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¿ ABORDAJE ANESTESICO DE LA ENFERMEDAD CARDIACA EN LA EMBARAZADA?

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Presentación del tema: "¿ ABORDAJE ANESTESICO DE LA ENFERMEDAD CARDIACA EN LA EMBARAZADA?"— Transcripción de la presentación:

1 ¿ ABORDAJE ANESTESICO DE LA ENFERMEDAD CARDIACA EN LA EMBARAZADA?
MARCELINO MURILLO DELUQUEZ ANESTESIA Y REANIMACIÓN UNIVERSIDAD DE CARTAGENA

2 PREVALENCIA DE LA CARDIOPATIA
1-4% ENFERMEDAD CARDIACA CONGENITA ENFERMEDAD REUMATICA CARDIACA La enfermedad cardiaca complica entre 1 % y 4 % de los embarazos en los Estados Unidos es la principal causa de morbilidad y mortali dad materna de causa no obstétrica en el Re Unido (1). La enfermedad reumática ha sido principal causa de enfermedad cardiaca en el embarazo en países en vía de desarrollo, pero con el incremento en el cuidado perinatal de recién nacidos con enfermedad cardiaca con nita (ECC) y el desarrollo de la cirugía cardiov cular, la ECC es ahora la causa más importa de cardiopatía en el embarazo (2,3). Las enfermedades cardiovasculares complican entre el 0,2 % - 3 % de los embarazos y son una causa importante de mortalidad materna (1,2). El embarazo y el trabajo de parto son bien tole- rados en pacientes con cardiopatías congénitas (CC), como comunicación interauricular (CIA), comunicación interventricular (CIV), ductus arterioso persistente y anomalía de Ebstein no complicadas (3). Esto no ocurre en mujeres con CC cianosantes no corregidas, como el síndrome de Eisenmenger y la tetralogía de Fallot (TOF) (4). El Eisenmenger y la hipertensión pulmonar primaria producen el 50 % de la mortalidad ma- terna por CC (5). La TOF produce el 10 % de las muertes, y la mortalidad por estenosis aórtica depende del área valvular funcional. Son signos de mal pronóstico en CC un Hto. > 60 %, SaO2 < 80 %, hipertensión ventricular derecha y epi- sodios sincopales (6). La enfermedad cardiaca en el embarazo impone un riesgo que debe ser evaluado de manera in- terdisciplinaria e instaurar de manera secuencial un protocolo de diagnóstico y manejo basado en la estratificación del riesgo, cuyo objetivo es evitar desenlaces fatales debidos a un manejo no pla- neado. La aplicación de esta aproximación podría impactar en una posible reducción de las compli- caciones cardiovasculares asociadas en este gru- po de pacientes. Los aspectos más importantes de esta aproximación se describen a continuación. La implementación de un protoco- lo de estratificación del riesgo de muerte y de la aparición de complicaciones cardiovasculares en la paciente embarazada con cardiopatía le permi- te al anestesiólogo hacer parte integral del grupo interdisciplinario de manejo y, así, tener impacto en la obtención de un mejor resultado materno y perinatal en este grupo de pacientes.

3 CLASE FUNCIONAL MORTALIDAD MATERNA II: 1% III-IV: 5 - 15%
MORTALIDAD PERINATAL III-IV : % Maternal outcome seems to correlate best with the functional classification of the patient according to the criteria of the New York Heart Association (NYHA) (

4 ESTRATIFICACIÓN DEL RIESGO
CLARK ET AL Severidad anatómica de la lesión Estenosis aortica severa HTP Enfermedad aortica Mortalidad 50% Eventos cardiacos previos? La implementación de un protoco- lo de estratificación del riesgo de muerte y de la aparición de complicaciones cardiovasculares en la paciente embarazada con cardiopatía le permi- te al anestesiólogo hacer parte integral del grupo interdisciplinario de manejo y, así, tener impacto en la obtención de un mejor resultado materno y perinatal en este grupo de pacientes. HCTO > 60% Sat O ₂ < 80 % HIPERTESIÓN VENTRICULAR DERECHA SINCOPE Maternal outcome seems to correlate best with the functional classification of the patient according to the criteria of the New York Heart Association (NYHA) ( Box 40-1 ).[4] Exceptions include patients with pulmonary hypertension, significant left ventricular dysfunction, and severe cases of Marfan syndrome (especially those women with significant enlargement of the aortic root). These lesions pose a very high risk and may contraindicate pregnancy, regardless of functional class. Otherwise, class I or II patients have a maternal mortality rate of less than 1%, whereas class III or IV patients have a mortality rate between 5% and 15%. Perinatal loss also is associated with maternal functional class; patients who are class III or IV have a perinatal mortality rate between 20% and 30%. [4] [5]

5 ESTRATIFICACIÓN DEL RIESGO
2001 se publico el estudiio tipo…., con 562 preg reclutadas, ya que hasta el momento no se habia definido adecuadamente el riesgo de morbimortalidad en el embarazo y neonatos asociado con el embarazo. El estudio CARPREG de siu et al, encontraron que eventos cardiacos previos predicen de forma independiente la ocurrencia de eventos maternos usando un indice de riesgo Ojo eventos cardiacos previos como:arrhythmia, poor functional class or cyanosis, left heart obstruction, and left ventricular systolic dysfunction son los factores independients de riesgo El 20% de neonatos que se complicaron estaban asociados a pobre clase funcional, cianosis, obstruccion ventricular izquierda, cigarrillo, embarazos multiples, anticoagulacion Estudio canadience busco validar el indice de reisgo. Estudio con 562 mujeres en 13 hostpitales Clark y colaboradores (6), define la severidad anatómica de las lesiones como el único modo de estratificación; es decir, pacientes con estenosis aórtica severa, hipertensión pulmonar de cual- quier etiología y enfermedad de la aorta, como las lesiones con mayor mortalidad (50 %). El pro- blema de esta clasificación es que sólo tiene en cuenta la lesión sin darles importancia a los datos clínicos o los eventos cardiacos previos. El índice de riesgo desarrollado por el estudio canadien- se, conocido como CARPREG (7,8), fue publicado con el fin de predecir complicaciones cardiacas relacionadas con el embarazo en pacientes con cardiopatías, teniendo en cuenta no sólo la lesión anatómica, sino los datos del estado clínico.

6 ESTRATIFICACIÓN DEL RIESGO
ESTUDIO CARPREG PREDICE COMPLICACIONES CARDIACAS COMBINA: LESION ANATOMICA DATOS DEL ESTADO CLINICO

7 ¿PREDICTORES DE EVENTOS CARDIO-VASCULARES?
NYHA III-IV O CIANOSIS ANTECED: ARRITMIA O EVENTO CARDIACO VM: <2CM VA: < 1.5 CM GRADIENTE VI > 30 mmHg DISFUNCIÓN VI - FE < 40%

8

9 INDICE DE RIESGO REVISADO
No. De predictores Riesgo Estimado 5% 1 27% >1 75

10 ¿QUÉ EVENTOS CARDIO-VASCULARES SE PRESENTARON?
EVENTOS CARDIACOS 13% 55% PREPARTO EDEMA PULMONAR NYHA III : 19% ARRITMIAS 4.7% INFARTO PCR 1% (6) MUERTE Para el desarrollo de eventos cardiacos, como edema pulmonar, arritmias, enfermedad cere- brovascular, paro de origen cardiaco y muerte, se identificaron cuatro predictores:

11 EVENTOS NEONATALES OCURRENCIA HEMORRAGIA INTRAVENTRICULAR
20% PEQUENOS PARA EDAD GESTACIONAL PREMATUREZ (62) CASOS HEMORRAGIA INTRAVENTRICULAR DISTRESS RESPIRATORIO

12 GUIAS DE LA ACC-AHA - ESC
Estenosis Aórtica severa con o sin síntomas. Estenosis Mitral sintomática NYHA II-IV Insuficiencia Aórtica o Mitral con NYHA III o IV Enfermedad valvular Aortica o Mitral con FE < 40%, o HTP > 75 mmHg Síndrome Marfan con o sin IA Válvula protésica mecánica requiere anticoagulación El Colegio Americano de Cardiología-Asociación Americana del Corazón (ACC/AHA, por sus si- glas en inglés), en el 2006, y la Sociedad Euro- pea de Cardiología (ESC), en el 2007, publicaron las guías para enfermedad cardiaca valvular, en las que consideran que son de alto riesgo mater- no y fetal durante el embarazo las mujeres con una de las siguientes lesiones (9,10): • Estenosis aórtica severa con o sin síntomas. • Estenosis mitral sintomática (NYHA II a IV). • Insuficiencia aórtica o mitral con NYHA III o IV. • Enfermedad valvular aórtica o mitral con disfunción ventricular izquierda severa (defi- nida como fracción de eyección < 40%) o se- vera hipertensión pulmonar (presión arterial sistólica arteria pulmonar > 75 mmHg). • Síndrome de Marfán con o sin insuficiencia aórtica (11). Válvula protésica mecánica que requiere an- ticoagulación.

