Mod VIII: Cardiac Disease and Primary Pulmonary HTN in the Parturient

Question 1

_{Cardiac Disease in the Parturient}

Why do Normal physiological changes associated with pregnancy lead to decompensation in parturient with preexisting cardiac disease?

Answer 1

Under maximum hemodynamic stress

Question 2

_{Cardiac Disease in the Parturient}

What are the maximum hemodynamic stress periods in the parturient, and what’s responsible for the increased hemodynamic stress?

Answer 2

2nd trimester

^{d/t most rapid inc in CO}

Labor & Delivery

^{d/t 2x pre-labor CO w/ auto transfusion into the maternal circulation of 300-500 mL during contraction}

Immediate PP

^{d/t 80-100% inc in CO w/ 500-700 mL of autotransfusion w/ sustained contractions}

This is why evaluation of previous CV dz is critical and requires a multidisciplinary management approach

Question 3

_{Cardiac Disease in the Parturient}

What’s responsible for increased hemodynamic stress in the 2nd trimester?

Answer 3

Most rapid inc in CO happens

Question 4

_{Cardiac Disease in the Parturient}

What’s responsible for increased hemodynamic stress during Labor & Delivery?

Answer 4

2x pre-labor CO

w/ auto transfusion into the maternal circulation of 300-500 mL during contraction

Question 5

_{Cardiac Disease in the Parturient}

What’s responsible for increased hemodynamic stress Immediate PP?

Answer 5

80-100% inc in CO

w/ 500-700 mL of autotransfusion w/ sustained contractions

Question 6

_{Cardiac Disease in the Parturient}

Cardiac Disease affect what % of Parturients? what are majors causes?

Answer 6

2%

Rheumatic fever

Congenital heart disease

Question 7

_{Cardiac Disease in the Parturient}

Anesthetic considerations regarding Cardiac Disease in the Parturient

Answer 7

Understanding that hemodynamic consequences of anesthetic technique might adversely affect parturient with specific cardiac lesion

Employ techniques that minimize added stress of labor & delivery

Question 8

_{Cardiac Disease in the Parturient}

Hemobynamic goals with w/ Aortic stenois in the Parturient:

Answer 8

Sinus Rhythm

Maintain HR

Avoid decreased SVR

Maintain Venous Return

_{In women with aortic stenosis, the decrease in afterload that occurs with epidural analgesia may need to be countered with a carefully titrated α-adrenergic agonist to prevent tachycardia and ischemia.}

Question 9

_{Cardiac Disease in the Parturient}

Hemobynamic goals with w/ Aortic insufficiency in the Parturient:

Answer 9

Mild increase in HR

Avoid increased SVR

_{Regurgitant valvular lesions and left-to-right shunts are tolerated better than stenotic lesions because the increased volume and decreased systemic vascular resistance favor forward flow}

Question 10

_{Cardiac Disease in the Parturient}

Hemobynamic goals with w/ Mitral stenosis in the Parturient:

Answer 10

Sinus Rhythm

Decrease HR

Maintain SVR

Maintain Venous Return

_{In mitral stenosis, the combination of increased heart rate and increased volume lead to increased left atrial pressure and risk for atrial fibrillation and left heart failure}

Question 11

_{Cardiac Disease in the Parturient}

Hemobynamic goals with w/ Mitral insufficiency in the Parturient:

Answer 11

Sinus Rhythm

Mild increase HR

Avoid increase SVR

Avoid increase Venous Return

_{Regurgitant valvular lesions and left-to-right shunts are tolerated better than stenotic lesions because the increased volume and decreased systemic vascular resistance favor forward flow}

Question 12

_{Cardiac Disease in the Parturient - Anesthetic Considerations}

Which anesthetic technique would parturients suffering from “Group 1 Disorders” (MVP, AI, congenital heart lesion with L-R shunt) benefit from and why?

Answer 12

Benefit from regional techniques

The induced sympathectomy from spinal or epidural techniques r_educes both preload and afterload,_

relieves pulmonary congestion, and in some cases,

increases cardiac output

Patients in the first group benefit from the reduced systemic vascular resistance caused by neuraxial analgesia and anesthesia techniques

Question 13

_{Cardiac Disease in the Parturient - Anesthetic Considerations}

Which anesthetic technique would parturients suffering from “Group 1 Disorders” (MVP, AI, congenital heart lesion with L-R shunt) Not benefit from?

