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Anesthesia for Termination
of Pregnancy in Patient
with Eisenmenger’sSyndrome
Erwin Siregar
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Background
• Pregnant woman with cardiac disease >>>• High risk !!!!
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Hemodynamic Changes
Normal pregnancy:
Changes begin during 2nd-7th weeks of pregnancy,
and peaks in the late 2nd trimester
– Blood volume 40-50 % due to activation of Renin Aldosterone axis – Anemia of pregnancy
– CO 30 -50 % :
• preload
• afterload
• maternal HR 10-15 /minute – BP decrease by 10 mmHg
• SVR
• Addition of utero-placental bed of low-resistance
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Normal pregnancy :
– Fatigue
– Dyspnoe
– Poor exercise tolerance
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How about pregnant women with heartdisease ????
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Pregnant Pt with Cardiac Disease
Several points to ponder
• Basic characteristics of each cardiac disease
• Present status of cardiac disease? – Hemodynamic fluctuations ?
– Pulmonary complications ?
• Regional ? General ?• What appropriate monitors ?
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KISS (Keep it Simple, Stupid)
• If the patient is comfortable in the supine position regional or general
• If the patient is comfortable only in the semi or sitting position with/ out difficulty in breathing :
General anesthesia• Monitors :
– Potential for hemodynamic fluctuations :Invasive :
• AL• CVP
• PA catheters (Pulmonary Hypertension)
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Pregnant women with heart disease
• NYHA predictor of outcome• NYHA class III atau IV :
– Mortality rate 7 %
– Morbidity rate 30 % – No pregnancy please !!!!!
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Risk Factor
• Siu et al (1997)
– Prior cardiac events (heart failure, transient
ischemic attack, stroke prior to pregnancy) – Cyanosis or poor functional class
– Left heart obstruction
– Systemic ventricular dysfunction
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Classification
Three classification
– Low risk lesions
– Moderate risk lesions – High risk lesions
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Low risk lesions
– Atrial Septal defect
– Ventricular septal defect
– Patent ductus arteriosus
– Asymptomatic AS with low mean gradient (<50 mmHg), andnormal LV function
– AR with normal LV function and NYHA class I or II
– MVP (isolated or with mild / moderate MR and normal LVfunction)
– MR with normal LV function and NYHA class I or II
– Mild /moderate MS (MVA > 1.5 cm2, mean gradient< 5mmHg) without severe pulmonary hypertension
– Mild/ moderate PS
– Repaired acyanotic congenital heart disease without residualcardiac dysfunction
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Moderate risk lesions
• Large left to right shunt• Coarctation of the aorta
• Marfan’s syndrome with a normal aortic root
• Moderate/ severe MS
• Mild/ moderate AS
• Severe PS
• History of prior peripartum cardiomyopathy with
no residual ventricular dysfunction
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High risk lesions
• Eisenmenger’s syndrome
• Severe PH• Complex cyanotic heart disease (TOF, Ebstein’s
anomaly, Tr Art, TGA, tricuspid atresia)
• Marfan’s syndrome with aortic root or valve involvement
• Severe AS with or without symptoms• Aortic and / or mitral valve disease with moderate/ severeLV dysfunction (EF < 40 %)
• NYHA class III to IV symptoms associated with anyvalvular disease or with cardiomyopathy of any etiology
• History of peripartum cardiomyopathy with persistent LVdysfunction
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Eisenmenger’s Syndrome Caused by continuous exposure of the pulmonary circulation
to high pressure due to L-R shunt
Obliterative changes in pulmonary circulation
Fixed increases in PVR
RV pressure
R – L shunt
cyanosis
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Eisenmenger’s Syndrome • A delicate balance between PVR and SVR
must be maintained
PVR SVR
Acidosis
Hypercarbia
PPV
R >>>> L Shunt
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Eisenmenger’s Syndrome • Definitions
Pulmonary hypertension at systemic level due to
high pulmonary vascular resistance, with
reversed or bidirectional shunt at
aortopulmonary, atrial or ventricular level
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• Pregnant women with low risk cardiaclesions :
regional or general --- no difference in
morbidity or mortality rate• Pregnant women that cannot tolerate
supine position, e.g. severe MI, MS, and
CTR > 70%; Eisenmenger’s syndrome :
general anethesia with controlled respiration
Technique
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Monitoring
• Pregnant women with low risk cardiac lesionand can tolerate supine position : noninvasive monitoring (NIBP, ECG, and pulseoxymetry)
• Pregnant women with moderate to high riskcardiac lesion :invasive monitoring
– Arterial line
– CVP
– Swan Ganz catheter
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Anesthetic Management
• Depends on condition of the patient : – Hemodynamic status
– Respiratory status
– Position best tolerated by patient at rest
• Determines :
– Anesthetic technique – Monitoring
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Drugs
• Vasodilators• Vasoconstrictors
• Inotropes
• Anti arrhythmias
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Case Illustration
• Pregnant women 32 yrs old, G4A2P1, 34weeks pregnant, with Eisenmenger’s
syndrome caused by ASD II
• Termination of pregnancy with SC becausematernal deterioration
• Preop visit :
– Difficulty in breathing, with nasal O2,
– Can only tolerate sitting position
– Sometimes O2 desaturation
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Anesthetic Management
• General anesthesia• Arterial line, CVP, and SG side port insertion
before induction of anesthesia
• Surgeon and surgical team in sterile gownbefore induction of anesthesia
• Induction of anesthesia with IV Sufentanyl
0.5 – 1 g/kg/bw and Midazolam andappropriate muscle relaxant for intubation
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Anesthetic Management
• As soon as the patient loosesconsciousness, she is put into supine
position, and surgical team immediately
begins incision while the patient is being
intubated
• After intubation a PA catheter is inserted
• NTG, Vasopressor, and Inotropes given if
needed to control hemodynamics
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S
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Summary
• Good team work between cardiologist,surgeon, and anesthesiologist is needed inthe proper management of delivery/termination of pregnancy in women with
heart disease• The surgeon has to be informed of the
anesthetic procedure prior to the operation
• Pediatricians has to be ready in the OR andcapable of resuscitation / intubation of baby