2. Outline The critical physiological changes of pregnancy. The critical physiological changes of pregnancy. Predictors of cardiac events during pregnancy Predictors of cardiac events during pregnancy Risk of cardiovascular complications during pregnancy Risk of cardiovascular complications during pregnancy Anesthetic management parturient with valvular diseases. Anesthetic management parturient with valvular diseases.

3. What are the critical physiological changes of pregnancy that affects a parturient with cardiac disease ?  50% increase in the blood volume  40% increase in cardiac output  25% increase in heart rate to approximately 80-100 beats/min.  Reduced systemic vascular resistance and pulmonary vascular resistance.  Labor and delivery itself imposes approximately 50% increase in CO and oxygen demand.

4. The main predictors of cardiac events during pregnancy are: Prior cardiac events: (heart failure, transient ischemic attack, stroke, or dysrrhythmias). Prior cardiac events: (heart failure, transient ischemic attack, stroke, or dysrrhythmias). Baseline New York Heart association functional class≥ II or the presence of cyanosis. Baseline New York Heart association functional class≥ II or the presence of cyanosis. Left heart obstruction: (mitral valve area ≤ 2cm 2, aortic valve area ≤ 1.5 cm 2, or left ventricular outflow tract gradient ≥ 30mmHg by echocardiography). Left heart obstruction: (mitral valve area ≤ 2cm 2, aortic valve area ≤ 1.5 cm 2, or left ventricular outflow tract gradient ≥ 30mmHg by echocardiography). Reduced left ventricular function (ejection fraction ≤ 40%). Reduced left ventricular function (ejection fraction ≤ 40%).

5. Many of the signs and symptoms of normal pregnancy can mimic those of cardiac disease. Many of the signs and symptoms of normal pregnancy can mimic those of cardiac disease. For example: Dyspnea due to LV failure From Labored breathing typical From Labored breathing typical of normal pregnancy of normal pregnancy Leg edema due to CHF Leg edema due to CHF From Venous stasis due to From Venous stasis due to aortocaval compression aortocaval compression

6. heart murmurs due to heart murmurs due to organic lesions organic lesions from those due to increased from those due to increased blood flow blood flow Rotation of the maternal Rotation of the maternal heart, because of heart, because of elevation of the diaphragm elevation of the diaphragm from cardiac hypertrophy. from cardiac hypertrophy.

7.  C.O: 30-50% during gestation  C.O: 30-50% during gestation 30-45% during labor 30-45% during labor After delivery After delivery 50%of patients with symptoms of heart disease during minimal activity or at rest when not pregnant develop CHF during pregnancy. 50%of patients with symptoms of heart disease during minimal activity or at rest when not pregnant develop CHF during pregnancy. Circulatory Changes and Co.Existing HeartDisease

8. Drug administered to the patients with heart disease may affect fetus: For Example: Lidocaine  neonatal depresion For Example: Lidocaine  neonatal depresion β-blockers  fetal bradycardia and hypoglycemia β-blockers  fetal bradycardia and hypoglycemia Digoxin  longer elimination half- life in fetus Digoxin  longer elimination half- life in fetus Electrical cardioversion  no adverse effects on the fetus Electrical cardioversion  no adverse effects on the fetus

9. Risk of cardiovascular complications during pregnancy Risk of cardiovascularcomplications during pregnancy Low risk of complications (≤ 1%) risk Intermediate riskof complications (5- 15%) risk High riskofcomplications or death (≥25%)

10.  Low risk of complications (≤ 1%): Corrected tetralogy of fallot Corrected tetralogy of fallot Atrial septal defect Atrial septal defect Ventricular septal defect Ventricular septal defect Patent ductus arteriosus Patent ductus arteriosus Mild pulmonic or tricuspid valve disease Mild pulmonic or tricuspid valve disease Mitral stenosis (NYHA class I, II) Mitral stenosis (NYHA class I, II) Mild regurgitant valve lesion Mild regurgitant valve lesion Bioprosthetic valve Bioprosthetic valve Compensated heart failure (NYHA class I, II) Compensated heart failure (NYHA class I, II)

11.  Intermediate risk of complications (5- 15%): Mechanical valve prosthesis Mechanical valve prosthesis Aortic stenosis (mild to moderate) Aortic stenosis (mild to moderate) Mitral stenosis with atrial fibrillation Mitral stenosis with atrial fibrillation Mitral stenosis (NYHA class III, IV) Mitral stenosis (NYHA class III, IV) Uncorrected cyanotic congenital heart disease (tetralogy of fallot) Uncorrected cyanotic congenital heart disease (tetralogy of fallot) Uncorrected coarctation of the aorta Uncorrected coarctation of the aorta Previous myocardial infarction Previous myocardial infarction