13 ESTUDIO EUROPEO RETROSPECTIVO DESDE 1980 A 2007, NOMBRE ZAHARA,
In 1802 women with CHD, 1302 completed pregnancies were observed. Independent predictors of cardiac, obstetric, and neonatal complications were calculated using logistic regression. The most prevalent cardiac complications during pregnancy were arrhythmias (4.7%) and heart failure (1.6%). Factors independently associated with maternal cardiac complications were the presence of cyanotic heart disease (corrected/uncorrected) (P , ), the use of cardiac medication before pregnancy (P , ), and left heart obstruction (P , ). New characteristics weremechan- ical valve replacement (P ¼ ), and systemic (P ¼ 0.04) or pulmonary atrioventricular valve regurgitation related with the underlying (moderately) complexCHD(P ¼ 0.03). Anewrisk score for cardiac complications is proposed. The most prevalent obstetric complications were hypertensive complications (12.2%). No correlation of maternal charac- teristics with adverse obstetric outcome was found. The most prevalent neonatal complications were premature birth Limitations of the score for patients with CHD are that it is developed based on a cohort that included patients with primary electrical disease as well as acquired heart disease. Moreover, several types of (mainly complex) CHD were underrepresented. 2,3 It is suggested that the CARPREG cardiac risk score therefore needs to be modified to assess the risk of pregnancy in women with CHD Methods For the present ZAHARA study, female patients with CHD aged 18– 58 years enrolled in the nation-wide CONgenital CORvitia (CONCOR) registry and a Belgian 63% NULIPARAS COMPLICACION CARDIACA MAYOR: ARRITMIA Y FALLA CARDIACA DE LAS COMPLICACIONES OBSTETRICAS HTA COMPLICACION NEONATAL: PEQUEÑO PARA EDAD GESTACIONAL Y PARTO PREMATURO

14 ESTUDIO ZAHARA NUEVOS FACTORES IND. CONFIRMA: INSUFICIENCIA VALVULAR
ENF CIANOSANTE CORREGIDA O NO PROTESIS VALVULARES CONFIRMA: HISTORIA DE ARRITMIA NYHA OBSTRUCCIÓN TRACTO SALIDA USO DE MEDICAMENTOS ESTUDIO EUROPEO RETROSPECTIVO DESDE 1980 A 2007, NOMBRE ZAHARA, In 1802 women with CHD, 1302 completed pregnancies were observed. Independent predictors of cardiac, obstetric, and neonatal complications were calculated using logistic regression. The most prevalent cardiac complications during pregnancy were arrhythmias (4.7%) and heart failure (1.6%). Factors independently associated with maternal cardiac complications were the presence of cyanotic heart disease (corrected/uncorrected) (P , ), the use of cardiac medication before pregnancy (P , ), and left heart obstruction (P , ). New characteristics weremechan- ical valve replacement (P ¼ ), and systemic (P ¼ 0.04) or pulmonary atrioventricular valve regurgitation related with the underlying (moderately) complexCHD(P ¼ 0.03). Anewrisk score for cardiac complications is proposed. The most prevalent obstetric complications were hypertensive complications (12.2%). No correlation of maternal charac- teristics with adverse obstetric outcome was found. The most prevalent neonatal complications were premature birth Limitations of the score for patients with CHD are that it is developed based on a cohort that included patients with primary electrical disease as well as acquired heart disease. Moreover, several types of (mainly complex) CHD were underrepresented. 2,3 It is suggested that the CARPREG cardiac risk score therefore needs to be modified to assess the risk of pregnancy in women with CHD Methods For the present ZAHARA study, female patients with CHD aged 18– 58 years enrolled in the nation-wide CONgenital CORvitia (CONCOR) registry and a Belgian 63% NULIPARAS COMPLICACION CARDIACA MAYOR: ARRITMIA Y FALLA CARDIACA DE LAS COMPLICACIONES OBSTETRICAS HTA COMPLICACION NEONATAL: PEQUEÑO PARA EDAD GESTACIONAL Y PARTO PREMATURO

15 COMPLICACIONES ASOCIADAS

16 MODELO MULTIVARIABLE: COMPLICACIONES CARDIACAS CORREGIDAS POR EDAD Y PARIDAD MATERNA
OR (IC 95%) VALOR DE P Historia de arritmias 4.3 (1.8–10.2) 0.0011 Medicamentos cardiacos previos 4.2 (2.1–8.6) <0.0001 NYHA Clase funcional 2.2 (1.1–4.5) 0.0298 Gradiente AV >50, AVA 1.0 cm2 12.9 (3.9–42.3) Insuficiencia Aortica moderada/severa 2.0 (1.0–4.0) 0.0427 Insuficiencia pulmonar mode/severa 2.3 (1.1–5.0) 0.0287 Válvula proteica mecánica 74.7 (5.3–1057) 0.0014 Enf ermedad cardiaca cianosante 3.0 (1.7–5.0) In concordance with the CARPREG and other investigators, we entified NYHA functional class .II, left heart obstructive lesions, nd a history of arrhythmias to be independent predictors ofmaternal ardiac complications. 20,21 It needs to be added that arrhythmiaswere he most common cardiac complication in women with a history of rrhythmias. Silversides et al. 22 reported earlier that in women with re-existing cardiac rhythm disorders, exacerbation of arrhythmic pisodes during pregnancy was common. In contrast to the CARPREG report, a decreased systemic entricular function was a univariate but not multivariate predictor cardiac complications. In this retrospective study, we had to use less accurate definition for decreased left ventricular function ubjective mostly echocardiographic estimation vs. measurement ejection fraction in the CARPREG study) which may in part xplain this difference. The association between significant sys- mic AV valve regurgitation and decreased systemic ventricular nction (e.g. in patients with a systemic right ventricle) may be nother part of the explanation, as systemic AV valve regurgitation merged as an independently associated characteristic in our study. yanosis and a history of cardiac complications also did not corre- te with adverse cardiac outcome. The low incidence of these riables may at least be in part the explanation. Cyanotic omen are often advised against pregnancy. 23

17 MODELO MULTIVARIABLE: COMPLICACIONES NEONATALES CORREGIDAS POR EDAD Y PARIDAD MATERNA
OR (IC 95%) VALOR DE P Gemelar o múltiple 5.4 (1.9–15.2) 0.0014 Tabaquismo en embarazo 1.7 (1.2–2.4) 0.0070 Enf cardaiaca cianosante 2.0 (1.4–2.9) 0.0003 Valvula protesica mecánica 13.9 (1.2–157) 0.0331 Medicación cardíaca 2.2 (1.4–3.5) 0.0009

18 COMPLICACIONES OBSTETRICAS
ENFERMEDAD HIPERTENSIVA: 12.2% PREECLAMPSIA 4.4%

19 Risk scores The CARPREG risk score performed inadequately in our popu- 27,28 reports. lation and largely overestimated risk, in line with other The differences between the populations that we incidence of cardiac complications appears relatively low (7.6%) CARPREG cardiac risk score in our population. In addition, the pointed out may in part explain the poor performance of the in comparison to 13 and 19.4% reported by Siu et al. Khairy et al. and 2,3,29 However, the cardiac complication rate in the 4 at higher risk. The cohort investigated by Khairy et al. had an over- cies). Apparently, acquired or arrhythmic heart disease patients are CARPREG study in patients with CHD is 7.1% (32 in 445 pregnan- representation of complex CHD, which may explain the higher that we needed to use in this retrospective study could also in heart failure (therapeutic interventions had to be performed) cardiac complication rate. Nonetheless, the different definition of cations in our study, however, is comparable to the frequency part explain this discrepancy. The incidence of cardiac compli- The modification 1 found in a recently published literature review. of the risk index (as explained in the Results section) seems to The representation of risk factors in the population determines scores have significant limitations restricting indiscriminative use. enhance discrimination and calibration. Importantly, both risk ary arterial hypertension are likely to be underrepresented in con- which risk factors emerge. Important risk factors such as pulmon- lation of risk scores should be only a part of pre-pregnancy risk identified. Therefore, it is important to underline that the calcu- temporaneous cohorts, preventing such risk factors to be assessment. We advocate a pre-pregnancy evaluation in an outpa- expert in the field. In addition to weighing predictors found in and an echocardiography according to a predefined protocol by an tient setting, including physical examination, laboratory evaluation, ZAHARA and CARPREG and calculating risk scores, disease- risk calculation. Also existing guidelines and expert articles pregnancy risk in order to avoid over-simplification implied by specific information should always be used when estimating should be consulted. score in a large prospective study remains necessary, before use External validation of our modified risk 30 Limitations in everyday practice is possible. lacks a historical ‘matching’ control population. This is, however, rospective design. First and most importantly, the present study Most of the limitations of the present study are related to the ret- not as straightforward and simple exercise, as the vast majority gynaecological hospital care are a selected population with (mainly home with the help of a midwife. Therefore, the women consulting of healthy women in the Netherlands and Belgium deliver at complications. Moreover, the concept of a control population is, obstetric or neonatal) complications or at higher risk for these fore, a prospective study would be the best option, on the other in an identical fashion according to a predefined protocol. There- in our opinion, only sustainable, when both cohorts are followed hand, to collect the number of pregnancies provided in the ation is the possibility of underreporting. Because data-retrieval interfere with the contemporaneous applicability. A second limit- present study; data collection would take at least 10 years and educated personnel) were included. Third, we need to take into was retrospective, only documented complications (by medically account that for the present study, a survivor cohort was selected

