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Acta Anaesthesiol Scand 2010; 54: 46–54 r 2009 The Authors

Printed in Singapore. All rights reserved Journal compilation r 2009 The Acta Anaesthesiologica Scandinavica Foundation

ACTA ANAESTHESIOLOGICA SCANDINAVICA


doi: 10.1111/j.1399-6576.2009.02080.x

Regional anaesthesia for a Caesarean section in women


with cardiac disease: a prospective study
E. LANGESÆTER, M. DRAGSUND and L. A. ROSSELAND
Division of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway

Background We conducted a prospective observational patients (18 emergencies), general anaesthesia in eight
survey of pregnant women with cardiac disease. The aim patients (five emergencies), and a planned vaginal deliv-
was to analyse and present the mode of delivery, outcome, ery in 44 patients. There was no mortality among the
and haemodynamic changes during a caesarean section mothers or the babies during the hospital stay or 6 months
under regional anaesthesia in women with cardiac disease. postpartum. Pre-operative cardiovascular stability during
Methods All pregnant women with a cardiovascular diag- the caesarean section was maintained by volume and
nosis, except hypertension, were included in the registry. phenylephrine infusion guided by invasive monitoring of
Based on the cardiac diagnoses, and on the New York haemodynamic variables.
Heart Association classification, a multidisciplinary group Conclusion Our study suggests that pregnant women with
made recommendations for each patient and decided on cardiac disease may safely deliver the baby by a caesarean
the mode of delivery. The data from continuous, invasive section under regional anaesthesia. According to our find-
haemodynamic monitoring in intermediate- and high-risk ings, haemodynamic stability can be obtained by titrated
patients under regional anaesthesia for a caesarean section regional anaesthesia, intravenous (i.v.) volume, pheny-
were analysed and presented. lephrine infusion, and small repeated doses of i.v. oxytocin
Results The hospital had approximately 9000 deliveries in guided by invasive monitoring.
the period from November 2003 to April 2008. A total of
113 pregnancies in 107 women were included. Thirty-two
Accepted for publication 25 June 2009
(28.3%) pregnancies were classified into the high-risk
category. Of 103 deliveries, caesarean sections were per- r 2009 The Authors
formed in 59 (52.2%) cases, with regional anaesthesia in 51 Journal compilation r 2009 The Acta Anaesthesiologica Scandinavica Foundation

T HE number of pregnant women with heart


disease is increasing. Information regarding
the incidence and epidemiology is highlighted in
Rikshospitalet is a national centre for congenital
heart surgery in Norway and a tertiary centre for
pregnancy disorders. The majority of women with
the UK registry of high-risk anaesthesia,1 and in the a high-risk pregnancy due to heart disease are
Confidential Enquiries into Maternal Deaths in the transferred to our hospital from all other delivery
United Kingdom.2,3 Maternal mortality in women departments in Norway.
with cardiac disease has increased from 7.6 per We have conducted a prospective observational
million pregnancies in 1980 to 22 per million in the survey of pregnant women with cardiac disease in
period 2000–2002.4 Cardiac disease is now the most our department from November 2003 to April 2008.
common cause of indirect deaths as well as of The aim of the study was to analyse and present
maternal deaths overall.3 In general, vaginal deliv- the management, mode of delivery, haemodynamic
ery has been recommended,5,6 but arguments have changes, and outcome during a caesarean section
been put forward for a more frequent use of a under regional anaesthesia in women with cardiac
caesarean section.7 There have been a number of disease.
case reports, but only a few studies on the anaes-
thetic techniques, monitoring, and practical man-
agement of these high-risk patients have been
Materials and methods
conducted.4,8 No relevant randomized clinical The protocol for the study was approved by The
trials have been published. Regional Medical Research Ethics Committee for