Answer 13

Excessive fluid administration

Question 14

_{Cardiac Disease in the Parturient - Anesthetic Considerations}

Why would regional anesthetic technique be detrimental for parturients suffering from “Group 2 Disorders” (AS, R-L shunt, bidirectional shunt, Eisenmenger’s syndrome)?

Answer 14

Induced sympathectomy → ↓ preload & afterload poorly tolerated

Reductions in venous return (preload) or afterload are usually poorly tolerated

These patients are better managed with intraspinal opioids alone, systemic medications, pudendal nerve blocks, and, if necessary, general anesthesia.

Question 15

_{Cardiac Disease in the Parturient - Anesthetic Considerations}

When does Eisenmenger’s syndrome occurs?

Answer 15

when uncorrected L-R shunt results in pulmonary HTN,

which when severe, reverses flow to a R-L shunt

Question 16

_{Cardiac Disease in the Parturient - Anesthetic Considerations}

Which anesthetic technique would parturients suffering from “Group 2 Disorders” (AS, R-L shunt, bidirectional shunt, Eisenmenger’s syndrome) benefit from for L&D?

Answer 16

Intraspinal opioids alone or with dilute concentration local anesthetic, systemic analgesia for L&D

Question 17

_{Cardiac Disease in the Parturient - Anesthetic Considerations}

What’s the preferred anesthetic technique for parturients suffering from “Group 2 Disorders” (AS, R-L shunt, bidirectional shunt, Eisenmenger’s syndrome) for C-s?

Answer 17

GETA for C/S preferred technique

Question 18

_{Cardiac Disease in the Parturient - Anesthetic Considerations}

Which is the preferred level of anesthesia monitoring for parturients suffering from “Group 2 Disorders” (AS, R-L shunt, bidirectional shunt, Eisenmenger’s syndrome)?

Answer 18

Consider invasive monitoring

Question 19

_{Primary Pulmonary HTN in the Parturient}

What’s the Maternal mortality rate for Primary Pulmonary HTN in the Parturient?

Answer 19

30-55%

Question 20

_{Primary Pulmonary HTN in the Parturient}

When, in the course of pregnancy and delivery, does maternal mortality from Primary Pulmonary HTN in the Parturient the highest? What’s the primary cause?

Answer 20

Most during Labor & early postpartum period

Due to right heart failure

Question 21

_{Primary Pulmonary HTN in the Parturient}

What are delivery options for partureint w/ Primary Pulmonary HTN?

Answer 21

Vaginal

^{Smaller hemodynamic shifts & less blood loss}

Planned C-S preferred

^{Ensures optimal conditions}

Question 22

_{Primary Pulmonary HTN in the Parturient}

For a parturient with Primary Pulmonary HTN, which delivery option is associated with a Smaller hemodynamic shifts & less blood loss?

Answer 22

Vaginal delivery

Question 23

_{Primary Pulmonary HTN in the Parturient}

For a parturient with Primary Pulmonary HTN, which delivery option Ensures optimal conditions and is the preferred option

Answer 23

Planned C-S

Question 24

_{Primary Pulmonary HTN in the Parturient}

Why is Regional anesthesia, with dilute LA & opioid considered an appropriate technique for labor in a parturient w/ Primary Pulmonary HTN?

Answer 24

Minimizes decreased SVR

Avoids increase PVR due to pain/hyperventilation

Question 25

_{Primary Pulmonary HTN in the Parturient}

Which anesthetic technique is preferred for C-S in a parturient w/ Primary Pulmonary HTN?

Answer 25

GETA

Question 26

_{Primary Pulmonary HTN in the Parturient}

Which regional anesthetic technique is acceptable for C-S in a parturient w/ Primary Pulmonary HTN?

Answer 26

Epidural

Question 27

_{Primary Pulmonary HTN in the Parturient}

Which regional anesthetic technique is Not acceptable for C-S in a parturient w/ Primary Pulmonary HTN?

Answer 27

Spinal

Question 28

_{Primary Pulmonary HTN in the Parturient}

Why is invasive monitoring controversial in parturient w/ Primary Pulmonary HTN?

Answer 28

Risk pulmonary artery rupture greater in these patients

Benefits offset these risks

Question 29

_{Primary Pulmonary HTN in the Parturient}

T/F: Avoid N20 & hyperventilation in the anesthetic management of a parturient w/ Primary Pulmonary HTN?

Answer 29

True