20 ENFERMEDAD CARDÍACA CONGÉNITA SEVERA
7.6% complicaciones 1% Mortalidad Insuficiencia valvular pulmonar severa Disfunción ventricular severa Sindrome Eissenmenger Asociados a: 1. ICC: 4.8% 2. Arritmias: 4.5%

21 Blood loss Bleeding may result from impaired coagulation resulting from anticoagulant therapy or associated with polycy- thaemia, or from uterine atony secondary to withholding of oxytocic drugs (see below). There are also obstetric causes of bleeding such as cervical or vaginal tears, or bleeding associated with operative delivery. Blood loss is particularly important in patients with cardiac disease for two reasons. First, they may have a reduced capacity to compensate for hypovolaemia, for example if cardiac output is relatively fixed, as in aortic stenosis, or dependent on venous return, as in the Fontan circulation. Compensatory increases in heart rate may be obtunded by drugs such as b blockers, or prevented by cardiac conduction abnormalities. Second, overzealous infusion of intravenous fluid can result in pulmonary oe- dema (see below). For these reasons, it is vital to ensure both adequate monitoring and management of labour and delivery, and prompt recognition and treatment of haemorrhage. Delivery in such cases is not routine and should be performed by the most experienced staff available.

22 CONTROL PERIPARTO Sangrado Edema Pulmonar Arritmias
Sd de Hipotensión Aortocava Embolismo Endocarditis Bacteriana. Bleeding may result from impaired coagulation resulting Blood loss from anticoagulant therapy or associated with polycy- thaemia, or from uterine atony secondary to withholding of oxytocic drugs (see below). There are also obstetric bleeding associated with operative delivery. causes of bleeding such as cervical or vaginal tears, or Blood loss is particularly important in patients with cardiac disease for two reasons. First, they may have a reduced capacity to compensate for hypovolaemia, for stenosis, or dependent on venous return, as in the Fontan example if cardiac output is relatively fixed, as in aortic Oxytocics The cardiovascular side effects of standard doses of oxy- tocin have been known for 30 years (decreased mean tance by 50%; increased cardiac output by 50% and arterial pressure by 30% and systemic vascular resis- heart rate and stroke volume by 20-30%10 ), but their potentially deleterious consequences in women with car- recently. diac disease have been less widely acknowledged until 2,11 The highlighting of this danger in a recent Report on Confidential Enquiries into Maternal Deaths 12 has led to a dramatic change in practice. However, this creates a dilemma since withholding oxytocin may lead to haemorrhage, which may also be dangerous in these though, and these are presented in Table 5. patients (see above). A number of options remain, Pulmonary oedema Pulmonary oedema may result from a combination of fluid retention associated with pregnancy, shifts between failure and/or preeclampsia, and excessive intravenous fluid compartments around the time of delivery, heart fluids. During a long labour, the total volume of paren- teral fluids given can easily mount up when intravenous drugs such as antibiotics and oxytocin are included in druple-strength solutions should be used and careful the count. In women with severe disease, double- or qua- hourly calculations made of fluid balance. During cae- sarean section, when fluid shifts are more dramatic, we often favour giving a 5-mg dose of furosemide at sion of blood from the contracting uterus, although we the time of delivery to counter the effect of autotransfu- are aware that this practice is not evidence-based. Arrhythmias All pregnant women are prone to tachycardia and these may impair cardiac filling and output, and coro- arrhythmias; in women with pre-existing cardiac disease nary perfusion. Drugs that are known to cause tachycar- dia (such as oxytocin [see above] and ephedrine) should be avoided if possible. If vasoconstrictors are indicated our drug of choice. If arrhythmias occur, the treatment in regional anaesthesia, phenylephrine has always been options are influenced by the underlying lesion, experience with any previous drugs in that patient, the closeness of delivery and the degree of cardiovascular compromise. The risk of aortocaval compression and paired or DC cardioversion is required) should always aspiration of gastric contents (if consciousness is im- be borne in mind. Reduced systemic vascular resistance A decrease in SVR may be dangerous in cardiac disease may be profound, and for which the compromised car- for two reasons. First, it may lead to hypotension that diovascular system is unable to compensate. This is especially likely if the cardiac output is fixed, for exam- ple with left-sided stenotic/obstructive lesions. Second, a shunt (or the potential for such a shunt) exists, reduc- reduced SVR may increase right-to-left shunting if such ing pulmonary blood flow further. This can lead to a spiral of worsening hypoxaemia, leading to pulmonary vasoconstriction and yet further hypoxaemia, with potentially disastrous results. Drugs that cause vasodila- possible; traditionally the same has been said for regio- tation (such as oxytocin; see above) should be avoided if nal techniques, 13 although there is now extensive expe- be used safely in such conditions. rience suggesting that spinal and epidural techniques can 14–16 Acute pulmonary hypertension Sudden increases in pulmonary arterial pressure (pul-monary hypertensive crisis) may lead to right ventricular and catastrophic. The danger is well recognised in failure and ischaemia; furthermore, this may be sudden known cases of severe primary or secondary pulmonary hypertension, but more recently the possibility of such crises has been suggested in relatively mild disease. Embolism oping thrombosis, and embolism may occur peripartum. Women with cardiac disease are at greater risk of devel- A particular risk in women with a right-to-left shunt (or the potential for one) is a systemic embolus, which bypasses the lungs and causes ischaemia or infarction in men are also at risk from air embolism; thus a small vital organs such as the heart, brain or kidney. Such wo- amount of air thatmight ordinarily be filtered by the lungs can cause catastrophic systemic effects such as stroke or myocardial infarction. Obsessional care must therefore Bacterial endocarditis be taken to exclude air from all intravenous lines. It is easy to overlook simple antibiotic prophylaxis amidst the complexity of congenital heart disease. It is important to ensure that prophylactic antibiotics such as amoxycil- Management of delivery lin and gentamicin are given, using standard regimens. The overall aim is to reduce the stress on the mother and her heart, whilst of course maintaining cardiac output, and placental and fetal circulation. To do this the mother disruption to her cardiovascular system. This can be requires effective pain relief and the minimum possible achieved first, by close clinical monitoring, second, by avoiding sudden changes whenever possible and taking care to introduce interventions such as regional anaes- complications that may supervene, in particular pre- thesia gradually and third, by close attention to obstetric eclampsia and haemorrhage. Good communication and patience are required on the part of all members of the team, and the obstetricians must give the anaesthetist compression must be avoided at all times. plenty of notice if intervention is required. Aortocaval In contrast to traditional obstetric management whereby mothers with cardiac disease would routinely undergo elective caesarean section, the approach taken 17 in our unit is one of minimal surgical intervention when- ever possible in order to avoid complications such as infection, bleeding, deep vein thrombosis and instability 18,19 associated with anaesthesia. Monitoring Pulse oximetry and electrocardiography should be con- sidered for all but the mildest cases even though the try is vital in cyanotic heart disease as an indicator of the mother may find the extra wires intrusive. Pulse oxime- degree of shunting, while in cases at risk of developing pulmonary oedema it may detect the early stages before clinical features are apparent. invasive monitoring depending on the nature and sever- In general, we have developed an escalating scale for ity of the underlying condition, the severity of symp- toms, and the likelihood for obstetric intervention or complications. Conditions associated with a higher risk impairment and/or the mothers symptoms are severe, of mortality (Table 1), or those in which the degree of would routinely receive invasive arterial monitoring, as would those who develop preeclampsia or are thought to be at high risk of bleeding. In such situations, the alerting staff to problems and guiding vasoconstrictor beat-by-beat information provided is invaluable for or inotropic therapy. Contrary to the experience of some others, we have found the management of arterial lines on the labour ward to pose few practical problems if thetic and technical staff. the midwifery staff are adequately supported by anaes- We place central venous lines less often, and this practice reflects that in other units in the UK. 15,16 vasoactive drugs, and to allow central venous monitoring Central venous lines are particularly useful for infusing in patients at risk from fluid overload, such as those already with cardiac failure, or those especially sensitive to hypovolaemia, such as those with valve stenosis. measured in complex cardiac disease, and central lines However, it is not always clear what is actually being are not without risk. Furthermore, mothers in late preg- nancy, especially those with cardiac disease, find it diffi- cult to lie flat, let alone head-down, and the increased soft lation difficult. When a central line is deemed necessary, tissues and fluid retention of pregnancy may make cannu- we usually favour peripheral access, via the antecubital fossa, if possible. The same caveats apply to the use of pulmonary artery catheters, though their complications more dangerous. For this reason, even though pulmonary (arrhythmias, pulmonary artery rupture) may be even artery catheters may provide indirect information relating to the left ventricle and allow a route for infusing drugs into the pulmonary circulation, we rarely place them. 20 Transeosophageal echocardiography, 21 Doppler car- diography and other tools for measuring cardiac output