46
Caesarean section in women with cardiac disease

Southern Norway, and the patients gave written (CO), lithium chloride 0.3 mmol is injected through
informed consent. All pregnant women with a a peripheral line and the lithium is detected by a
cardiac diagnosis who delivered at Rikshospitalet lithium ion-sensitive external electrode connected
from November 2003 to April 2008 were included. to a peripheral arterial line. The lithium dose has
Parturients with only chronic hypertension or no pharmacological effect on the woman or the
pregnancy-induced hypertension were not in- foetus.12 The LiDCOPlus gives continuous blood
cluded. The database included information about pressure and a beat-to-beat measurement of CO,
patient history, cardiac diagnosis and treatment, stroke volume (SV), and systemic vascular resis-
functional classification according to the New York tance (SVR).13 We started to use this monitor in our
Heart Association (NYHA), and echo cardiogra- anaesthetic department in 2005. The CO monitor
phy.4,9,10 The patients were classified as high, inter- has been validated in other patient groups,14 and in
mediate, or low risk based on guidelines in the the last year there have been publications on its use
publications by Siu and Colman,6 and Dob and in pregnant women.15–17
Yentis.11 The NYHA classification was based on a A prophylactic low-dose phenylephrine infusion
standardized exercise test. The women walked up and cohydration with crystalloids was part of a
a stairway, with continuous monitoring of heart standard protocol for preventing haemodynamic
rate and oxygen saturation, and stopped when they instability during a caesarean section, based on
felt the need, due to dyspnoea. The exercise test data from healthy women.17 Haemodynamic in-
was repeated during the pregnancy in intermedi- stability was defined as a decrease in CO to levels
ate- and high-risk patients. below 70% of the baseline, and systolic blood pres-
In the beginning, in November 2003, there was no sure (SBP)o90 mmHg, until s
delivery of the baby.
organized multidisciplinary group, but this devel- Oxytocin (Syntocinon , Novartis, Copenhagen,
oped during the survey period. From 2005, a multi- Denmark) used to be given as boluses of 5 U, which
disciplinary team of cardiologists, obstetricians, was the standard dose in our department in 2003.
obstetric anaesthetists, and a cardiac anaesthetist The use of oxytocin changed during the study
have had regular meetings to discuss all pregnant period. We reduced the dose to repeated boluses
women with a cardiac diagnosis planned for deliv- of 0.5 U in the beginning of the study. Based on the
ery in our hospital. This group decided on the two studies by Carvalho and colleagues18,19, and
individual recommendations for each patient in- our own experience, we reduced the dose further to
cluding whether the woman should have a planned 0.1 U, repeated until there was an adequate effect
caesarean section or a vaginal delivery. This decision on uterine contractions.
was based on an individual assessment of the risk We registered the mode of delivery and anaes-
group. Central in the evaluation of the recom- thetic technique during a caesarean section, use of
mended method of delivery was the functional phenylephrine, use of oxytocin, bleeding, haemo-
classification according to NYHA. Our routine strat- globin concentration pre- and post-delivery, need
egy in most high-risk patients was to deliver by an for transfusion, and the maternal outcome in all
elective caesarean section with regional anaesthesia, patients 6 months postpartum. The Apgar score
unless there were contraindications such as antic- and umbilical venous and arterial pH were re-
oagulation. Patients with a previous uncomplicated corded for all the babies.
vaginal delivery were considered for vaginal deliv- The haemodynamic data were stored in the LiD-
ery, even in the high-risk group. COPlus-monitor and downloaded as csv files (text
Standard routine monitoring for an elective cae- files) for each patient. Construction of the data set
sarean section was an arterial line in all high- and was performed using MATLAB version R2007a (The
intermediate-risk patients. In addition to invasive MathWorks, Natick, MA). Outliers were removed,
blood pressure, we measured haemodynamic vari- and the beat-to-beat data set was constructed using a
ables using LiDCOPlus (LiDCO Ltd, Cambridge, centred moving average of 30 observations.
UK), which is a monitor that provides continuous
haemodynamic measurements. This new mini-
mally invasive technique is based on two methods: Results
a continuous arterial waveform analysis system
(PulseCO) coupled to a single-point lithium indi- Patients
cator dilution calibration system (LiDCO). For the Our obstetric department at Rikshospitalet had
calibration to measure the actual cardiac output approximately 9000 deliveries from November

47
E. Langesæter et al.

2003 to April 2008. We included 113 pregnancies in Table 3


107 women with heart disease in this period. Cardiac diagnosis and risk classification.
Patients who were transferred from other hospitals
Diagnosis High risk Medium risk Low risk Total
after delivery, because of cardiac disease, were not
Cardiomyopathy
included. There were 32 high-risk patients, 31 Dilated 10 0 1 11
patients with an intermediate risk, and 50 patients HOCM 2 2 1 5
in the low-risk group. Table 1 shows descriptive HCM 0 0 4 4
AS/AI/AVR 1 6 2 9
data on the 103 parturients (the 10 abortions are not MS/MI/MVR 1 5 12 18
included). The characteristics of the newborn are PI/PS 2 2 5 9
shown in Table 2. Diagnoses and risk groups are PHT 4 1 0 5
shown in Table 3. Eisenmenger 3 0 0 3
Heart; tx 0 1 1 2
Ten patients had an abortion. Four high-risk ASD 1 0 3 4
patients were advised to terminate the pregnancy. VSD 0 0 3 3
Two patients with Eisenmenger syndrome and one CoA 2 1 0 3
TGA, mustard 3 4 0 7
patient with hypertrophic obstructive cardiomyo- Fallot’s tetrade 0 6 4 10
pathy (HOCM) had a surgical abortion with a low- Arrhythmias
dose spinal anaesthesia. One patient with severe LQTS 0 0 6 6
VT/WPW/AF 0 0 9 9
myocarditis had a medical abortion using miso- Myocarditis 1 0 0 1
prostol. TAA 0 1 0 1
Following the multidisciplinary assessment, 48 Coronary disease 1 0 0 1
Ebstein anomaly 0 1 0 1
patients were scheduled for an elective caesarean Double-chamber RV 0 1 0 1
section and 55 patients were planned for a vaginal Total N 32 31 50 113
delivery. Eleven of the planned vaginal deliveries
HOCM, hypertrophic obstructive cardiomyopathy; HCM, hyper-
ended as an emergency caesarean section, and 12 of trophic cardiomyopathy; AS/AI/AVR, aortic stenosis/aortic in-
the planned caesarean section had to be conducted sufficiency/aortic valve replacement; MI/MS, mitral insufficiency/
earlier than planned due to obstetric indications. In stenosis; MVR, mitral valve replacement; PI/PS, pulmonary
insufficiency/stenosis; PHT, pulmonary hypertension; ASD/
several high-risk patients, there were no changes in VSD, atrial/ventricular septal defect; TAA, thoracic aortic anuer-
the findings on repeated echocardiography, ism; CoA, aortic coarctation; TGA, transposition of the great
although the patient’s functional capacity wor- arteries; LQTS, long QT syndrome; VT, ventricular tachycardia;
WPW, Wolff–Parkinson–White syndrome; double-chamber RV,
sened during the pregnancy judged by the exercise double-chamber right ventricle.
tests.

