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PERIPARTUM ANESTHETIC MANAGEMENT OF PATIENTS WITH HEART DISEASE IN A SINGLE INSTITUTION IN MEDELLIN, COLOMBIA, SOUTH AMERICA.
Abstract Number: 245
Abstract Type: Case Report/Case Series
Cardiac disease is becoming more common in women presenting for obstetric care and is a cause of maternal mortality.
Retrospective chart review of 37 obstetric patients admitted to high dependency unit(HDU), between October 2005 and December 2009. We did a classification based in CARPREG stratification risk and included peripartum cardiomyopathy(PPCM) patients.
The average data were: age 27 years old (18-42)and gestational age of 36 weeks (9-39).The main diagnoses were congenital heart disease (Table 1), valvular heart disease (Table 2) and 5 patients with PPCM. Mode of delivery: 35% cesarean section (CS): 23% general anesthesia(GA), 30% spinal anesthesia (SA), 37% combined spinal/epidural anesthesia (CSE) and 8% epidural anesthesia (EA).59% were vaginal delivery (VD) under epidural analgesia and 6% needed curettage under GA. 64.8% required invasive hemodynamic monitoring. Early low dose epidural analgesia/CSE for labor was used. Epidural or spinal morphine were used for post cesarean analgesia. The indication for GA was severe ventricular dysfunction in PPCM. Complications included pulmonary edema in one patient, cardiogenic shock in two patients, acute renal failure in one patient and arrhythmias in five patients, one of them associated to sudden death that required a transvenous pacemaker; Two patients required prolonged mechanical ventilation. Five patients were transferred to a cardiac intensive care unit(ICU). There were no maternal deaths.
The main complications in our report appeared in patients with PPCM associated to severe compromise in ventricular function, NYHA III-IV and right ventricular dysfunction. Our anesthetic management focuses on achievement of hemodynamic goals, careful titration of regional anesthesia and rational use of vasopressors. GA was reserved for patients with severe impairment of ventricular function and NYHA IV; the other patients were managed with regional anesthesia included Eissenmenger`s syndrome one. In high risk patients, we use invasive blood pressure and CVC; Pulmonary artery catheter was reserved for severe impairment of ventricular function.We apply a strict protocol for post cesarean analgesia to allow early mobilization;infective endocarditis and thromboembolic prophylaxis protocols are used in high risk patients;anticoagulation was used in Eissenmenger syndrome patients and PPCM with severe left ventricular dilation.
REFERENCES: Circulation 2001;104:515-21