23 MONITORIA PULSO-OXIMETRIA LINEA ARTERIAL CVC ECO TRANSTRAQUEAL
BIOMARCADORES Monitoring mother may find the extra wires intrusive. Pulse oxime- sidered for all but the mildest cases even though the Pulse oximetry and electrocardiography should be con- try is vital in cyanotic heart disease as an indicator of the clinical features are apparent. pulmonary oedema it may detect the early stages before degree of shunting, while in cases at risk of developing ity of the underlying condition, the severity of symp- invasive monitoring depending on the nature and sever- In general, we have developed an escalating scale for toms, and the likelihood for obstetric intervention or impairment and/or the mothers symptoms are severe, of mortality (Table 1), or those in which the degree of complications. Conditions associated with a higher risk to be at high risk of bleeding. In such situations, the as would those who develop preeclampsia or are thought would routinely receive invasive arterial monitoring, beat-by-beat information provided is invaluable for others, we have found the management of arterial lines or inotropic therapy. Contrary to the experience of some alerting staff to problems and guiding vasoconstrictor thetic and technical staff. the midwifery staff are adequately supported by anaes- on the labour ward to pose few practical problems if We place central venous lines less often, and this Central venous lines are particularly useful for infusing 15,16 practice reflects that in other units in the UK. already with cardiac failure, or those especially sensitive in patients at risk from fluid overload, such as those vasoactive drugs, and to allow central venous monitoring to hypovolaemia, such as those with valve stenosis. are not without risk. Furthermore, mothers in late preg- measured in complex cardiac disease, and central lines However, it is not always clear what is actually being tissues and fluid retention of pregnancy may make cannu- cult to lie flat, let alone head-down, and the increased soft nancy, especially those with cardiac disease, find it diffi- lation difficult. When a central line is deemed necessary, pulmonary artery catheters, though their complications fossa, if possible. The same caveats apply to the use of we usually favour peripheral access, via the antecubital artery catheters may provide indirect information relating more dangerous. For this reason, even though pulmonary (arrhythmias, pulmonary artery rupture) may be even to the left ventricle and allow a route for infusing drugs we rarely place them. 20 into the pulmonary circulation, Doppler car- 21 Transeosophageal echocardiography, diography and other tools for measuring cardiac output cially during caesarean section when there is little room but their place is uncertain, espe- have been described22 Labour and vaginal delivery awake and unable to tolerate an oesophageal probe. or time for bulky equipment, and the patient may be We would now recommend low-dose epidural analgesia anticoagulation, although the advantage of regional labour, an exception being those receiving therapeutic for virtually all women with cardiac disease undertaking Solutions containing bupivacaine 60.1% with fentanyl epidural haematoma when prophylactic heparin is used. analgesia usually outweighs the relatively small risk of 2-5 lg/mL provide good cardiostability, even in those and we have found no 19,23 with fixed output states, scribed, either as a single injection or as the initial thecal opioids without local anaesthetic have been de- advantage of infusions over boluses of 5-15 mL. Intra- part of a combined epidural-spinal or continuous spinal although we have no experience of this 21,23 technique, pital in the third trimester, there is usually plenty of time women with severe disease are usually admitted to hos- ourselves, finding the epidural regimen adequate. Since to site the epidural either in early labour or before labour women undergoing labour are, first: appropriate moni- its siting. Two key features of the management plan for is induced, so that they are in minimal discomfort during effects of the Valsalva manoeuvre. lowed in the second stage in order to limit or avoid the toring (see above) and second: limited or no pushing al- Caesarean section and it is our belief that it is the care with which each scribed for caesarean section in most cardiac conditions Both regional and general anaesthesia have been de- enced by a number of factors: is most important. The choice of technique can be influ- technique is used, rather than the technique itself, that (i) The likelihood of complications and the appropri- which is more easily administered during general of arrhythmias may require DC cardioversion, ate treatment, for example: those with a high risk induced by regional anaesthesia, compared with (ii) The risk from a potentially severe drop in SVR anaesthesia. the risk from the negative inotropic effects of gen- for example, a drop in SVR may cause a cata- syndrome and a large ventricular septal defect, eral anaesthesia. In a patient with Eisenmengers erations, depending on the particular case. This although this may be outweighed by other consid- strophic reduction in pulmonary blood flow, On the other hand, carefully controlled regional might favour general anaesthesia in certain cases.

24 VÍA DEL PARTO Analgesia para el trabajo de parto
Parto vaginal excepto: Aortopatía con raiz aortica > 4 cms Disección aórtica Aneurisma de aorta toráxica Protesis mecánica y anticoagulación warfarina Hipertesión pulmonar severa Vía del parto La vía del parto debe ser decidida por las con- diciones obstétricas; en general, está permitido el parto vaginal. En nuestro reporte, el 60 % de las pacientes terminaron su embarazo por par- to vaginal, todas bajo analgesia conductiva. Las únicas indicaciones de cesárea por causa car- diaca son: la aortopatía con raíz aórtica > 4 cm o crecimiento progresivo de ésta, disección aórtica o aneurisma de aorta torácica y anticoagulación con warfarina en las pacientes con prótesis val- vulares mecánicas, por el riesgo de hemorragia intraventricular cerebral en el feto (6). Los grandes centros de referencia de enferme- dades cardiacas en el embarazo (17) están re- comendando recientemente la posibilidad de cesárea programada en pacientes con enferme- dad cardiaca con muy alto riesgo de muerte o de desarrollo de complicaciones cardiovasculares graves, como en el caso de pacientes con hiper- tensión pulmonar severa de cualquier etiología, debido a la posibilidad de realizar el proceso de terminación del embarazo en un ambiente “con- trolado”, que permita evitar complicaciones rela- cionadas con la presencia de personal no fami- liarizado con la patología o la falta de recursos en escenarios no planeados, principalmente, fi- nes de semana y turnos nocturnos.

25 TÉCNICA ANESTÉSICA METAS HEMODINAMICAS TECNICA ESPINAL CONTINUA
TECNICA COMBINADA ANESTESIA GENERAL No existe en este momento en la literatura la po- sibilidad de definir si la mortalidad de este grupo de pacientes está influenciada por la elección de una técnica anestésica en particular. Los grupos de anestesia obstétrica se inclinan, recientemente, por el uso de técnicas conductivas (18). En nuestro reporte, las pacientes de riesgo alto, como tetralo- gía de Fallot, y las pacientes con CMP que tenían disfunción ventricular severa fueron manejadas con anestesia general; el resto, con técnicas con- ductivas basadas en lo que denominamos “metas hemodinámicas”. Es decir, mantener normovole- mia e incremento en las resistencias vasculares en pacientes catalogadas como de alto riesgo. La aplicación de técnicas conductivas que per- mitan la titulación del grado anestésico deseado han sido descritas en el caso de pacientes con le- siones estenóticas severas del corazón izquierdo, como estenosis aórtica severa (19) o lesiones aso- ciadas con hipertensión pulmonar severa (20), lo cual reporta seguridad con su utilización. Both regional and general anaesthesia have been de- scribed for caesarean section in most cardiac conditions and it is our belief that it is the care with which each technique is used, rather than the technique itself, that is most important. The choice of technique can be influ- enced by a number of factors: (i) The likelihood of complications and the appropri- ate treatment, for example: those with a high risk of arrhythmias may require DC cardioversion, which is more easily administered during general anaesthesia. (ii) The risk from a potentially severe drop in SVR induced by regional anaesthesia, compared with the risk from the negative inotropic effects of gen- eral anaesthesia. In a patient with Eisenmengers syndrome and a large ventricular septal defect, for example, a drop in SVR may cause a cata- strophic reduction in pulmonary blood flow, although this may be outweighed by other consid- erations, depending on the particular case. This might favour general anaesthesia in certain cases. On the other hand, carefully controlled regional anaesthesia may preserve cardiac function and be preferable in cases where there is markedly impaired cardiac contractility. The presence of pulmonary hypertension. The risk of precipitating an acute pulmonary hypertensive crisis due to tracheal intubation, inadequate neuro- muscular blockade, coughing, etc, must be weighed against the ability, with general anaesthe- sia, both to give 100% oxygen and to avoid the risk of a poor regional block. The potential risk of thromboembolism and the need for prophylactic or therapeutic anticoagula- tion, and issues around the timing of the latter. The likelihood of maternal death and the mothers attitude. If the outlook for either the mother or the fetus is very poor she may be desperate to see and hold her baby at least once, during the operation, favouring regional anaesthesia. On the other hand, if for example she experiences severe cyanotic and/or pulmonary hypertensive crises when anx- ious, it might be better to avoid this stress intra- operatively by electing for general anaesthesia. The likely need for postoperative controlled venti- lation and/or further invasive treatment, including cardiac procedures. (vii) The likelihood for prolonged/complicated surgery, for example, if there are associated intra-abdomi- nal congenital abnormalities. (ix) The presence of any associated abnormalities affecting the airway. (x) The anaesthetists preference. The overall approach is as we have already discussed above. The aim is for gradual, careful introduction of general or regional anaesthesia, with close attention to the problems already considered and prompt interven- tion should the need arise. If emergency caesarean sec- tion is required, we aim to extend a pre-existing regional block if time permits and if not, consider gen- eral anaesthesia. The choice of drugs for the latter is the same as for non-pregnant cases and depends on the anaesthetists preference and the physical status of the mother, the effects on the fetus being a secondary issue. POSTPARTUM All the problems highlighted above may also occur after delivery. This is a particularly important time since there is a tendency for congratulation and distraction away from the close attention that these mothers require. Care- ful monitoring in an appropriately staffed area able to provide high dependency care is vital. Fluid balance is a particular area of concern, especially if there is ongoing bleeding, perhaps as a result of withholding oxy- tocin. The possibility of coincidental preeclampsia or other obstetric complications must also be remembered. Falling oxygen saturation may indicate worsening shunt or pulmonary oedema as well as the usual causes such as atelectasis, aspiration, etc. Adequate postoperative anal- gesia is important; neuraxial opioids are particularly use- ful. Prophylaxis against deep vein thrombosis should be (re)started and care taken to detect and treat genital tract or wound infection early. How long close observation is required is uncertain; we have developed an approach that errs on the side of caution, depending on the lesion and coloured by our own experience of complications that may occur several days after delivery. In Eisenm- engers syndrome, for example, sudden death typically occurs 1-2 weeks after delivery, possibly from multiple pulmonary embolism, pulmonary haemorrhage, or both.

