Anaesthetic management and non-invasive monitoring for Caesarean section in a patient with cardiomyopathy

Abstract

Peripartum cardiomyopathy (PPCM) is defined as the development of heart failure in the last trimester of pregnancy or up to the sixth postpartum month. There is absence of demonstrable heart disease prior to the last trimester and no aetiology can be found.l'2The major concerns in a patient with PPCM during Caesarean section are to optimise fluid administration and to avoid factors which may cause myocardial depression. Appropriate haemodynamic monitors shoutd be employed and chosen according to the clinical condition of each patient. Our criteria for selecting a non-invasive monitoring technique arc described in the following Case Report.

Anesthetic management for caesarean section in a case of peripartum cardiomyopathy

“…Previously, successful outcome using only non-invasive monitoring has been reported. [9] We used dopamine throughout the surgery and gradually tapered and stopped it over twenty four hours post-operatively. Its positive inotropic, chronotropic and vasoconstrictive effects make it suitable for management of adverse cardiovascular effects of anesthesia.…”

Case Report and Mini Literature Review: Anesthetic Management for Severe Peripartum Cardiomyopathy Complicated with Preeclampsia Using Sufetanil in Combined Spinal Epidural Anesthesia

“…Induction of labour is considered if patient's condition worsens despite maximal medical management 5,9,21,28,37. Labor analgesia is favored because of its ability to reduce sympathetic stress response of labor pain 5,42,61,62. Although a graded epidural is most often used for labor analgesia in PPCM,5,41,61 combined spinal epidural (CSE) and continuous spinal analgesia (CSA) may be better choices (the reasons for this are described later) 5,26,41,42,61.…”

“…These patients will need to be monitored in the ICU for the initial 2-3 postoperative or post-delivery days due to increased risk of pulmonary edema caused by fluid overload and post-anesthetic cardiac dysfunction 5,6,12,20,35,37,44. NYHA class III or IV patients require ICU admission for aggressive management with invasive monitoring, ionotropic, mechanical circulatory and ventilatory support, and ECMO for preoperative optimization 2,5,20-23,26,28,37,41,60,62. Apart from classical inotropes, inodilators like dobutamine, amrinone, milrinone, enoximone and levosimendan may be beneficial in selective cases 5,22,29,30,37,59,60…”

“…Cesarean sections in PPCM patients have been performed under general as well as regional anesthesia 21-24,26,39,41,42,45,57,62. General anesthesia is mostly used in emergency surgery or when regional anesthesia is contraindicated,12,21,22,28,39,41,42 and it offers the advantage of controlling airway and ventilation 5,26,42,61.…”

Anesthesia in pregnancy with heart disease

“…Successful outcome was achieved with epidural anesthesia and noninvasive hemodynamic monitoring for cesarean delivery. [107] In another report wherein cardiomyopathy presented atypically, a parturient with no history or physical signs of heart disease suffered a cardiac arrest at induction of GA for emergency cesarean delivery. [108] After resuscitation and delivery of the child, the diagnosis was confirmed by echocardiography, but no etiology for the cardiomyopathy was determined.…”