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Anaesthetic management of obstetric patient for heart disease.

Anaesthetic management of obstetric patient for heart disease. SPEAKER DR. PRAGATI NANDA. MODERATOR DR. SANJEEV ANEJA. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Case presentation. 29yr F resident of massigarh village. c/c amenorrhea x 8 months.

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Anaesthetic management of obstetric patient for heart disease.

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  1. Anaesthetic management of obstetric patient for heart disease. SPEAKER DR. PRAGATI NANDA. MODERATOR DR. SANJEEV ANEJA. www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. Case presentation. • 29yr F resident of massigarh village. • c/c amenorrhea x 8 months. • Incresing breathlessness x 3 months. • HOPI ; 3 months back breathless on exertion now on less than ordinary activity. • Complains of anxiety and problem in breathing at night for which she goes to window to breath fresh air. • H/O palpitation off and on .

  3. No H/O chest pain, dizziness. No H/O pain abdomen, sweating. H/o swelling feet present but that is relieved on rest. No H/o dysphagia or hoarseness of voice. No H/o tender pulp of fingers, pigmentation of palm and soles or haematuria.

  4. H/o first trimester; No H/o exessive nausea and vomiting. No H/o fever , cough or diarrhoea. No H/o x-ray expossure, drug administration or blood transfusion. H/o second and third trimester; H/o quickning at 5th month. H/o 2 doses of tetanus toxoid. H/o increasing breathlessness. No H/o headache, blurring of vision, epigastric pain. No H/o bladder and bowel trouble. No H/o bleeding or leaking p/v.

  5. Past history; • When patient was 7 yr old, she sufferd from fever and sore throat,assosiated with joint pains in elbow and knee joints and skin pigmentation on abdomen.subsided on its own. No h/o hospitalisation or injections every 3 wk. • No h/o TB, DM, HTN, Seziure, asthma, drug allergy or surgery in the past. • Obs history; G1 P1 A0 with POG 36 wk.

  6. Menstural history; • DLMP; NK. • Menarche at 13 yr. • Normal cycles;4-5 days every 28 days,regular. • No h/o dysmenorrhoea or menorrhagia. • Personal history; • School teacher, non alcoholic, nonsmoker, nonvegetarion. • Drug history; Tab. Fersolate OD. • Tab. Shelcal OD

  7. GPE; GC fair ,moderately build , moderately nourished, comfortably lying in bed. • Ht. 5’2. wt.78 kg. • P+, I-, Cl-, Cy-, LAP-, PO+, JVP-NR. • PR-96/min in R radial a. regular, good volume, no radio femoral delay. • BP-108/86 mmhg in R arm,supine pt. • Chest- B/L air entry equal and clear.

  8. CVS-; Inspection; precordium smooth and symetrical. Apex beat-4 ICS. 2.5 cm lat. to mid clavicular line. No other pulsations,dialated veins or scar marks. Palpation; Apex beat ;tapping. Parasternal heave +. Palpable P2 in 2nd L ICS. No thrill +. Percussion;base- 2nd ICS. Apex-4th ICS Auscultation; loud s1,mid diastolic rumbling murmer with presystolic accentuation,heard in left lateral position. Intensity increased with hand grip. Os could not be appreciated.

  9. Airway examination; MO adeqate. • MPG; 2, neck movements normal, TM jt. Movement normal. • Breast; B/L symetrical. Montogmery tubercles +. S/C veins visible. • No hepatospleenomegaly. • P/A; INSPECTION; utreus – uniformlydistended. Umblicus centrally placed and inverted. No scar marks ,lenia nigra + . Stria gravidarum +.

  10. Palpation; ut. Relaxed. 36 wk size. • Fundal grip; broad, soft, irregular part-breech. • Lat. Grip; Rt.- Smooth ,curved ,resistant-back. • Lt.-knob like parts –limbs. • Pelvic grip; smooth , hard globular-head. Not engaged. • SFH; 36cm. • Abd. Girth; 74 cm. • Auscultation; FSH; 140/min on rt. Side.

  11. 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.

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

  13. 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.

  14. 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 preasence of essential criteria.

  15. Pathophisiology of MS.

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

  17. 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.

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

  19. X-ray findings • straightening of left heart • Double atrial shadow. • Kerly B lines. • Pulmonary edema.

  20. ECHOCARDIOGRAPHY • Diagnostic mainstay. • Anatomy of valve; hockey stick appearance. • Stenosis severity; • 1.doppler echo; pressure gradient ∞ 4v² • [v=transmitral flow velocity] • 2. valve area = 220/pressure T½ • [press T½ is time taken in decrease of peak velocity to v/ Г2.] • Suitability of BMV. • Assosiated lesions,EF, LV function.

  21. 5. cardiac cathetrisation; when noninvasive data and clinical picture are discordant. • gorlin’s equation; • Valve area = flow/ k x Гmean transvalv. Gr. • [flow = SV/diastolic time , k =press constant] • 6. P-V LOOP

  22. MEDICAL MANAGEMENT • 1. DIURETICS; ↓ preload ,decongest lungs. • 2. DIGOXIN; ↓HR hence ↑LV filling. ↑LA contractility . • 3.AF with sudden decompensation ; DC Cardioversion or verapamil. • 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.

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

  24. Management of pregnancy. • Addmission; • 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. • Rapid digitalisation;0.25mg ----0.1mg/hr slow iv. • Antibiotic prophylaxis ampicillin 2g iv and Gentamycin 1.5mg/kg iv on onset of labour and after 8 hr.

  25. 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.

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

  27. Haemodynamic goals. • 1.AVOID TACHYCARDIA;[to maintain diastolic time] Continue digoxin Treat pain adequately Avoid light GA, hypercarbia, acidosis. IV Propranolol 0.5mg increments if required.

  28. 2.AVOID MARKED ↓ IN SVR. [to avoid compensatory tachycardia.] Prefer Epidural over spinal anaesthesia. Metraminol infusion[ 10mg in 250ml ] or Intermittent Phenylephrine. Avoid ephedrine as it may cause tachycardia.

  29. 3.AVOID MARKED ↑ IN CENTRALBLOOD VOLUME. [ppt RVF,PHT,AF.] Monitor CVP/PCWP. IV Frusemide Judicious use of Oxytocin.

  30. 4. AVOID INCREASE IN PVR.[ppt RVF] Avoid hypoxia, hypercarbia, acidosis, lung hyperinflation. If PHT and RV compromise exist; Dopamine 3-8 mic/kg/min. Sodium Nitroprusside 0.1-0.5 mic/kg/min.

  31. 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.

  32. 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.

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

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