1 / 36

Anaesthetic management of obstetric patient for heart disease.

Anaesthetic management of obstetric patient for heart disease. SPEAKER DR. PRAGATI NANDA. MODERATOR DR. SANJEEV ANEJA. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Case presentation. 29yr F resident of massigarh village. c/c amenorrhea x 8 months.

semah
Download Presentation

Anaesthetic management of obstetric patient for heart disease.

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Anaesthetic management of obstetric patient for heart disease. SPEAKER DR. PRAGATI NANDA. MODERATOR DR. SANJEEV ANEJA. www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. Case presentation. • 29yr F resident of massigarh village. • c/c amenorrhea x 8 months. • Incresing breathlessness x 3 months. • HOPI ; 3 months back breathless on exertion now on less than ordinary activity. • Complains of anxiety and problem in breathing at night for which she goes to window to breath fresh air. • H/O palpitation off and on .

  3. No H/O chest pain, dizziness. No H/O pain abdomen, sweating. H/o swelling feet present but that is relieved on rest. No H/o dysphagia or hoarseness of voice. No H/o tender pulp of fingers, pigmentation of palm and soles or haematuria.

  4. H/o first trimester; No H/o exessive nausea and vomiting. No H/o fever , cough or diarrhoea. No H/o x-ray expossure, drug administration or blood transfusion. H/o second and third trimester; H/o quickning at 5th month. H/o 2 doses of tetanus toxoid. H/o increasing breathlessness. No H/o headache, blurring of vision, epigastric pain. No H/o bladder and bowel trouble. No H/o bleeding or leaking p/v.

  5. Past history; • When patient was 7 yr old, she sufferd from fever and sore throat,assosiated with joint pains in elbow and knee joints and skin pigmentation on abdomen.subsided on its own. No h/o hospitalisation or injections every 3 wk. • No h/o TB, DM, HTN, Seziure, asthma, drug allergy or surgery in the past. • Obs history; G1 P1 A0 with POG 36 wk.

  6. Menstural history; • DLMP; NK. • Menarche at 13 yr. • Normal cycles;4-5 days every 28 days,regular. • No h/o dysmenorrhoea or menorrhagia. • Personal history; • School teacher, non alcoholic, nonsmoker, nonvegetarion. • Drug history; Tab. Fersolate OD. • Tab. Shelcal OD

  7. GPE; GC fair ,moderately build , moderately nourished, comfortably lying in bed. • Ht. 5’2. wt.78 kg. • P+, I-, Cl-, Cy-, LAP-, PO+, JVP-NR. • PR-96/min in R radial a. regular, good volume, no radio femoral delay. • BP-108/86 mmhg in R arm,supine pt. • Chest- B/L air entry equal and clear.

  8. CVS-; Inspection; precordium smooth and symetrical. Apex beat-4 ICS. 2.5 cm lat. to mid clavicular line. No other pulsations,dialated veins or scar marks. Palpation; Apex beat ;tapping. Parasternal heave +. Palpable P2 in 2nd L ICS. No thrill +. Percussion;base- 2nd ICS. Apex-4th ICS Auscultation; loud s1,mid diastolic rumbling murmer with presystolic accentuation,heard in left lateral position. Intensity increased with hand grip. Os could not be appreciated.

  9. Airway examination; MO adeqate. • MPG; 2, neck movements normal, TM jt. Movement normal. • Breast; B/L symetrical. Montogmery tubercles +. S/C veins visible. • No hepatospleenomegaly. • P/A; INSPECTION; utreus – uniformlydistended. Umblicus centrally placed and inverted. No scar marks ,lenia nigra + . Stria gravidarum +.

  10. Palpation; ut. Relaxed. 36 wk size. • Fundal grip; broad, soft, irregular part-breech. • Lat. Grip; Rt.- Smooth ,curved ,resistant-back. • Lt.-knob like parts –limbs. • Pelvic grip; smooth , hard globular-head. Not engaged. • SFH; 36cm. • Abd. Girth; 74 cm. • Auscultation; FSH; 140/min on rt. Side.

  11. Heart disease in pregnancy. • INCIDENCE, 3.6% to 1.6%. • Rheumatic – 75% - 90% mitral stenosis. • Congenital-25%. • Maternal mortality; <1% in asymptomatic pt. • 17% in MS with AF. • 0.4% in NYHA class 1 and 2. • 6.8% in NYHA class 3 and 4.

  12. Rheumatic fever. • Gp. A beta haemolytic streptococci. • Autoimmune attack on heart and connective tissue. • Inflamation of all 3 layers of heart, mainly endocardium- valve leaflet thickens, calcify and become funnel shaped. • RF equal among M/F. MS 2-3 times common in females.

  13. Jones criteria for diagnosis of RF. • Major criteria; • 1. carditis • 2.artharitis • 3.subcutaneous nodules • 4.chorea • 5.erythema marginatum • Minor criteria; clinical; 1.fever • 2. arthralgia • 3. previous RF or rheumatic heart disease.

  14. Lab. • 1. increased acute phase reactants; ↑ ESR. • ↑ CRP • Leucocytosis. • Essential criteria; evidence of recent streptoccocal infection. • 1. ↑ antistreptolysin o titer. • 2. positive throat culture. • 3. recent scarlet fever. • DIAGNOSIS; 2 major or 1 major and 2 minor criteria in preasence of essential criteria.

  15. Pathophisiology of MS.

  16. EFFECT OF PREGNANCY • Anatomically moderate stenosis becomes functionally severe. • Progressive stress on CVS leads to advancement of of pt. from one NYHA class to another. • Cardiac output ↑es by 30 -40% till 28wks. • HR ↑es by 15% and SV by 30%.