Table 1
Patient characteristics.* Table 4

Age 30.5 (20.0–42.5) Delivery and anaesthesia (emergency C-section in bracket).


GA 37.6 (24.9–42.5) Total: 113 High risk Intermediate Low risk
Weight (kg) 77.6 (40.0–130.0) risk
Height (cm) 167 (150–179) (n 5 32) (n 5 31) (n 5 50)
BMI (kg/m2) 27.9 (17.8–42.4)
Mode of delivery
Data are presented as mean (range). C-section (n 5 59) 23 (8) 16 (7) 20 (8)
*Ten women having an abortion, were not included. Vaginal delivery (n 5 44) 5 11 28
GA, gestational age; BMI, body mass index. Abortion (n 5 10) 4 4 2
Anaesthesia
General anaesthesia 5 (4) 2 (1) 1
Regional anaesthesia 18 (4) 14 (6) 19 (8)
Table 2
Characteristics of the newborn.
Apgar 1 9 (2–10) Regional anaesthesia was administered in 51
Apgar 2 9 (6–10) patients (18 emergencies), and general anaesthesia
Umbilical vein pH 7.34 (6.98–7.46)
Umbilical artery pH 7.27 (6.97–7.39) in eight patients (five emergencies) of a total of 59
Birth weight (g) 3084 (1300–4590) caesarean sections (57.3% of the deliveries) (see
Table 4). Twenty of the 23 emergency caesarean
Data are presented as median (range) for Apgar score or mean
(range) for pH and birth weight. Apgar 1: Apgar score after 1 sections were for an obstetric indication. In the
min; Apgar 2: Apgar score after 5 mins. high-risk group, 82.1% had a caesarean section.

