Anesthetic management and outcomes of parturients with dilated cardiomyopathy in an academic centre

Abstract

Purpose This study examines the peripartum anesthetic management and outcomes of women with dilated cardiomyopathy in a large university medical centre over a seven-year period. Principal findings Twenty-five women were included in this series, 18 with a new diagnosis of cardiomyopathy and seven with a history of cardiomyopathy. Sixteen patients (64%) identified themselves as African American, seven (28%) were Caucasian, and two patients (8%) were Hispanic. The median (range) gestational age at the time of a new diagnosis of cardiomyopathy was 29 (7-38) weeks. Eight women (32%) had New York Heart Association class III/IV symptoms at the time of delivery or in the immediate postpartum period. A multidisciplinary team of obstetricians, anesthesiologists, cardiologists, and pediatricians were involved in the care of these women. The median (range) gestational age at the time of delivery was 33.5 (30-40) weeks. There were nine vaginal deliveries and 15 operative deliveries. One patient had fetal loss at 19 weeks gestation. Twelve women had labour induced with an intravenous infusion of oxytocin at a rate of 0.001-0.02 IUÁmin -1 . An oxytocin infusion at a variable rate with a maximum dose of 0.05 IUÁmin -1 was administered after vaginal delivery to maintain uterine tone. Epidural analgesia was initiated prior to induction of labour or in the latent phase of labour. Seven Cesarean deliveries were performed under combined spinal-epidural anesthesia, five were performed under epidural anesthesia, and three women had general anesthesia. Oxytocin was administered via an intravenous infusion at a rate of 0.05-0.2 IUÁmin -1 after operative delivery. One patient had a cardiac arrest on induction of general anesthesia and was successfully resuscitated. There were no maternal or neonatal deaths. Ten women were followed up at our institution and at six months postpartum; 50% of these patients were still symptomatic. Conclusion We report favourable outcomes in 25 pregnant women with dilated cardiomyopathy who were managed by a multidisciplinary team. Résumé

Peripartum cardiomyopathy: a systematic literature review

“…The majority of PPCM cases are diagnosed postpartum, but in case of heart failure during pregnancy, delivery must be managed. Data are, however, very few and originate from heterogeneous populations of women with several different heart diseases , which stresses the importance of individual decisions on timing, mode and management of delivery made by a multidisciplinary team of experienced obstetricians, cardiologists and anesthesiologists. A hemodynamically unstable woman in acute severe heart failure and in need of inotropics and/or invasive therapy may require emergent delivery by cesarean section , but in a stabilized woman where fetal well‐being can be confirmed by ultrasound, early delivery may not be necessary and vaginal delivery is an option to consider .…”

The peripartum anesthesiologist

“…This report by Ituk et al 7 highlights the lack of available information on the diagnosis and management of PPCM. In the present case series, the authors used the Duke Heart Disease in Pregnancy Registry and an electronic anesthesia database to identify patients.…”

“…In summary, this case series by Ituk et al 7 provides the largest case series available on the management and outcomes of pregnant patients with dilated cardiomyopathy. Due to the infrequent nature of this disease, multicentred observational studies are required to help delineate proper management, risk factors, and outcomes.…”

“…3,4 Delivery of the fetus is usually indicated when the cardiac failure is intractable. 3 In this month's edition of the Journal, Ituk et al 7 report on the peripartum anesthetic management and outcomes of 25 women with dilated cardiomyopathy -four of whom were designated as having PPCM. With an average age of 32 and a history of hypertension and diabetes, these patients represent a higher risk group than the overall obstetrical population, which is in keeping with previous reports of PPCM risk factors.…”

“…7 constitue la plus grande série de cas disponible sur la gestion et l'évolution de patientes enceintes porteuses de cardiomyopathie dilatée. Compte tenu de la rareté de cette maladie, des études observationnelles multicentriques sont nécessaires pour contribuer à en déterminer correctement la gestion, les facteurs de risque et les aboutissements.…”