26 CESAREA INDICACION ABSOLUTA
PODALICO DISECCIÓN AORTICA RAIZ AORTICA < 2 CMS MARFAN RAIZ A > 4 CM HTP SEVERA SD EISENMENGER

27 Y POST PARTO QUE? MUERTE SUBITA 1-2 SEMANAS DESPUES.
EMBOLISMO PULMONAR HEMORRAGIA PULMONAR

28 CUIDADOS ESPECIALES SHUNTS IZQ-DER COARTACION AORTICA BURBUJAS DE AIRE
PERIDURAL EMBOLISMO PARADOJICO CONTROL DEL DOLOR OXIGENO COARTACION AORTICA MONITORIZAR GRADIENTE DISECCIÓN HEREDITARIO MORTALIDAD FETAL MONITORIA INVASIVA Left-to-Right Shunts Lesions such as a small atrial septal defect (ASD), ventricular septal defect (VSD), or patent ductus arteriosus (PDA) may produce a modest degree of left-to-right intracardiac shunting, which often is well tolerated during pregnancy. Anesthetic management of patients with these defects should include attention to the following details. First, care should be taken to avoid the accidental intravenous infusion of air bubbles. Second, if epidural anesthesia is used, the anesthesiologist should use a loss-of-resistance to saline rather than air to identify the epidural space. Epidural injection of even small amounts of air can result in systemic embolization. Transient reversals of atrial pressure gradients during the cardiac cycle may allow paradoxical air emboli to occur, even when mean right atrial pressure is lower than mean left atrial pressure.[7] Third, early administration of epidural anesthesia is desirable. Pain causes increased maternal concentrations of catecholamines and increased maternal SVR and may increase the severity of left-to-right shunt resulting in pulmonary hypertension and right ventricular failure. Early administration of epidural anesthesia allows a pain-free labor and prevents the increased maternal concentrations of catecholamines and increased maternal SVR. Fourth, a slow onset of epidural anesthesia is preferred. A rapid decrease in SVR could result in a reversal of shunt flow, and an asymptomatic left-to-right shunt may become a right-to-left shunt with maternal hypoxemia. Finally, the patient should receive supplemental oxygen, and it seems prudent to monitor hemoglobin oxygen saturation. Even mild hypoxemia can result in increased pulmonary vascular resistance and reversal of shunt flow. It also is important to avoid hypercarbia and acidosis, which may increase pulmonary vascular resistance. Coarctation of the Aorta Coarctation of the aorta is a congenital lesion that is more common in males than in females. Patients who have undergone successful corrective surgery and who have normal arm and leg blood pressures do not require special precautions or monitoring. An arm-to-leg gradient of less than 20 mm Hg is associated with a good outcome of pregnancy.[8] Pregnant women with uncorrected coarctation or a residual decrease in aortic diameter are at high risk for left ventricular failure, aortic rupture or dissection, and endocarditis. In such pregnancies the fetal mortality rate may approach 20% because of decreased uterine perfusion distal to the aortic lesion.[9] The incidence of congenital heart disease is approximately 3% in the offspring of mothers with aortic coarctation.[8] Compared with the general population, patients with aortic coarctation are more likely to have a bicuspid aortic valve (hence the increased risk of endocarditis) or an aneurysm in the circle of Willis. Thus these patients may be at increased risk for a cerebrovascular accident.[10] Physical examination should be directed toward the comparison of the right-sided versus left-sided blood pressures and upper versus lower extremity pressures. The electrocardiogram (ECG) may show left ventricular hypertrophy. Magnetic resonance imaging may be a useful means of confirming the diagnosis in a pregnant patient. The pathophysiologic manifestations include a fixed obstruction to aortic outflow and distal hypoperfusion. The cardiovascular demands of pregnancy tend to exacerbate both the risk and consequences of this lesion. Attention should be directed toward maintaining normal to slightly elevated SVR, a normal to slightly increased heart rate, and adequate intravascular volume. In patients with uncorrected coarctation, neuraxial anesthesia should be administered with great caution, if at all. For cesarean section, general anesthesia is preferred. Remifentanil has been used and facilitates maintenance of hemodynamic stability.[11] Invasive hemodynamic monitoring can help guide the administration of intravenous fluids. Uterine perfusion pressure is usually reflected more accurately by using a postductal intraarterial catheter instead of a preductal catheter. Ephedrine and dopamine are the vasopressors of choice because of their mild positive chronotropic effects.