48
Caesarean section in women with cardiac disease

Anaesthetic technique changes induced by regional anaesthesia without


All elective caesarean sections were performed any clinical deterioration.
with regional anaesthesia apart from three cases
on anticoagulation therapy. Standard doses of
spinal anaesthesia with bupivacaine plain 8– Use of oxytocin
10 mg and sufentanil 5 mg or fentanyl 20 mg were Oxytocin decreases SVR and increases CO.21 In this
administered using spinal or a combined spinal– heterogenic patient group the haemodynamic ef-
epidural (CSE) technique in 49 cases. One patient fects of small doses of oxytocin will differ from
had an epidural top-up for an emergency caesarean patient to patient, but given in small titrated doses,
section, and one patient with severe peripartum the haemodynamic changes were minor and tran-
cardiomyopathy had a spinal catheter for contin- sient without aggravating any symptoms. Only one
uous spinal anaesthesia. Eight patients had general patient (Fig 1; patient 3) had a short period of
anaesthesia with Pentothal and Suxamethonium as dyspnoea after oxytocin 0.1 U. The haemodynamic
part of a rapid sequence induction.20 None of the effects of oxytocin in 24 high- and intermediate-risk
patients receiving regional anaesthesia needed con- patients are shown in Fig. 1. These patients were
version to general anaesthesia. One patient with administered boluses from 0.05 to 0.5 U oxytocin i.v.
CSE had a local anaesthetic skin infiltration and
fentanyl intravenous (i.v.) while waiting for the
epidural top-up to have effect. Outcome
There was no maternal or child mortality after 6
months. The Apgar scores were 2 and 6 at 1 and 5
min, respectively, in one baby whose mother had
Invasive haemodynamic monitoring an HOCM and pulmonary hypertension. She had
Arterial line monitoring of blood pressure was an emergency caesarean section due to circulatory
used in 49 patients during a caesarean section, in ‘collapse’ in the operation theatre while inserting a
four vaginal deliveries, and in six abortions. Thir- central venous catheter, during the preparation for
teen patients for a caesarean section had a central regional anaesthesia, and before inserting an arter-
venous catheter inserted. Six patients had a pul- ial line. Probably, the combination of anxiety, over-
monary artery catheter. We used the LiDCOplus in night fasting, and inferior vena cava compression
33 patients during a caesarean section. Hypoten- resulted in bradycardia and unconsciousness. She
sion was prevented and treated with an i.v. crystal- was dependent on a high heart rate of 120/min
loid solution and phenylephrine infusion. The with a low SV due to severe hypertrophic myocar-
median requirement of phenylephrine in all cae- dium (septum 43 cm). An emergency caesarean
sarean section patients peri-operatively was 140 mg section was performed under general anaesthesia
(0–1960 mg). Twenty of the 59 patients for a caesar- and both the mother and the baby survived. A
ean section had no phenylephrine. The haemody- second patient with a subvalvular aortic stenosis
namic changes during regional anaesthesia in 24 was haemodynamically stable during a caesarean
intermediate- and high-risk patients are shown in section with CSE anaesthesia (see Figs 1–3). She
Fig. 1. Two patients (patients 6 and 14) had an SBP died 7 months postpartum after a cardiac re-opera-
below 90 mmHg for a short period. Three patients tion when she suffered a post-operative coronary
(patients 14, 20, and 24) had a decrease in CO infarction with heart failure. A third patient, with a
below 70% of the baseline. In patient 2, the changes severe heart failure due to peripartum cardiomyo-
in CO and SBP at 18 min were due to an artefact pathy (ejection fraction 15–20%, left ventricle 9 cm,
caused by temporary technical problems with the heart rate 150/min), was haemodynamically stable
arterial line. Seven low-risk patients, one inter- during a caesarean section using continuous spinal
mediate-risk patient with general anaesthesia, and anaesthesia (see Figs 1 and 2). This patient had,
one intermediate-risk patient with technical pro- prophylactically, an introducer for an intra-aortic
blems with the arterial line are not displayed. The balloon pump (IABP), and an introducer for pul-
haemodynamic changes in CO and SBP are pre- monary catheter. A pulmonary catheter was in-
sented after the start of regional anaesthesia when serted post-operatively. On the first post-operative
the patient was positioned in the left lateral tilt and day, she deteriorated and required treatment with
until delivery of the baby, including the effects of IABP and an i.v. infusion of nitroprusside. A
oxytocin. All patients tolerated the haemodynamic coronary angiography on the second day showed

49
E. Langesæter et al.

16 200 16 200 16 200


1. Eisenmenger 2. PPCM 3. Subvalv AS
14 180 14 180 14 180

SBP (mmHg)

SBP (mmHg)

SBP (mmHg)
12 160 12 160 12 160
CO (L/Min)

CO (L/Min)

CO (L/Min)
10 140 10 140 10 140
8 120 8 120 8 120
6 100 6 100 6 100
4 80 4 Oxy 0.05 80 4 80
Oxy 0.1 Oxy 0.1
2 60 2 60 2 60
16 200 16 200 16 200
4. PI 5. TGA 6. PPCM
14 180 14 180 14 180
12 160 12 12 160

SBP (mmHg)

SBP (mmHg)

SBP (mmHg)
160
CO (L/Min)

CO (L/Min)

CO (L/Min)
10 140 10 140 10 140
8 120 8 120 8 120
6 100 6 100 6 100
4 80 4 80 4 80
Oxy 0.5 Oxy 0.5 Oxy 0.5
2 60 2 60 2 60

16 200 16 200 16 200


7. AS/AI 8. PHT 9. ASD
14 180 14 180 14 180
160 160 160
SBP (mmHg)

SBP (mmHg)

SBP (mmHg)
12 12 12
CO (L/Min)

CO (L/Min)

CO (L/Min)
10 140 10 140 10 140
8 120 8 120 8 120
6 100 6 100 6 100
4 80 4 80 4 80
Oxy 0.5 Oxy 0.5 Oxy 0.2
2 60 2 60 2 60

16 200 16 200 16 200


10. MI, PE 11. AS/AI 12. STEMI
14 180 14 180 14 180
160 160 160
SBP (mmHg)

SBP (mmHg)

SBP (mmHg)
12 12 12
CO (L/Min)

CO (L/Min)

CO (L/Min)
10 140 10 140 10 140
8 120 8 120 8 120
6 100 6 100 6 100
4 Oxy 0.1 80 4 80 4 80
Oxy 0.1 Oxy 0.5
2 60 2 60 2 60

