCM.,, The goals of perioperative management are to avoid excessive anesthetic-induced myocardial depression, maintaining euvolemia, and to decrease the inherent sympathetic stimulation associated with surgery.
We opted for GA,, as it is advantageous in patients with DCM (specially with severe systolic dysfunction) because even slight degree of sympathetic blockade caused by RA may lead to fulminant and fatal heart failure in already compromised heart, though there are reported cases with the successful use of it. In patient with DCM induction of anesthesia with propofol can lead to cardiac arrest. So we used etomidate as it has least cardiovascular depressing effect. A MAC of 1%–1.5% isoflurane with oxygen was delivered to patient as no N2O was used, which could have further increased the pulmonary artery hypertension in our patient. Though the avoidance of high concentrations of volatile agents, atropine, ephedrine, and hypovolemia may prevent dramatic cardiac depression and uncontrolled changes in after load and preload in patients with DCM. We used fentanyl, which is short acting opioid so as to obtund the intubation response and to minimize the hemodynamic instability. Fluid management in patients with DCM is very crucial and should be used judiciously. Infusion of oxytocin should be carefully titrated, bolus should never be given as it may cause hypotension and tachycardia, which may precipitate cardiac failure.
Conventionally patients of severe DCM, are advised against pregnancy or termination in first trimester. Discrimination is to be made with peripartum cardiomyopathy (PPCM), which is defined by: 1) No preexisting or identified cause for cardiac failure, 2) left ventricular ejection fraction (LVEF) <45%, and 3) occurring in the last trimester to five months after delivery. While DCM is defined by: (a) LVEF <45% (b) left ventricular (LV) end diastolic (LVED) diameter >117% excluding any known cause of any myocardial disease. In these patients, left and/or right ventricular systolic pump function is impaired, leading to progressive cardiac enlargement, by a process called remodeling producing symptoms of CHF. Although no cause is specific, DCM is probably the end result of the myocardial damage produced by various metabolic, toxic, or infectious agents. The predictors of poor prognosis are an EF <25%, LVED dilatation, hypokinetic LV, and the presence of mitral and tricuspid regurgitation. During pregnancy increase in intravascular volume and metabolic demand can further complicate the condition in patients with DCM, specifically in 3rd trimester. Furthermore, the history of cardiac events like previous episodes of CHF, atrial fibrillation, or flutter before pregnancy are highly predictive of pregnancy-related adverse outcomes, as was in our case.
In cases reported by Shnaider et al., Kotekar et al. and Nallam et al., which were elective procedures combined spinal epidural anesthesia and spinal alone was used, patients had an LVEF of 20%, 41%, and 29%, respectively, the use of RA was done by probable explanation of improving myocardial performance by reducing the after load on the left ventricle without improving contractility. Epidural anesthesia has also been used safely and effectively. The changes in preload and after load produced by epidural anesthesia mimic the pharmacological goals, which can be used in elective cases., We did not use epidural anesthesia keeping in view the need of quick induction of anesthesia.
| Conclusion|| |
Successful management of GA is described in a case of preexisting severe DCM undergoing emergency lower segment cesarean section.
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.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Ramachandran R, Rewari V, Trikha A. Anaesthetic management of patients with peripartum cardiomyopathy. J Obstet Anaesth Crit Care 2011;1:5-12. [Full text]
Shnaider R, Efri T, Sjmuk P, Larson S, Warters RD, Katz J. Combined spinal – epidural anaesthesia for cesarean section in a patient with peripartum dialated cardiomyopathy. Can J Anaesth 2001;48;681-3.
Soni B, Gautam PL, Grewal A, Kaur H. Anaesthetic management of two cases of peripartum cardiomyopathy. J Obstet Anaesth Crit Care 2011;1:41-5. [Full text]
Kotekar N, Nagalakshmi NV, Chandrashekar. A rare case of peripartum cardiomyopathy posted for caesarean section. Indian J Anaesth2007;51:60-4. [Full text]
Singh T, Taxak S, Hasija N, Anand A. Anaesthetic management of a parturient with dilated cardiomyopathy: A case report. Egypt J Anaesth 2014;30:439-41.
Ituk US, Habib AS, Polin CM, Allen TK. Anesthetic management and outcomes of parturients with dilated cardiomyopathy in an academic centre. Can J Anaesth 2015;62:278-88.
Nallam SR, Kosinepalle S, Jyothirmai I, Ratnamaiah A, Reddy KS. Perioperative anaesthetic management of a case of severe dilated cardiomyopathy undergoing elective lower segment caesarean section under epidural anaesthesia. Int J Sci Stud 2014;2:225-7.
Stergiopoulos K, ShiangE, BenchT. Pregnancy in patients with pre-existing cardiomyopathies. JACC 2011;58:337–50.
Bajwa SS, Bajwa SK, Ghuman GS. Pregnancy with co-morbidities: Anesthetic aspects during operative intervention. Anesth Essays Res 2013;7:294-301. [Full text]
McCarroll CP, Paxton LD, Elliott P, Wilson DB. Use of remifentanil in a patient with peripatum cardiomyopathy requiring cesarean section. Brit J Anaesth 2001;86:135-8.
Wood WL, Kuczkowski KM, Beal BR. Anesthetic considerations for cesarean section in the parturient with familial cardiomyopathy. Acta Anaesthesiol Belg 2008;59:87-9.
Grewal J, Siu SC, Ross H, Mason J, Balint OH, Sermer M, et al
. Pregnancy outcomes in women with dilated cardiomyopathy. J Am Coll Cardiol 2009;55:45-52.
Malik R, Sharma P. Successful outcome in a patient with idiopathic dilated cardiomyopathy with bad obstetric history with no live issue. Int J Reprod Contracept Obstet Gynecol 2016;5:1225-7.