29 CUIDADOS ESPECIALES TETRALOGIA DE FALLOT SD EISENMENGER
5% DE EMBARAZADAS CIANOSIS ECOCARDIOGRAFIA EKG SD EISENMENGER SHUNT DER-IZQUIERDA SINTOMAS MORTALIDAD MATERNA TROMBOEMBOLISMO ANALGESIA Tetralogy of Fallot DEFECTO SEPTOVENTRICULAR HIPERTROFIA VD ESTENOSIS PULMONAR AORTA ANULAR Tetralogy of Fallot accounts for 5% of cases of congenital heart disease in pregnant women. This lesion includes four components: (1) a VSD, (2) right ventricular hypertrophy, (3) pulmonic stenosis with right ventricular outflow tract obstruction, and (4) an overriding aorta (i.e., the aortic outflow tract receives blood from both the right and left ventricles). Tetralogy of Fallot is the most common congenital heart lesion associated with a right-to-left shunt. Patients typically present with cyanosis. INTERACTION WITH PREGNANCY In the absence of corrective surgery, the number of women who reach childbearing age and become pregnant is quite small. Most pregnant women with tetralogy of Fallot have had corrective surgery. The surgical treatment, typically performed in childhood, involves closure of the VSD and widening of the pulmonary outflow tract. This surgery generally is successful and results in an asymptomatic patient. In some cases, a small VSD may recur, or progressive hypertrophy of the pulmonary outflow tract may occur slowly over the first several decades of life. The cardiovascular changes of pregnancy (e.g., increased blood volume, increased cardiac output, decreased SVR) may unmask these previously asymptomatic residua of corrected tetralogy of Fallot. The severity of symptoms depends on the size of the VSD, the magnitude of the pulmonic stenosis, and the contractile performance of the right ventricle. Patients with corrected tetralogy of Fallot, even if they have been asymptomatic for many years, should undergo echocardiography before and during early pregnancy. ANESTHETIC MANAGEMENT Anesthetic management for patients with successful correction of tetralogy of Fallot often does not differ from that for a woman without this lesion. Patients with corrected tetralogy of Fallot may manifest various atrial and ventricular arrhythmias, owing to surgical injury to the cardiac conduction channels. Thus a 12-lead ECG and ECG monitoring during labor are desirable. Greater attention should be given to the parturient with uncorrected tetralogy of Fallot or corrected tetralogy of Fallot with residua. The anesthesiologist should avoid causing a decrease in SVR, which increases the severity of right-to-left shunt. It also is important to maintain adequate intravascular volume and venous return. In the presence of right ventricular compromise, high filling pressures are needed to enhance right ventricular performance and ensure adequate pulmonary blood flow. Administration of a neuraxial block during early labor is advisable and helps prevent an increase in pulmonary vascular resistance and consequent right-to-left shunting. For cesarean delivery, regional anesthesia should be administered slowly; single-shot spinal anesthesia is a poor choice because the abrupt reduction in SVR may cause shunt reversal and hypoxemia. Eisenmenger Syndrome A chronic, uncorrected left-to-right shunt may produce right ventricular hypertrophy, elevated pulmonary artery pressures, right ventricular dysfunction, and ultimately, the syndrome first described by Eisenmenger in 1897.[12] The primary lesion may be either an ASD or VSD, or an aortopulmonary communication, such as PDA or truncus arteriosus. The pulmonary and right ventricular musculature undergoes remodeling in response to chronic pulmonary volume overload. High, fixed pulmonary arterial pressure gradually limits flow through the pulmonary vessels. A reversal of shunt flow occurs when pulmonary artery pressure exceeds the level of systemic pressure. The primary left-to-right shunt becomes a right-to-left shunt. Initially the shunt may be bidirectional; acute changes in pulmonary vascular resistance or SVR may influence the primary direction of intracardiac blood flow. However, the pulmonary vascular occlusive disease ultimately leads to irreversible pulmonary hypertension. Therefore correction of the primary intracardiac lesion is not helpful at this stage. The clinical manifestations of Eisenmenger syndrome include the sequelae of arterial hypoxemia and right ventricular failure (e.g. dyspnea, clubbing of the nails, polycythemia, engorged neck veins, peripheral edema). These women often are unable to respond to the increased demands for oxygen during pregnancy. Maintenance of satisfactory oxygenation requires adequate pulmonary blood flow. The decrease in pulmonary vascular resistance seen in normal pregnancy does not occur in these women because pulmonary vascular resistance is fixed. The decrease in SVR associated with pregnancy tends to exacerbate the severity of the right-to-left shunt. The pregnancy-associated decrease in functional residual capacity also may predispose the patient to maternal hypoxemia. Maternal hypoxemia results in decreased oxygen delivery to the fetus, which results in a high incidence of intrauterine growth restriction (IUGR) and fetal demise.[13] Maternal mortality is as high as 30% to 50% among these patients. [5] [14] Thromboembolic phenomena are responsible for as many as 43% of all maternal deaths in patients with Eisenmenger syndrome. Many of these deaths occur postpartum—as late as 4 to 6 weeks after delivery.[5] OBSTETRIC MANAGEMENT Patients with Eisenmenger syndrome who become pregnant should be counseled to terminate the pregnancy.[15] If the patient desires to remain pregnant, a multidisciplinary approach with close communication among the obstetrician, cardiologist, and anesthesiologist is essential. The obstetrician most likely will want to perform an early instrumental vaginal delivery to minimize maternal expulsive efforts. Some obstetricians favor prophylactic anticoagulation during the intrapartum period, but it is unclear whether this improves maternal outcome.[5] The primary goals of anesthetic management are as follows [16] [17] [18]:    1    Maintain adequate SVR.    2.    Maintain intravascular volume and venous return. Avoid aortocaval compression.    3.    Prevent pain, hypoxemia, hypercarbia, and acidosis, which may cause an increase in pulmonary vascular resistance.    4.    Avoid myocardial depression during general anesthesia. Treatment of Pulmonary Hypertension Inhaled nitric oxide (iNO) selectively dilates the pulmonary vascular bed without producing systemic hemodynamic effects. Thus, iNO can improve right ventricular function and may consequently enhance left ventricular function by improving oxygenation. Experience with iNO in parturients is limited. Goodwin et al.[19] reported its use during the second stage of labor and postpartum in a parturient with Eisenmenger syndrome. The administration of iNO was associated with an improvement in the patient's hypoxemia and a reduction in her pulmonary artery pressure. It was discontinued after 48 hours and vasodilator therapy was maintained with an infusion of prostacyclin; however, the patient died 2 days later.[19] In a similar case the woman died 3 weeks postpartum.[20] However, use of iNO has been associated with good outcome in women with severe primary pulmonary hypertension.[21] Labor Supplemental oxygen should be provided at all times. The pulse oximeter is the most useful monitor for detecting acute changes in shunt flow.[22] Pollack et al.[17] described the simultaneous use of pulse oximeters on the right hand and left foot of a parturient whose severe Eisenmenger syndrome resulted from an uncorrected PDA. The right hand receives preductal blood flow, whereas the flow to the lower extremities is postductal. Thus the authors could rapidly estimate relative changes in shunt fraction. An intraarterial catheter facilitates the rapid detection of sudden changes in blood pressure, and a central venous pressure (CVP) catheter can help reveal clinically significant changes in cardiac filling pressures. However, the insertion of a CVP catheter occasionally produces complications (e.g., air emboli, infection, hematoma, pneumothorax), which can be disastrous in these patients. Although some physicians have stated that a pulmonary artery catheter is “essential” for the intrapartum management of pregnant women with Eisenmenger syndrome,[18] we and others [17] [23] disagree and believe that a pulmonary artery catheter may be relatively contraindicated for several reasons. First, it is difficult, if not impossible, to properly position the balloon-tipped, flow-directed catheter within the pulmonary artery. Second, if the catheter does go into the pulmonary artery, the risks of pulmonary artery rupture and hemorrhage are great. Third, these patients may not tolerate catheter-induced arrhythmias. Fourth, measurements of cardiac output by thermodilution are uninterpretable in the presence of a large intracardiac shunt. Fifth, pulmonary artery pressure monitoring rarely yields clinically useful information in the presence of severe, fixed pulmonary hypertension. Sixth, the pulmonary artery catheter may predispose to pulmonary thromboembolism.[24] Finally, the risks of placing/using a pulmonary artery catheter include the entire spectrum of complications associated with placement of a CVP catheter. Effective analgesia is necessary to prevent labor-induced increases in plasma catecholamines, which may further increase pulmonary vascular resistance. During the first stage of labor, intrathecal administration of an opioid is ideal, because it produces profound analgesia with minimal sympathetic blockade. For the second stage of labor, epidural or intrathecal doses of a local anesthetic and an opioid will provide satisfactory analgesia; alternatively, a pudendal block can be placed early in the second stage of labor. In some instances, maternal anticoagulation may complicate or contraindicate the use of regional anesthetic techniques. In such cases an intravenous infusion of remifentanil, with or without patient-controlled analgesia (PCA), may be the next best option.[25] However, the quality and reliability of intravenous opioid analgesia is not as good as that provided by a regional anesthetic technique.[26] Cesarean Section Historically, anesthesiologists have avoided regional anesthesia because the vasodilation that accompanies sympathectomy can worsen a right-to-left shunt. However, favorable outcomes have been achieved with epidural anesthesia, which has become the technique of choice for parturients with Eisenmenger syndrome. [18] [27] The key to the safe use of spinal or epidural anesthesia is incremental injection of local anesthetic while carefully correcting any adverse hemodynamic sequelae.[28] It is critical that the anesthesiologist avoid aortocaval compression and maintain adequate venous return. Intravenous crystalloid and small doses of phenylephrine are administered as needed to maintain maternal preload, SVR, and oxygen saturation. Several disadvantages are associated with the use of general anesthesia. Positive-pressure ventilation results in decreased venous return, which compromises cardiac output. The volatile halogenated agents can cause myocardial depression and decreased SVR. Rapid-sequence induction with agents such as thiopental or propofol characteristically decreases both contractility and SVR, which may exacerbate a right-to-left shunt. On the other hand, a slow induction of general anesthesia predisposes to maternal aspiration. This risk notwithstanding, a rapid-sequence induction of general anesthesia is usually avoided in patients with Eisenmenger syndrome. Measures to decrease the risk of anesthesia-related aspiration include (1) maintaining the patient NPO for solids for at least 8 hours before the induction of anesthesia, (2) preoperative pharmacologic therapy (e.g., H2-receptor antagonist, metoclopramide, sodium citrate), and (3) the use of cricoid pressure. Although opioids are not routinely used when giving general anesthesia in healthy women undergoing cesarean section, it seems appropriate to include a systemic opioid during administration of general anesthesia to help maintain hemodynamic stability in women with severe cardiovascular disease. Regardless of the anesthetic technique used, these women are at high risk for hemodynamic compromise immediately after delivery. Large losses of blood should be replaced promptly with crystalloid, colloid, and/or appropriate blood products. Cautious fluid therapy is important when the blood loss is minimal, because the postpartum autotransfusion may cause intravascular volume overload in women with myocardial dysfunction. to Colleague Print Version

30 PROFILAXIS PARA ENDOCARDITIS
1/8.000 PARTOS 29% MORTALIDAD MADRE 23% MORTALIDAD FETAL COLEGIO A. G/O: NO USAR ACC/AHA : ANTES DEL PARTO VAGINAL RUPTURA DE MEMBRANAS VALVULAS PROTESICAS ENFERMEDAD CARDIACA CIANOSANTE SHUNT ENDOCARDITIS PREVIA