  17. Each uterine contraction in 1st stage of labour ↑es CO by 10-15% • In second stage by-45%. • Immediately after delivery by 80-150% . • BP usually remains constant because of decrease in SVR. • Pregnancy being a hypercoagulable state adds to thromboembolism associated with AF.

  18. MANAGEMENT OF PATIENT • INVESTIGATIONS; • 1.Complete haemogram, coagulation profile, serum electrolytes, RFT, urine C/E. • 2. ECG; P mitale, AF , RAD, RAH .

  19. X-ray findings • straightening of left heart • Double atrial shadow. • Kerly B lines. • Pulmonary edema.

  20. ECHOCARDIOGRAPHY • Diagnostic mainstay. • Anatomy of valve; hockey stick appearance. • Stenosis severity; • 1.doppler echo; pressure gradient ∞ 4v² • [v=transmitral flow velocity] • 2. valve area = 220/pressure T½ • [press T½ is time taken in decrease of peak velocity to v/ Г2.] • Suitability of BMV. • Assosiated lesions,EF, LV function.

  21. 5. cardiac cathetrisation; when noninvasive data and clinical picture are discordant. • gorlin’s equation; • Valve area = flow/ k x Гmean transvalv. Gr. • [flow = SV/diastolic time , k =press constant] • 6. P-V LOOP

  22. MEDICAL MANAGEMENT • 1. DIURETICS; ↓ preload ,decongest lungs. • 2. DIGOXIN; ↓HR hence ↑LV filling. ↑LA contractility . • 3.AF with sudden decompensation ; DC Cardioversion or verapamil. • 4.Anticoagulants for AF to be continued. • Heparin 5000 u BD S/C till 12 wk. Warfarin 3mg OD Upto 36 wk. Heparin ……..7 days postpartum. • 5.IM penidura/3wk throughout pregnancy.

  23. Definitive therpy • Mechanical relief of obstruction. • BMV, Open comissurotomy, mitral valve replacement. Indications; 1.symptomatic pt.,NYHA ≥gr2, 2.PHT [even if anticiated] , 3.medical therapy has failed to relieve symptoms. BMV is preffered option , in 16 -24 wk.

  24. Management of pregnancy. • Addmission; • NYHA gr.1- 2wk prior to EDOD. • NYHA gr 2- at 28 wk. • NYHA gr3/4 - throughout pregnancy.Management of 1st stage; • Bed rest, lt.lateral position, 02 by side. • No role of induction. • Cautious fluid ;75 ml/hr. • Rapid digitalisation;0.25mg ----0.1mg/hr slow iv. • Antibiotic prophylaxis ampicillin 2g iv and Gentamycin 1.5mg/kg iv on onset of labour and after 8 hr.

  25. Epidural analgesia;prevents increase in CO to higher extents. ↓es pain and tachycardia, prevents fatigue and exertion. • Second stage; delay is to be curtailed using ventouse or forceps. • IV ergometrine is to be withheld. • Third stage; slight blood loss is benificial. • Oxytocin infusion only if exessive blood loss. • IV frusemide can be given.

  26. Elective LSCS ; • Premedication ; tab ranitidine 150 mg • tab perinorm 10 mg • Endocarditis prophylaxis. • MONITORING; • NYHA Gr1/2 - ECG, NIBP,Pulseoxymeter, EtCO2,Temparature, Esophageal stethoscope,foley’s catheter for UO. • NYHA Gr.3/4- IABP,CVP/Swan ganz cather[PAP,PCWP,CO]

  27. Haemodynamic goals. • 1.AVOID TACHYCARDIA;[to maintain diastolic time] Continue digoxin Treat pain adequately Avoid light GA, hypercarbia, acidosis. IV Propranolol 0.5mg increments if required.

  28. 2.AVOID MARKED ↓ IN SVR. [to avoid compensatory tachycardia.] Prefer Epidural over spinal anaesthesia. Metraminol infusion[ 10mg in 250ml ] or Intermittent Phenylephrine. Avoid ephedrine as it may cause tachycardia.

  29. 3.AVOID MARKED ↑ IN CENTRALBLOOD VOLUME. [ppt RVF,PHT,AF.] Monitor CVP/PCWP. IV Frusemide Judicious use of Oxytocin.

  30. 4. AVOID INCREASE IN PVR.[ppt RVF] Avoid hypoxia, hypercarbia, acidosis, lung hyperinflation. If PHT and RV compromise exist; Dopamine 3-8 mic/kg/min. Sodium Nitroprusside 0.1-0.5 mic/kg/min.

  31. Regional v/s GA. • For mitral valve disease regional anaesthesia is benifecial since it decreases both preload and afterload and decongests lungs. • GA is prefered if; PHT,AF , assosiated AS, emergency or patient is haemodynamically unstable.

  32. Technique for GA • Anaesthesia machine and intubation trolley are checked. • Patient supine ,wedge under right hip. • Monitors applied. • Large bore IV cannula. • Preoxygenation for 3 min. • RSI with preset doses of Thiopentone and Succinylcholine. Cricoid pressure maintained till cuff is inflated.

  33. Maintanence ; O2 ; N2o 50% each. Halothane preferred [↓HR, least vasodialating] Atracurium 0.5mg/kg. • Maintain sinus rythum. In presence of AF, control ventricular rate with Diagoxin or Diltiazam. • If sudden SVT develops; DC Cardioversion. • Maitain SVR. Phenylephrine can be used. • After delivery of baby, Morphine 0.15mg/kg. • Oxytocin cautiously if exessive blood loss. • Smooth Extubation.

  34. THANK YOU. www.anaesthesia.co.inanaesthesia.co.in@gmail.com

More Related