1. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Management of Hemodynamically Unstable Pregnant Woman with Mitral Stenosis Laura Sommer Hansen 1,2, Carl-Johan Jakobsen 1, Dorthe Viemose Nielsen 1 1 Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark 2 Department of Cardiothoracic Surgery, Aarhus University Hospital, Denmark

2. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Background Rheumatic mitral valve stenosis (MS) is an uncommon but clinically significant valvular disease in pregnant women in western countries Moderate to severe MS is poorly tolerated during pregnancy with high maternal and fetal morbidity and mortality A hemodynamically unstable pregnant patient due to an undiagnosed MS is rare in western countries Incidence may rise due to increased immigration from high-risk areas

3. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Case presentation 27 years old woman from Afghanistan 26 weeks pregnant (2 children y11 and y6, 2 missed abortions during the past year) No medical history Progressive dyspnea, treated with Penicillin for 10 days (GP) Admitted to primary hospital Quickly deteriorates: Blood pressure 60/30 Heart rate 150 Pulmonary edema Saturation 61% (15L O 2 ) pH 7.12 Oliguria

4. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Actions Intubated (FiO 2 100%, PEEP 15) Phenylephrine Loop diuretics Limited effect on saturation, blood pressure and diuresis ?

5. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine spontaneous contrast/ ”smoke” LA LV MV Echocardiography Severe MS 0.7 cm 2, peak- gradient 4m/s Empty left ventricle (EF 77%) “Smoke” in left atrium Pulmonary hypertension >90mmHg Hypertrophic right ventricle

6. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Pleural effusion Lung Bilateral pleural effusions >2L

7. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Actions Bilateral pleural pigtail catheters Heart rate control: ß-Blocker, Amiodarone Circulation control: Norephinephrine Forced diuresis: Loop diuretics pO 2 8 kPa (60mmHg) Blood pressure 80/50 Heart rate 80 +Diuresis Transfer to University Hospital Upon arrival: high uterine tonicity Obstetric ultrasound reveals the fetus to be dead Abruptio Placenta? DIC? What should we do next?

8. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Obstetrician: Fetus dead Obs abruptio placenta ACHD team: Balloon valvuloplasty and then… Cardiologist: Caesarean section and then… Caesarean section Balloon valvuloplasty

9. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Coagulation parameters OK Course of events MS improved from severe (0.7cm 2 ) to moderate:1.2 cm 2, mean gradient 10 mmHg Patient stable Pulmonary arterial pressure 70/40 Central venous pressure 11mmHg Percutaneous mitral balloon valvuloplasty Uncomplicated caesarian 15-20 minutes after surgery: fluid shifts Cardiogenic shock – again! Blood pressure  Heart rate 140 Systolic pulmonary pressure 90mmHg Central venous pressure 17mmHg No effect of ß-Blocker, Ephinephrine and Loop diuretics

10. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Septum Left ventricl e Mitral valve OK But – backward failure with dilated right side of heart due to volume overload Right ventricl e NO inhalation with great effect Supplemented with ß-Blocker, Norephinephrine, Ephinephrine and Loop diuretics Hospitalized 1 month (ICU 10 days) Repeated mitral balloon valvuloplasty after 3 months  mild stenosis Repeated echocardiography

11. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Conclusions MS in pregnancy carries great maternal risk due to progressive heart failure In the hemodynamically unstable patient, heart rate control and forced diuresis remains the strategy of choice No matter the severity of MS, hemodynamic instability due to fluid shifts may occur after caesarean section or giving birth

12. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Want to know more ?

13. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Recommendations 1,2 Women with moderate or severe MS should be advised against pregnancy Women with MS regardless of severity should be followed closely during pregnancy Percutaneous mitral balloon valvuloplasty can be carried out safely in pregnancy and should be considered in women with moderate or severe MS Delivery should take place in a tertiary centre with specialist multidisciplinary team care 1) Regitz-Zagrosek V et al: ESC Guidelines on the management of cardiovascular diseases during pregnancy, Eur Heart J. 2011, Dec;32(24):3147-97 2) Silverside CK et al: Cardiac Risk in Pregnant Women with Rheumatic Mitral Stenosis, Am J Cardiol. 2003 Jun 1;91(11):1382-5Am J Cardiol.

14. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Degree of mitral stenosis Mean gradientMitral valve area Mild<5 mmHg<1.5cm 2 Moderate5-10 mmHg1.0-1.5 cm 2 Severe>10 mmHg<1.0 cm 2 Mitral stenosis - definitions

15. Laura Sommer Hansen MD, PhD fellow 33 nd Annual International Symposium: Clinical Update in Anesthesiology, Surgery and Perioperative Medicine Physiological changes during pregnancy Blood volume  50% from 6.-28. gestational week Red blood cell volume  20-30%  relative anemia Stroke volume  30-50% from 6.-20 gestational week (max. week 28) Overall increased workload  progressive strain on the suffering heart