12.  High risk of complications or death (≥25%): Pulmonary hypertension (severe) Pulmonary hypertension (severe) Eisenminger syndrome Eisenminger syndrome Marfan disease with aortic root involvement Marfan disease with aortic root involvement Peripartum cardiomyopathy Peripartum cardiomyopathy Severe aortic stenosis Severe aortic stenosis NYHA class IV heart failure NYHA class IV heart failure

13. One of the most common maternal heart diseases are: Acquired valvular heart diseases Acquired valvular heart diseases included : MS (the most common type of cardiac included : MS (the most common type of cardiac ( valvular defect in pregnant MR (the second most common cardiac MR (the second most common cardiac valvular defect seen in pregnancy) valvular defect seen in pregnancy) AS ( rarely seen in pregnancy) AS ( rarely seen in pregnancy) AI ( is not common in pregnancy) AI ( is not common in pregnancy)

14. Valvular Heart Disease: In general regurgitant valvular lesions are well tolerated during pregnancy, where as stenotic lesions have a greater potential for decompensation. In general regurgitant valvular lesions are well tolerated during pregnancy, where as stenotic lesions have a greater potential for decompensation. Pregnant patients with valvular heart disease can expect to have worsening of their New York Heart Association (NYHA) functional class, while others may have adverse foetal outcome i.e. preterm birth or still birth. Pregnant patients with valvular heart disease can expect to have worsening of their New York Heart Association (NYHA) functional class, while others may have adverse foetal outcome i.e. preterm birth or still birth.

15. Mitral stenosis (MS): Normal mitral valve orifice has a surface area of4-6cms2, in mild stenosis the valve area (1.5 to 3 cm 2 ), moderate mitral stenosis the valve area (1.1 to 1.5 cm 2 ), while severe mitral stenosis the valve area (less than 1cm 2 ). Normal mitral valve orifice has a surface area of4-6cms2, in mild stenosis the valve area (1.5 to 3 cm 2 ), moderate mitral stenosis the valve area (1.1 to 1.5 cm 2 ), while severe mitral stenosis the valve area (less than 1cm 2 ).

16. Mitral valve stenosis prevents emptying of the left atrium (LA), with increased left atrial and pulmonary artery pressure, resulting in dyspnoea, haemoptysis and pulmonary oedema. Mitral valve stenosis prevents emptying of the left atrium (LA), with increased left atrial and pulmonary artery pressure, resulting in dyspnoea, haemoptysis and pulmonary oedema. Mitral stenosis (cont.):

17. Peripartum considerations: The hyperdynamic state of pregnancy is poorly tolerated by women with severe mitral stenosis: Increased plasma volume can cause pulmonary edema and worsen the left atrial enlargement. Increased plasma volume can cause pulmonary edema and worsen the left atrial enlargement. Tachycardia decreases the left ventricular diastolic filling through the stenotic valve. Tachycardia decreases the left ventricular diastolic filling through the stenotic valve. AF is common with MS, with loss of the atrial kick; which accounts for = 30% of the left ventricular stroke volume. Medical management of AF by a beta-adrenergic blocking agent. AF is common with MS, with loss of the atrial kick; which accounts for = 30% of the left ventricular stroke volume. Medical management of AF by a beta-adrenergic blocking agent.

18. Anesthetic considerations: Should be based on the severity of the lesion,( according to the valve area, and the hemodynamic stability of the patient). Should be based on the severity of the lesion,( according to the valve area, and the hemodynamic stability of the patient). Avoid increased heart rate. Avoid increased heart rate. Maintain venous return and SVR. Maintain venous return and SVR. Avoid aorto-caval compression. Avoid aorto-caval compression. Treat atrial fibrillation (AF) aggressively. Treat atrial fibrillation (AF) aggressively. Maintain sinus rhythm. Maintain sinus rhythm. Prevent pain, hypoxaemia, hypercarbia and acidosis as these can increase PVR. Prevent pain, hypoxaemia, hypercarbia and acidosis as these can increase PVR.

19. There are increased incidence of:  Pulmonary edema  Pulmonary edema  Atrial fibrilation  Atrial fibrilation  Paroxismal atrial tachycardia  Paroxismal atrial tachycardia Control of the heart rate is critical Excessive perioperative fluid administration Trendelenburg position Autotransfusion (via uterine contraction)   central blood volume  CHF. Autotransfusion (via uterine contraction)   central blood volume  CHF. Pregnant patients with Mitral Stenosis

20. Invasive monitoring is usually not necessary in the absence of cardiac symptoms. Exceptions are parturients with: Exceptions are parturients with: Pulmonary hypertension Pulmonary hypertension Right-to-left intracardiac shunts Right-to-left intracardiac shunts Coarctation of the aorta Coarctation of the aorta invasive cardiac monitoring should be continued for 48 hours after delivery invasive cardiac monitoring should be continued for 48 hours after delivery Monitoring