31 HIPERTENSIÓN PULMONAR PRIMARIA
MORTALIDAD 30-40% ASOCIADO A: RCIU MORTINATO PARTO PRETERMINO PREVENIR: HIPOXEMIA, HIPERCAPNIA COMPRESIÓN AORTOCAVA HTP FIJA PRIMARY PULMONARY HYPERTENSION The syndrome of primary pulmonary hypertension is characterized by markedly elevated pulmonary artery pressures in the absence of an intracardiac or aortopulmonary shunt.[29] Unlike those with Eisenmenger syndrome, patients with primary pulmonary hypertension often have a reactive pulmonary vasculature that can respond to vasodilator therapy. The maternal mortality rate may be as high as 30% to 40%. These patients also have a high incidence of IUGR, fetal loss, and preterm delivery.[30] The hemodynamic goals of obstetric and anesthetic management are similar to those for the patient with Eisenmenger syndrome [16] [31] [32]:    1    Prevent pain, hypoxemia, acidosis, and hypercarbia, which cause an increase in pulmonary vascular resistance.    2.    Maintain intravascular volume and venous return. Avoid aortocaval compression and replace blood loss at delivery.    3.    Maintain adequate SVR, as women with fixed pulmonary hypertension cannot increase their cardiac output to compensate for a decrease in blood pressure that results from a decrease in SVR.    4.    Avoid myocardial depression during general anesthesia, especially in women with fixed pulmonary hypertension. Supplemental oxygen is a superb pulmonary vasodilator and should be administered routinely in these patients. Monitoring typically includes placement of both an arterial and a CVP catheter. A pulmonary artery catheter can guide treatment when the pulmonary vascular resistance (PVR) is responsive to vasodilator therapy; however, the physician should weigh carefully the risks versus benefits of pulmonary artery catheterization (vide supra).[33] Transesophageal echocardiography has been used intraoperatively during cesarean delivery.[34] Agents that have been used to treat primary pulmonary hypertension include iNO, nitroglycerin, calcium-entry blocking agents, prostaglandins, and endothelin antagonists. [21] [35] [36] [37] [38] [39] A successful maternal and fetal outcome was recently reported in a woman with primary pulmonary hypertension who had received epoprostenol throughout pregnancy.[40] Continuous neuraxial block is preferred for labor and delivery. [41] [42] Epidural anesthesia allows for a pain-free first and second stage of labor and facilitates elective forceps delivery. Several reports have noted the successful use of epidural anesthesia for cesarean section. [31] [43] Slow induction of epidural anesthesia is of critical importance. If hypotension occurs it should be treated initially with intravenous fluid. Vasopressors such as ephedrine should be used with caution because these agents can further increase the pulmonary artery pressures. Single-shot spinal anesthesia may cause severe hemodynamic instability and should be avoided except in those rare instances when it is used in preference to general anesthesia. Continuous spinal anesthesia[44] and general anesthesia have also been successfully used in patients with primary pulmonary hypertension. Weeks and Smith[32] reviewed all published cases of intrapartum anesthetic management for women with primary pulmonary hypertension. They concluded the following: Epidural anesthesia has been used with success, but in the presence of pre-existing right ventricular failure, any large decrease in systemic vascular resistance may lead to a further decrease in cardiac output. Refractory hypotension may also cause right ventricular ischemia, leading to a further deterioration in right ventricular function. The potential hazards of general anesthesia include increased pulmonary artery pressure during laryngoscopy and intubation, the adverse effects of positive pressure ventilation on venous return and the negative inotropic effects of certain anesthetic agents. However, these adverse effects can be minimized by the use of a narcotic-based induction and maintenance technique. Any resulting narcotic-induced neonatal depression should be easily treated. Intensive postoperative management is of critical importance and should probably continue for one week because of the high incidence of sudden death during this period.[32]

32 HIPERTENSIÓN PULMONAR PRIMARIA
CATETER CENTRAL ECOTRANSESOFAGICO TTO: OXIDO NITRICO, NITROGLICERINA BLOQ CANALES DE CALCIO PROSTAGLANDINAS ANTAGONISTA DE LA ENDOTELINA ANESTESIA ESPINAL CONTINUA

33 CARDIOMIOPATIA HIPERTROFICA
OBSTRUCCIÓN TRACTO DE SALIDA. PREVENIR: TAQUICARDIA RESISTENCIA VASCULAR COMPRESIÓN AORTOCAVA ARRITMIA MUERTE SUBITA

