Adult congenital heart disease and pregnancy

Abstract

There is an increasing number of women with congenital heart disease surviving to childbearing age, with more complex conditions. Women with adult congenital heart disease may tolerate the physiological changes of pregnancy poorly, and can deteriorate at any point, including postpartum. Such women should be counselled of the risks of pregnancy with their condition, and be managed by a specialist multidisciplinary team. Early epidural and a 'low cardiac output' approach allows many women to achieve a normal delivery, but others may require Caesarean section to prevent deterioration in labour. Caution is advised with the commonly used uterotonic drugs. Cardiac disease has remained the leading cause of maternal mortality since the 2000e2002 triennium. Between 2009 and 2014 the deaths of 189 women who died from heart disease associated with, or aggravated by, pregnancy were reported by MBRRACE-UK (Mothers and Babies: Reducing Risk through Physiological changes of pregnancy Pregnancy induces changes in the cardiovascular system to meet the increased metabolic demands of the mother and fetus 5,6 : (i) total blood volume increases by 45% on average; (ii) cardiac output (CO) increases by 30e50%, peaking in the second trimester; (iii) heart rate rises progressively, peaking in Luke Bishop MB ChB FRCA is an advanced trainee in obstetric anaesthesia.

Low Dose Spinal Anesthesia in Pregnant Patient with Eisenmenger Syndrome undergoing Caesarean Section

“…Autotransfusion of uterine contractions postpartum can improve cardiac output approximately 25% resulting in an increase in pulmonary artery pressure and trigger heart failure and arrhythmias. 3,7,12,13 Anesthetic considerations in this patient are maintaining SVR, intravascular volume, preventing aortocaval compression, pain, hypoxemia, hypercarbia, and acidosis; therefore, pulmonary artery pressure does not increase and prevent myocardial depression. The recommended choice of anesthetic technique is epidural anesthesia or combined spinal epidural anesthesia rather than general anesthesia which is more risk of causing myocardial depression and decreased preload due to positive pressure ventilation.…”

Late diagnosis of Ebstein anomaly after pregnancy: A rare case report

“…The latter complication of atrial transient reversal shunt has a 14% risk of paradoxical embolus (Hakman & Cowling, 2022). In the postpartum, the increased plasma volume may persist due to autotransfusion from uterine involution and edema resorption (Bishop et al, 2018). She was one year after delivery, and the symptoms of heart failure worsened.…”

Pregnancy Management in a Patient With Congenital Heart Disease and Severe Right Ventricle to Pulmonary Artery Conduit Stenosis

“…General anesthesia is often avoided in patients with RV dysfunction because all induction and inhalational agents, apart from etomidate, tend to reduce RV contractility, and mechanical ventilation increases pulmonary vascular resistance. 20 Also, for patients undergoing a planned cesarean section, regional anesthesia is preferred to general anesthesia. For patients with ACHD, the regional block can be started initially with a spinal approach and gentle titration of epidural block to minimize hemodynamic instability.…”

“…For patients with ACHD, the regional block can be started initially with a spinal approach and gentle titration of epidural block to minimize hemodynamic instability. 20 With obstruction of the RV outflow, reducing catecholamine release and subsequent stress on the RV is imperative.…”