21. Spinal anesthesia For most elective and urgent C/S Epidural anesthesia Decrease likelihood of hypotension Combined Spinal-Epidural anesthesia General anesthesia Anesthetic technique Anesthetic technique

22. Advantages : -A decreased risk of failed intubation and aspiration -A decreased risk of failed intubation and aspiration of gastric contents of gastric contents -Avoidance of depressant agents -Avoidance of depressant agents -The ability of the mother to remain awake -The ability of the mother to remain awake and enjoy the birthing experience and enjoy the birthing experience - Reduced blood loss - Reduced blood lossDisadvantages: - Dural puncture - Dural puncture - Reduced SVR & BP - Reduced SVR & BP - Slower onset - Slower onset Neuraxial anesthesia techniques

23. Advantages: - Speed of induction - Speed of induction - Control of the airway - Control of the airway - Superior homodynamic - Superior homodynamicDisadvantages: - Failed intubation - Failed intubation - Pulmonary aspiration of gastric contents - Pulmonary aspiration of gastric contents - Neonatal depression - Neonatal depression - Maternal awareness - Maternal awareness General anesthesia technique

24. Regurgitation of blood through an incompetent mitral valve  chronic volume over load and dilatation of the LA Regurgitation of blood through an incompetent mitral valve  chronic volume over load and dilatation of the LA In the acute type, there is acute pulmonary congestion and pulmonary edema results. In the acute type, there is acute pulmonary congestion and pulmonary edema results. If the patient survives this episode of acute mitral regurgitation, pulmonary artery pressure continues to increase and right heart failure occurs. If the patient survives this episode of acute mitral regurgitation, pulmonary artery pressure continues to increase and right heart failure occurs. Mitral Regurgitation (MR):

25. Anesthetic consideration: Primary considerations are: Maintain slightly increased heart rate Maintain slightly increased heart rate Prevent increase in SVR. Prevent increase in SVR. Prevent hypoxemia, hypercarbia, acidosis which may increase PVR. Prevent hypoxemia, hypercarbia, acidosis which may increase PVR. Avoid aortocaval compression and myocardial depression. Avoid aortocaval compression and myocardial depression.

26. Aortic stenosis (AS): The pathophysiology of severe AS entail a narrowing of the valve to less than 1 cm 2 associated with a trans-valvular gradient of 50mmHg with significant increase in after load to the LV. The pathophysiology of severe AS entail a narrowing of the valve to less than 1 cm 2 associated with a trans-valvular gradient of 50mmHg with significant increase in after load to the LV. A valvular gradient which exceeds 100mmHg carries an increased risk of myocardial ischemia as the LV hypertrophies significantly. A valvular gradient which exceeds 100mmHg carries an increased risk of myocardial ischemia as the LV hypertrophies significantly. In aortic stenosis transvalvular gradient increases progressively throughout pregnancy, due to increasing blood volume and decreasing SVR In aortic stenosis transvalvular gradient increases progressively throughout pregnancy, due to increasing blood volume and decreasing SVR

27. Avoid tachycardia (decrease time for coronary perfusion of the hypertrophied LV), and bradycardia (slow heart rate decreases CO). Avoid tachycardia (decrease time for coronary perfusion of the hypertrophied LV), and bradycardia (slow heart rate decreases CO). Maintain intravascular volume and venous return. Maintain intravascular volume and venous return. Avoid aortocaval compression and myocardial depression. Avoid aortocaval compression and myocardial depression. Arrhythmias are not well tolerated and should be promptly treated. Arrhythmias are not well tolerated and should be promptly treated. Patients with trans-valvular gradient more than 50mmHg with symptomatic AS should have invasive monitoring i.e. A-line and PA catheter in place. Patients with trans-valvular gradient more than 50mmHg with symptomatic AS should have invasive monitoring i.e. A-line and PA catheter in place. Anaesthetic considerations:

28. Aortic regurge (AR): The pathophysiology is chronic volume overload of the LV, with hypertrophy and dilatation and increase in LV End Diastolic Volume (LVEDV), decrease in ejection fraction (EF) and signs and symptoms of pulmonary edema. The pathophysiology is chronic volume overload of the LV, with hypertrophy and dilatation and increase in LV End Diastolic Volume (LVEDV), decrease in ejection fraction (EF) and signs and symptoms of pulmonary edema. Patients with aortic insufficiency tolerate pregnancy well as pregnancy results in a modest increase in heart rate. Patients with aortic insufficiency tolerate pregnancy well as pregnancy results in a modest increase in heart rate.

29. Anaesthetic considerations: Prevent catecholamine – induced increases in SVR due to pain, and avoid bradycardia, which may increase regurgitant flow. Prevent catecholamine – induced increases in SVR due to pain, and avoid bradycardia, which may increase regurgitant flow.