Fig. 1. This figure shows the changes in cardiac output (CO) and systolic blood pressure (SBP) during regional anaesthesia in 24 high- (1–
12) and intermediate- (13–24) risk patients during a caesarean section. The curves start at induction of anaesthesia. Time is shown on the
x-axis with a 2-min interval. Baseline for CO is marked on the left y-axis. Baseline for SBP is marked on the right y-axis. The arrow on the
x-axis marks the administration of oxytocin. PPCM, peripartum cardiomyopathy; Subvalv AS, subvalvular aortic stenosis; PI, pulmonary
insufficiency; TGA, transposition of the great arteries; AS/AI, aortic stenosis/aortic insufficiency; PHT, pulmonary hypertension; ASD,
atrial septal defect; MI, mitral insufficiency; PE, preeclampsia; STEMI, ST-elevation myocardial infarction; CoA, aortic coarctation; AVR,
aortic valve replacement; Heart tx, heart transplantation; Fallot, Tetralogy of Fallot; and TAA, thoracic aortic aneurism.

a dissection of the proximal left descending cor- Discussion


onary artery, which was stented. After 71 days she
had a successful heart transplantation and the Vasodilatation, a reduction in blood pressure, and
IABP was removed. Throughout this period she the risk of right to left shunting have been given as
did not need invasive respiratory support. reasons for not using regional anaesthesia in preg-
Eight patients needed a blood transfusion. The nant women with cardiac disease. In our opinion,
mean preoperative and post-operative haemoglo- the arguments against regional anaesthesia are not
bin concentrations were 11.9 (SD 1.4) and 10.8 (SD valid, and several case reports demonstrate a fa-
1.3), respectively, in the caesarean section patients. vourable outcome.22,23 The reduction in SVR after
The mean estimated blood loss was 500 ml (150– induction of spinal anaesthesia can be counteracted
2500) in the caesarean section group and 410 ml by giving smaller doses of spinal anaesthetic,
(150–2500) in the vaginal delivery group. One cohydration with crystalloids, and a concurrent
patient had a post-operative wound infection after infusion of phenylephrine.17 Phenylephrine is re-
a caesarean section. garded as safe for the baby and is the vasopressor

50
Caesarean section in women with cardiac disease

16 200 16 200 16 200


13. TAA 14. Ebstein 15. CoA
14 180 14 180 14 180

SBP (mmHg)

SBP (mmHg)

SBP (mmHg)
CO (L\Min) 12 160 12 160 12 160

CO (L/Min)

CO (L/Min)
10 140 10 140 10 140
8 120 8 120 8 120
6 100 6 100 6 100
4 80 4 80 4 Oxy 0.5 80
Oxy 0.5 Oxy 0.5
2 60 2 60 2 60

16 200 16 200 16 200


16. AVR 17. PI 18. Heart tx
14 180 14 180 14 180
160

SBP (mmHg)

SBP (mmHg)

SBP (mmHg)
12 160 12 160 12
CO (L\Min)

CO (L\Min)

CO (L\Min)
10 140 10 140 10 140
8 120 8 120 8 120
6 100 6 100 6 100
4 80 4 80 4 80
Oxy 0.1 Oxy 0.1 Oxy 0.1
2 60 2 60 2 60

16 200 16 200 16 200


19. Fallot PI 20. Fallot PI 21. AS/AI
14 180 14 180 14 180
SBP (mmHg)

SBP (mmHg)

SBP (mmHg)
12 160 12 160 12 160
CO (L\Min)

CO (L\Min)

CO (L\Min)
10 140 10 140 10 140
8 120 8 120 8 120
6 100 6 100 6 100
4 80 4 80 4
Oxy 0.1 Oxy 0.1 Oxy 0.1 80
2 60 2 60 2 60

16 200 16 200 16 200


22. MI 23. PI 24. Fallot PI
14 180 14 180 14 180
SBP (mmHg)

SBP (mmHg)

SBP (mmHg)
12 160 12 160 12 160
CO (L\Min)

CO (L\Min)

CO (L\Min)
10 140 10 140 10 140
8 120 8 120 8 120
6 100 6 100 6 100
4 80 4 Oxy 0.1 80 4 80
Oxy 0.1 Oxy 0.1
2 60 2 60 2 60

Fig. 1. Continued.

of choice during a caesarean section under a 550 mg compared with 140 mg in our study. The
neuraxial blockade in uncomplicated pregnan- lower dose of phenylephrine used in our study,
cies.24,25 Animal studies have shown that the use mainly using a single shot spinal and CSE techni-
of phenylephrine may not be as well tolerated in que, could be explained by the use of continuous
the compromised foetus.26 The impact of this in CO monitoring in our study to guide haemody-
clinical obstetric anaesthesia is questionable. Phe- namic stability and the need for a vasopressor.
nylephrine has a negative effect on maternal CO, From the start of this study, with no systematic
and the use of a vasopressor in haemodynamically routines, we now have regular multidisciplinary
compromised pregnant women should be guided group meetings to decide how to manage parturi-
with CO monitoring, as blood pressure alone often ents with cardiac disease. The major limitation of
gives a poor indication of tissue blood flow. Mon- this study is that the impact of different anaesthetic
itoring of CO is recommended in other patient methods on patient outcome cannot be analysed.
groups with circulatory derangements, and obste- During the study period, we have gained experi-
tric patients should be no exception.27 ence in invasive monitoring and how this can be
A recent publication showed that a titrated implemented in the treatment protocols in order to
spinal anaesthesia using a spinal catheter in preg- reduce haemodynamic instability during a caesar-
nant patients with mild to moderate signs of ean section under regional anaesthesia.
cardiac failure induced a symptomatic transient Compared with a recently published article from
hypotension in 18%.28 Their patients were moni- the United Kingdom29 with only 5% high-risk
tored with continuous invasive blood pressure. The patients in pregnant women with congenital heart
mean dose of phenylephrine used in this study was disease, nearly 30% of our patients were high-risk

