Anaesthetic management of obstetric patient with MS.

1. Anaesthetic management of obstetric patient with MS. SPEAKER DR. AMANDEEP SINGH MODERATOR DR. S CHAWLA. www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. 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.

3. Rheumatic fever. • Gp. A beta haemolytic streptococci. • Autoimmune attack on heart and connective tissue. • Inflammation 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.

4. 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.

5. 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 presence of essential criteria.

6. Pathophisiology of MS.

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

8. 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.

9. SYMPTOMS • Can be precipitated by • Exertion • Excitement • Fever • Severe anemia • Paroxysmal tachycardia • pregnancy

10. symptoms • fatigue • Dyspnea on exertion • Orthopnea • Paroxysmal nocturnal dyspnea • Dyspnea at rest • Hemoptysis • Pulmonary or systemic embolization

11. Physical examination • Inspection and palpation • Sev MS – malar flush and pinched and blue facies • Sinus rhythm – JVP with prominent a waves • AF – JVP with c-v waves • Systemic BP is normal or low • RV tap along L sternal border – enlarged RV • Diastolic thrill at cardiac apex • Tapping apex beat – palpable S1 + displacement of LV by enlarged RV

12. auscultation • S1 – accentuated and snapping, and slightly delayed • S2 – split with P2 accentuated • Opening snap – heard best in expiration • at or just medial to cardiac apex, • L sternal edge, • base of heart.

13. auscultation • Low pitched , rumbling diastolic murmur, heard best at apex with bell of stetho with pt. in L lat position in expiration. Aacentuated with mild exercise • Presystolic accentuation in pts. with sinus rhythm

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

16. X-ray findings • straightening of left heart • Prominence of main pulmonary arteries • Dilation of upper lobe pulmonary veins • Double atrial shadow. • Kerly B lines. • Pulmonary edema. • Backward displacement of esophagus by enlarges LA

17. ECHOCARDIOGRAPHY • Diagnostic mainstay • Severity of stenosis • Mitral orifice size • Anatomy of mitral valve • Estimate of transvalvular gradient pressure gradient ∞ 4v² • Presence and severity of MR • Size of cardiac chambers • Estimation of PA pressures • suitability of BMV

18. Grades of MS severity modern management of mitral stenosis, Circulation 2005;112;432-437

19. Severity of MS

20. MEDICAL MANAGEMENT • 1. DIURETICS; ↓ preload ,decongest lungs. • 2. DIGOXIN; therapy needs to be continued through pregnancy (aim to control HR < 110) • 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.

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

22. Management of pregnancy. Admission; • 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. • Antibiotic prophylaxis ampicillin 2g iv and Gentamycin 1.5mg/kg iv on onset of labour and after 8 hr.

23. Hemodynamic goals

24. Avoid tachycardia • AF with fast rate – Not tolerated • Acute AF • Cardioversion starting with 25J • Or β-blocker (propranolol 0.2-0.5 mg iv every 3 mins, maximum 0.1 mg/kg) • Or digoxin • 0.5mg iv over 10 mins followed by 0.25 mg iv every 2 hrs to achieve full digitalisation • Each dose has an effect in 15 mins with full effect in 1 – 2 hrs

25. avoid Sinus tachycardia – HR>140, or decrease in CO, increase in PCWP • Reverse the precipitating event • Pain • Light anesthesia • Hypercarbia • Acidosis • Or administer β-blocker

26. Avoid marked increase in central blood volume • Overtransfusion • Trendelenburg position • Auto transfusion Monitered by CVP or PCWP • Marked decrease in SVR may not be tolerated

27. Avoid increase in PVR • Hypercarbia • Hypoxia • Acidosis • Lung hyperinflation • Volume overload • Prostaglandins for uterine atony – caution • Pulmonary vasodilators • Prolonged mechanical ventilation may be reqiured

28. Vaginal delivery • 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.

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

30. 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.

31. 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.

32. Drugs that produce tachycardia are to be avoided • Atropine • Pancuronium • Pethidine • Ketamine

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 Digoxin 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. Post op care in ICU • If ventilated post op • ABG • Pulmonary mechanics and • CXR • Should be monitored

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