34 ENFERMEDAD ISQUEMICA 1:10.000 19% MORTALIDAD MATERNA
17% MORTALIDAD PERINATAL ABUSO DE COCAINA ASOCIADO A : FEOCROMOCITOMA ENF COLAGENO CELULAS FALCIFORMES ESPASMO CORONARIO ISCHEMIC HEART DISEASE Myocardial infarction accounts for nearly 2000 deaths yearly in women under the age of 45.[52] Fortunately, myocardial infarction is a rare event during pregnancy. In 1952, Ginz[53] estimated that the incidence was less than 1 in 10,000 pregnancies. However, the incidence of myocardial ischemia during pregnancy may be increasing for several reasons. First, there is a greater prevalence of delayed childbearing. Indeed, assisted reproductive techniques have resulted in pregnancies in postmenopausal women older than 50 years of age. Second, many young women continue to abuse tobacco. Third, there is an increased incidence of cocaine abuse by women of child-bearing age. Fourth, the use of oral contraceptives after age 35 may increase the risk of ischemic heart disease. Pathophysiology Badui and Enciso[54] reviewed reports of 136 parturients with peripartum myocardial infarction. The average maternal age was 32; some 43% of affected women had no obvious risk factors, and 47% had no evidence of atherosclerosis. The maternal mortality rate was 19%, and the perinatal mortality rate was 17%.[54] The etiology of myocardial infarction during pregnancy is multifactorial. Coronary artery morphology has been studied in 125 patients who had a myocardial infarction during pregnancy. Coronary atherosclerosis (with or without intracoronary thrombus) was found in 43% of patients, coronary thrombus without atherosclerotic disease was found in 21%, coronary dissection was noted in 16%, and normal coronary arteries were found in 29% of patients.[55] An intrapartum myocardial infarction in a woman with normal coronary arteries may be caused by disorders such as pheochromocytoma, collagen vascular disease, sickle cell anemia, or protracted coronary artery spasm (secondary to cocaine abuse, pregnancy-induced hypertension, or administration of an ergot alkaloid). Pregnancy results in increased heart rate, myocardial wall tension and contractility, basal metabolic rate, and oxygen consumption. Labor causes a further, progressive increase in oxygen consumption. Pain results in increased maternal concentrations of catecholamines, which increase myocardial oxygen demand. Each uterine contraction results in an autotransfusion of 300 to 500 mL of blood to the central circulation. Autotransfusion increases preload and may further compromise the balance between myocardial oxygen supply and demand. Oxygen consumption peaks at delivery. Maternal expulsive efforts at delivery may result in a 150% increase in oxygen consumption. Oxygen consumption remains 25% higher than nonpregnant levels in the immediate postpartum period. Elective cesarean section does not eliminate the cardiovascular stress of delivery; cardiac output increases as much as 50% during and after elective cesarean section. Interaction with Pregnancy The cardiovascular changes of pregnancy, labor, and delivery may precipitate myocardial ischemia or infarction in women with coronary artery disease or other cardiac lesions ( Table 40-1 and Box 40-2 ). Cocaine abuse can cause myocardial ischemia as a result of tachycardia, hypertension, arrhythmias, coronary artery spasm, coronary thrombosis, and the acceleration of atherosclerotic disease.[56] Thus the possibility of cocaine abuse should be considered when a pregnant woman develops myocardial ischemia or infarction. TABLE 40-1   -- BALANCE BETWEEN MYOCARDIAL OXYGEN SUPPLY AND DEMAND Parameter Effect of pregnancy Supply   Diastolic time Decreased Coronary perfusion pressure May be decreased Arterial oxygen content    Arterial oxygen tension Increased  Hemoglobin concentration Decreased Coronary vessel diameter Unchanged Demand   Basal oxygen requirements Increased Heart rate Increased Wall tension    Preload (ventricular radius) May be increased  Afterload Decreased Contractility Increased Atherosclerosis CAUSES OF MYOCARDIAL ISCHEMIA IN PREGNANT WOMEN Cocaine abuse Box 40-2  Coronary artery dissection Coronary artery aneurysm Coronary artery vasospasm Tachycardia (in association with left ventricular hypertrophy) Severe hypertension Coronary artery hematoma Anemia Hypoxemia Severe hypotension The diagnosis of myocardial ischemia is made by history, physical examination, and ECG. Among nonpregnant patients, the most significant symptoms include chest pain, dyspnea, diaphoresis, poor exercise tolerance, and syncope. However, all of these symptoms may occur in normal pregnant women. Chest pain that radiates to the left arm or syncope not explained by supine hypotension should prompt further evaluation. The diagnosis of myocardial infarction may be confirmed by serum cardiac enzyme determinations. The serum creatine kinase MB fraction may increase twofold 30 minutes after delivery in the absence of myocardial ischemia. Plasma troponin-1 is a useful test in patients with suspected peripartum myocardial infarction because it remains within the normal range unless myocardial injury has occurred. Diagnosis Severe aortic stenosis or regurgitation The ECG may be misleading; during pregnancy the normal ECG may show sinus tachycardia, a leftward axis shift, ST-segment depression, flattened or inverted T waves, and a Q wave in lead III.[57] Holter monitoring and echocardiography are noninvasive tests that remain useful during pregnancy. During early pregnancy, cardiac catheterization is used with caution because of the teratogenic effects of ionizing radiation.[58] However, the risk-benefit analysis may favor intrapartum cardiac catheterization with appropriate lead shielding.[59] The simultaneous use of echocardiography may decrease the need for cineangiography, thereby reducing fetal radiation exposure. Medical Management The pharmacologic agents (e.g., nitrates, beta-adrenergic receptor antagonists, calcium-entry antagonists) used in the treatment of myocardial ischemia in nonpregnant patients are also used during pregnancy. Treatment of myocardial ischemia improves cardiac function, which should increase uteroplacental perfusion. Conversely, overly aggressive therapy may adversely affect the fetus. For example, if nitroglycerin is given intravenously, the physician must beware of a sudden reduction in preload, which may decrease cardiac output and uterine blood flow and result in undesired uterine atony. It is useful to monitor the fetal heart rate (FHR) in such cases. Optimal management of the pregnant woman with coronary artery disease requires attention to the needs of both mother and fetus. Physicians should treat disease states (e.g., anemia, thyrotoxicosis, hypertension, infection, substance abuse) that may adversely affect myocardial oxygen supply and demand.[60] Schumacher et al.[65] reported a case of myocardial infarction that was treated with tissue plasminogen activator (TPA) at 21 weeks' gestation. Maternal outcome was good, and cesarean section for preterm labor was performed at 33 weeks. The safety of thrombolytic agent use during pregnancy has not yet been established. TPA has a short half-life, and because of its large molecular weight (65,000 d) it does not cross the placenta. Nevertheless, TPA increases the risk of placental abruption, intrauterine hemorrhage, and resultant fetal demise. The administration of TPA close to delivery may increase blood loss during operative procedures. Ischemia that is unresponsive to medical management may require percutaneous transluminal coronary angioplasty, [61] [62] stent placement,[63] or cardiopulmonary bypass surgery.[64] The risk of recurrent myocardial infarction in pregnant women with a history of previous infarction is unknown. Frenkel et al.[66] reviewed 24 published cases of patients who conceived after myocardial infarction. They noted that “each woman had an uneventful pregnancy with no cardiac or obstetric complications related to the myocardial infarction.”[66] They concluded that previous myocardial infarction does not contraindicate labor, and they recommended that cesarean section be reserved “for obstetric situations and…situations that are life-threatening to the mother and cannot be corrected immediately.”[66] Obstetric Management It has been suggested that acute myocardial infarction complicated by refractory congestive heart failure should prompt early cesarean section. Listo and Bjorkenheim[67] described a patient with an acute anterior wall myocardial infarction during labor who developed cardiogenic shock, which led to intrapartum fetal death. Cesarean section resulted in a rapid resolution of pulmonary edema. Mabie et al.[68] reported a 42-year-old woman with no known cardiac risk factors who had an acute myocardial infarction at 32 weeks' gestation and developed preterm labor. Symptoms of congestive heart failure improved promptly after cesarean section. The initial left ventricular dysfunction ultimately resolved. These authors suggested that early cesarean section may help protect stunned but viable myocardium. Cohen et al.[70] reviewed the advantages and disadvantages of cesarean section versus vaginal delivery in patients with a history of recent myocardial infarction. An elective cesarean section allows the obstetrician to control the timing of delivery. The performance of an elective cesarean section averts the prolonged maternal stress of labor and the hyperdynamic circulatory changes associated with maternal expulsive efforts during the second stage of labor. Disadvantages of cesarean section are related to (1) an increased risk of blood loss, (2) an increased risk of infection, (3) greater postpartum pain, (4) delayed ambulation, and (5) an increased risk of pulmonary morbidity after delivery. The use of epidural anesthesia throughout labor minimizes hyperdynamic circulatory changes associated with vaginal delivery. The risk of recurrent perioperative myocardial infarction is increased in patients who undergo major surgery within 6 months of a prior myocardial infarction. Invasive hemodynamic monitoring, maintenance of normal intravascular volume, and aggressive prophylaxis and therapy of ischemia may reduce this risk.[69] Early studies suggested that oxytocin decreases coronary artery blood flow; however, these studies used pituitary extracts that contained arginine vasopressin, a potent coronary artery vasoconstrictor. Intravenous infusion of synthetic oxytocin is considered safe for the induction of labor and treatment of postpartum uterine atony in women with coronary artery disease. However, a bolus injection of oxytocin may cause hypotension, and a prolonged infusion of large doses of oxytocin may result in hyponatremia and congestive heart failure. In summary, no consensus exists regarding the optimal method of delivery in these patients. Some obstetricians recommend the liberal use of cesarean section; but others argue that cesarean section is major surgery, which does not eliminate maternal hemodynamic stress and predisposes to hemorrhagic and infectious complications. It seems reasonable to reserve cesarean section for obstetric indications unless maternal hemodynamic instability mandates immediate delivery. Optimal management requires a multidisciplinary approach. The therapeutic options for parturients with coronary artery disease or active ischemia are similar to those for nonpregnant patients. The ECG and Spo2 should be monitored continuously during labor and vaginal or cesarean delivery. An arterial catheter and occasionally a pulmonary artery catheter may facilitate management of women who have had a recent myocardial infarction or who have left ventricular and/or valvular dysfunction. Anesthetic Management Supplemental oxygen should be administered during labor and delivery. Epidural anesthesia provides excellent pain relief, prevents hyperventilation, and reduces maternal concentrations of catecholamines. (Hypocapnia and catecholamines both cause coronary artery vasoconstriction.) Amniotomy should be delayed until satisfactory epidural analgesia is established. A dense epidural block ensures total relief of pain during labor, minimizes maternal expulsive efforts during the second stage of labor, and facilitates the rapid achievement of satisfactory anesthesia if urgent cesarean delivery is required. We usually do not include epinephrine in the local anesthetic solution because an unintentional intravascular injection of epinephrine can produce maternal tachycardia, and the systemic absorption of epidural epinephrine increases the likelihood of maternal hypotension. Treatment with ephedrine increases maternal heart rate, which increases myocardial oxygen demand and may aggravate myocardial ischemia. For this reason, phenylephrine is the preferred vasopressor for treatment of hypotension in patients with ischemic heart disease. LABOR A continuous epidural infusion technique facilitates hemodynamic stability during labor. Continuous spinal anesthesia may be used safely, but the placement of a large-gauge catheter is associated with a high incidence of postdural puncture headache (PDPH). Single-shot spinal anesthesia results in a rapid onset of sympathectomy and an increased risk of severe hypotension. Continuous epidural anesthesia is the preferred technique for cesarean section. [71] [72] It is reasonable to use local anesthetic solutions without epinephrine such as 0.75% ropivacaine or 0.5% levobupivacaine. When general anesthesia is required, a modified rapid-sequence induction (e.g., using etomidate, remifentanil, and succinylcholine) can be performed over 1 to 2 minutes without compromising hemodynamic stability. CESAREAN SECTION These women remain at increased risk for cardiovascular instability (myocardial infarction, pulmonary edema) after vaginal or cesarean delivery. Thus we often maintain an epidural infusion of a dilute solution of local anesthetic during the immediate postpartum period to achieve a partial sympathectomy, which decreases the effective intravascular volume and therefore decreases the risk of postpartum pulmonary edema. We monitor the patient in an obstetric intensive care setting for at least 24 hours after delivery. Cardiology consultation is helpful for postpartum management. Copyright © 2008 Elsevier Inc. All rights reserved. - to Colleague Print Version

35 ENFOQUE EVALUACIÓN DEL RIESGO PLANIFICACIÓN OPTIMIZACIÓN
DEFINIR LA SITUACIÓN OBSTETRICA

36 RESUMEN RIESGO SEVERO LESION ESTENOTICA VI
NECESIDAD DE ANTICOAGULACIÓN HTP SEVERA EISSENMENGER INSUFICIENCIA PULMONAR SEVERA FUNCIÓN SISTOLICA VD ELEVACIÓN BNP

37 Kee W D, Shen J, Chiu A T, Lok I, Khaw K S. Combined spinal-
epidural analgesia in the management of labouring parturients with mitral stenosis. Anaesth Intensive Care 1999; 27: 523–526. 23. Van de Velde M, Budts W, Vandermeersch E, Spitz B. Continuous spinal analgesia for labor pain in a parturient with aortic stenosis. Int J Obstet Anesth 2003; 12: 51–54.


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