51
E. Langesæter et al.

patients. This high proportion of severe cases may thesia or in case of an emergency caesarean section
reflect that our hospital is a tertiary centre for with no time for regional anaesthesia.
complicated pregnancies, and a national centre Blood loss during a caesarean section may be an
for congenital heart disease. overestimated risk factor in the debate concerning
International recommendations state that, with delivery. In this population, the median change in
few exceptions, these women should be planned pre-and post-operative haemoglobin was 1.1 g/dl.
for a vaginal delivery.4,6,11 Our practice differs from In two trials where the patients were randomized
this with 82% C-sections in the high-risk group. to a caesarean section or a vaginal delivery, there
The arguments against a caesarean delivery are the were no statistically significant differences in
higher risk of infection, bleeding, and anaesthetic bleeding between the two groups.34,35
complications. However, a vaginal delivery may The use of oxytocin is controversial. Some
increase the cardiovascular stress, even when opti- authors avoid i.v. oxytocin in pregnant women
mal pain relief is offered.30 There is sparse litera- with cardiac disease,36 and others administer oxy-
ture concerning the haemodynamic changes tocin as an infusion.11,36,37 However, the risk of
during vaginal delivery, especially during the sec- bleeding caused by uterine atony is also a major
ond stage, and this concern has not been a main concern. In this series we administered small in-
focus in previous papers discussing the mode of cremental doses of oxytocin until uterine tonus was
delivery in these high-risk patients. sufficient. We do not practice administering oxyto-
A planned caesarean section has, in our view, cin as an infusion, as recommended by others,11
many advantages in high-risk parturients, espe- because this may lead to an unnecessary volume
cially if the patient has not given birth before. One load after the delivery of the baby.38,39 For some
can decide on a definite date during the daytime patients this may aggravate congestive heart fail-
with experienced staff, with sufficient time for ure. In addition, a prophylactic B-lynch suture to
adequate monitoring, and for administering regio- prevent uterine atony and post-operative bleeding
nal anaesthesia. The relative risk (RR) for mortality may be indicated in some patients.
in a vaginal delivery vs. an elective caesarean Carvalho and colleagues have shown in two
section is 2.3. When a vaginal delivery is compared studies that the ED95% of oxytocin was 0.35 U in
with an instrumental vaginal delivery, the RR an elective caesarean section, and 3.0 U if the
increases to 3.6, and to 12 in case of an emergency patient was in labour with oxytocin stimulation
caesarean section.31 In the UK registry of high-risk before an emergency caesarean section.18,19
obstetric patients,32 only 50 out of 274 had a We find that the implementation of a minimally
spontaneously vaginal delivery. An emergency invasive technique for haemodynamic monitoring
caesarean section under general anaesthesia may peri-operatively is useful, and suitable for high-risk
also carry a risk of intubation failure. It is often pregnant women. In contrast to blood pressure
performed by less experienced staff, at an incon- alone, monitoring CO and SVR provides important
venient time, and with less monitoring. A previous information to guide therapy (volume, vasoactive
publication shows that a high number of pregnan- medication). Continuing the monitoring post-opera-
cies in high-risk cardiac patients attempting vagi- tively, the individual patient can be given optimal
nal deliveries ended up in an emergency caesarean treatment, and complications may be prevented.
section.1,33 Deaths due to intubation failure are Even though our observational study is small, our
rare, but the confidential enquiry 2000–20022 re- findings suggest that the haemodynamic changes
ported six deaths due to general anaesthesia in induced by regional anaesthesia are well tolerated
women with no cardiac disease. General anaesthe- in intermediate- and high-risk patients. We find CO
sia may also induce autonomic responses with monitoring useful in the high-risk patients both
hypo- or hypertension and tachycardia, which during a caesarean section and post-operatively to
may be less controllable. Positive pressure ventila- guide treatment. Further studies are needed to
tion may be an important additional concern in verify the usefulness of this minimally invasive
some patients. Unless a patient has a bleeding technique in obstetric patients.
disorder or is treated with high doses of antic-
oagulation drugs, we would recommend regional
Conclusion
anaesthesia for an elective caesarean section. In our
view, general anaesthesia should only be chosen Our study suggests that pregnant women with a
when there are contraindications to regional anaes- high-risk cardiac disease may safely deliver the

52
Caesarean section in women with cardiac disease

baby by a planned caesarean section under regional 13. Morgan P, Al-Subaie N, Rhodes A. Minimally invasive
anaesthesia. There is no evidence of an increased cardiac output monitoring. Curr Opin Crit Care 2008; 14:
322–6.
risk of bleeding compared with a vaginal delivery. 14. Costa MG, Della RG, Chiarandini P, Mattelig S, Pompei L,
Oxytocin i.v. administered as small repeated doses Barriga MS, Reynolds T, Cecconi M, Pietropaoli P. Contin-
can be used with minimal haemodynamic effects. uous and intermittent cardiac output measurement in
Haemodynamic stability can be obtained by titrated hyperdynamic conditions: pulmonary artery catheter vs.
lithium dilution technique. Intensive Care Med 2008; 34:
regional anaesthesia, i.v. volume, and phenylephr- 257–63.
ine infusion guided by invasive monitoring. 15. Dyer RA, Piercy JL, Reed AR, Lombard CJ, Schoeman LK,
James MF. Hemodynamic changes associated with spinal
anesthesia for cesarean delivery in severe preeclampsia.
Anesthesiology 2008; 108: 802–11.
Acknowledgements 16. Dyer RA, James MF. Maternal hemodynamic monitor-
ing in obstetric anesthesia. Anesthesiology 2008; 109:
The authors thank Tor H. Hauge (MSc, Oslo, Norway) for data 765–7.
handling in MatLab, and Mike S. Dodgson (MB ChB FRCA, 17. Langesaeter E, Rosseland LA, Stubhaug A. Continuous
Consultant Anaesthetist, Division of Anaesthesia and Intensive invasive blood pressure and cardiac output monitoring
Care Medicine, Rikshospitalet, Oslo, Norway) for linguistic during cesarean delivery: a Randomized, double-blind
advice. comparison of low-dose versus high-dose spinal anesthesia
with intravenous phenylephrine or placebo infusion. An-
esthesiology 2008; 109: 856–63.
18. Balki M, Ronayne M, Davies S, Fallah S, Kingdom J,
References Windrim R, Carvalho JC. Minimum oxytocin dose require-
1. Lewis NL, Dob DP, Yentis SM. UK registry of high-risk ment after cesarean delivery for labor arrest. Obstet Gyne-
obstetric anaesthesia: arrhythmias, cardiomyopathy, aortic col 2006; 107: 45–50.
stenosis, transposition of the great arteries and Marfan’s 19. Carvalho JC, Balki M, Kingdom J, Windrim R. Oxytocin
syndrome. Int J Obstet Anesth 2003; 12: 28–34. requirements at elective cesarean delivery: a dose-finding
2. deSwiet M, Nelson-Piercy C. Cardiac disease. In: Lewis G, study. Obstetr Gynecol 2004; 104: 1005–10.
ed. Why mothers die 2000–2002. Confidential enquiry into 20. Rasmussen LS, Viby-Mogensen J. Rapid sequence intuba-
maternal and child health. 6th ed. RCOG Press, London, tion – how? Acta Anaesthesiol Scand 2007; 51: 787–8.
2004: 137–50. 21. Langesaeter E, Rosseland LA, Stubhaug A. Hemodynamic
3. Lewis G., ed. The Confidential Enquiry into Maternal and effects of oxytocin during cesarean delivery. Int J Gynecol
Child Health (CEMACH). Saving Mothers’ Lives: review- Obstet 2006; 95: 46–7.
ing maternal deaths to make motherhood safer-2003–2005. 22. Olofsson C, Bremme K, Forssell G, Ohqvist G. Cesarean
The Seventh Report on Confidential Enquiries into Mater- section under epidural ropivacaine 0.75% in a parturient
nal Deaths in the United Kingdom. London: CEMACH, with severe pulmonary hypertension. Acta Anaesthesiol
2007. Scand 2001; 45: 258–60.
4. Swan L. Controversies in Pregnancy and Congenital Heart 23. Landau R, Giraud R, Morales M, Kern C, Trindade P.
Disease. Congen Heart Dis 2006; 1: 27–34. Sequential combined spinal–epidural anesthesia for cesar-
5. Oakley C, Bernard AC, Presbitero P, Tornos P. Expert ean section in a woman with a double-outlet right ventricle.
consensus document on management of cardiovascular Acta Anaesthesiol Scand 2004; 48: 922–6.
diseases during pregnancy. Eur Heart J 2003; 24: 761–81. 24. Lee A, Ngan Kee WD, Gin T. A quantitative, systematic
6. Siu SC, Colman JM. Heart disease and pregnancy. Heart review of randomized controlled trials of ephedrine versus
2001; 85: 710–5. phenylephrine for the management of hypotension during
7. Oakley CM. Pregnancy and congenital heart disease. Heart spinal anesthesia for cesarean delivery. Anesth Analg 2002;
1997; 78: 12–4. 94: 920–6.
8. Smith RL, Young SJ, Greer IA. The parturient with coronary 25. Ngan Kee WD, Khaw KS. Vasopressors in obstetrics:
heart disease. Int J Obstet Anesth 2008; 17: 46–52. what should we be using? Curr Opin Anaesth 2006; 19:
9. Thorne S, MacGregor A, Nelson-Piercy C. Risks of contra- 238–43.
ception and pregnancy in heart disease. Heart 2006; 92: 26. Erkinaro T, Makikallio K, Acharya G, Pakkila M, Kavasmaa T,
1520–5. Huhta JC, Alahuhta S, Rasanen J. Divergent effects of ephe-
10. Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, drine and phenylephrine on cardiovascular hemodynamics
Morton BC, Kells CM, Bergin ML, Kiess MC, Marcotte F, of near-term fetal sheep exposed to hypoxemia and maternal
Taylor DA, Gordon EP, Spears JC, Tam JW, Amankwah KS, hypotension. Acta Anaesthesiol Scand 2007; 51: 922–8.
Smallhorn JF, Farine D, Sorensen S. Prospective multicenter 27. Jhanji S, Dawson J, Pearse RM. Cardiac output monitoring:
study of pregnancy outcomes in women with heart disease. basic science and clinical application. Anaesthesia 2008; 63:
Circulation 2001; 104: 515–21. 172–81.
11. Dob DP, Yentis SM. Practical management of the parturient 28. Dresner M, Pinder A. Anaesthesia for caesarean section in
with congenital heart disease. Int J Obstet Anesth 2006; 15: women with complex cardiac disease: 34 cases using the
137–44. Braun Spinocath spinal catheter. Int J Obstet Anesth 2009;
12. Linton RA, Jonas MM, Tibby SM, Murdoch IA, O’Brien TK, 18: 131–6.
Linton NW, Band DM. Cardiac output measured by lithium 29. Curtis SL, Marsden-Williams J, Sullivan C, Sellers SM,
dilution and transpulmonary thermodilution in patients in Trinder J, Scrutton M, Stuart AG. Current trends in the
a paediatric intensive care unit. Intensive Care Med 2000; management of heart disease in pregnancy. Int J Card 2009;
26: 1507–11. 133: 62–9.

53
E. Langesæter et al.

30. Langesaeter E. Hemodynamic changes during vaginal 36. Hamlyn EL, Douglass CA, Plaat F, Crowhurst JA, Stocks
delivery in a parturient with no labor pain. Acta Anaes- GM. Low-dose sequential combined spinal–epidural: an
thesiol Scand 2009; 53: 398–9. anaesthetic technique for caesarean section in patients with
31. Cooper GM, Lewis G, Neilson J. Confidential enquiries significant cardiac disease. Int J Obstet Anesth 2005; 14:
into maternal deaths, 1997–1999. Br J Anaesth 2002; 89: 355–61.
369–72. 37. Tamhane P, O’Sullivan G, Reynolds F. Oxytocin in parturi-
32. Dob DP, Yentis SM. UK registry of high-risk obstetric ents with cardiac disease. Int J Obstet Anesth 2006; 15: 332–3.
anaesthesia: report on cardiorespiratory disease. Int J Ob- 38. Vercauteren M, Palit S, Soetens F, Jacquemyn Y, Alahuhta S.
stet Anesth 2001; 10: 267–72. Anaesthesiological considerations on tocolytic and utero-
33. Orbach-Zinger S, Friedman L, Avramovich A, Ilgiaeva N, tonic therapy in obstetrics. Acta Anaesthesiol Scand 2009;
Orvieto R, Sulkes J, Eidelman LA. Risk factors for failure 53: 701–9.
to extend labor epidural analgesia to epidural anesthesia 39. Bergum D, Lonnee H, Hakli TF. Oxytocin infusion: acute
for Cesarean section. Acta Anaesthesiol Scand 2006; 50: hyponatraemia, seizures and coma. Acta Anaesthesiol
1014–8. Scand 2009; 53: 826–27.
34. The European Mode of Delivery Collaboration. Elective
caesarean-section versus vaginal delivery in prevention of
vertical HIV-1 transmission: a randomised clinical trial. The Address:
European Mode of Delivery Collaboration. Lancet 1999; Eldrid Langesæter
353: 1035–9. Division of Anaesthesia and Intensive Care Medicine
35. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal Oslo University Hospital
S, Willan AR. Planned caesarean section versus planned Rikshospitalet
vaginal birth for breech presentation at term: a randomised N-0027 Oslo
multicentre trial. Term Breech Trial Collaborative Group. Norway
Lancet 2000; 356: 1375–83. e-mail: eldrid.langesaeter@rikshospitalet.no

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