Acta Anaesthesiol Scand 2010; 54: 46–54
Printed in Singapore. All rights reserved
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
survey of pregnant women with cardiac disease. The aim
was to analyse and present the mode of delivery, outcome,
and haemodynamic changes during a caesarean section
under regional anaesthesia in women with cardiac disease.
Methods All pregnant women with a cardiovascular diag-
nosis, except hypertension, were included in the registry.
Based on the cardiac diagnoses, and on the New York
Heart Association classification, a multidisciplinary group
made recommendations for each patient and decided on
the mode of delivery. The data from continuous, invasive
haemodynamic monitoring in intermediate- and high-risk
patients under regional anaesthesia for a caesarean section
were analysed and presented.
Results The hospital had approximately 9000 deliveries in
the period from November 2003 to April 2008. A total of
113 pregnancies in 107 women were included. Thirty-two
(28.3%) pregnancies were classified into the high-risk
category. Of 103 deliveries, caesarean sections were per-
formed in 59 (52.2%) cases, with regional anaesthesia in 51
T HE number of pregnant women with heart
disease is increasing. Information regarding
the incidence and epidemiology is highlighted in
the UK registry of high-risk anaesthesia,1 and in the
Confidential Enquiries into Maternal Deaths in the
United Kingdom.2,3 Maternal mortality in women
with cardiac disease has increased from 7.6 per
million pregnancies in 1980 to 22 per million in the
period 2000–2002.4 Cardiac disease is now the most
common cause of indirect deaths as well as of
maternal deaths overall.3 In general, vaginal deliv-
ery has been recommended,5,6 but arguments have
been put forward for a more frequent use of a
caesarean section.7 There have been a number of
case reports, but only a few studies on the anaes-
thetic techniques, monitoring, and practical man-
agement of these high-risk patients have been
conducted.4,8 No relevant randomized clinical
trials have been published.
46
r 2009 The Authors
Journal compilation r 2009 The Acta Anaesthesiologica Scandinavica Foundation
ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/j.1399-6576.2009.02080.x
patients (18 emergencies), general anaesthesia in eight
patients (five emergencies), and a planned vaginal deliv-
ery in 44 patients. There was no mortality among the
mothers or the babies during the hospital stay or 6 months
postpartum. Pre-operative cardiovascular stability during
the caesarean section was maintained by volume and
phenylephrine infusion guided by invasive monitoring of
haemodynamic variables.
Conclusion Our study suggests that pregnant women with
cardiac disease may safely deliver the baby by a caesarean
section under regional anaesthesia. According to our find-
ings, haemodynamic stability can be obtained by titrated
regional anaesthesia, intravenous (i.v.) volume, pheny-
lephrine infusion, and small repeated doses of i.v. oxytocin
guided by invasive monitoring.
Accepted for publication 25 June 2009
r 2009 The Authors
Journal compilation r 2009 The Acta Anaesthesiologica Scandinavica Foundation
Rikshospitalet is a national centre for congenital
heart surgery in Norway and a tertiary centre for
pregnancy disorders. The majority of women with
a high-risk pregnancy due to heart disease are
transferred to our hospital from all other delivery
departments in Norway.
We have conducted a prospective observational
survey of pregnant women with cardiac disease in
our department from November 2003 to April 2008.
The aim of the study was to analyse and present
the management, mode of delivery, haemodynamic
changes, and outcome during a caesarean section
under regional anaesthesia in women with cardiac
disease.
Materials and methods
The protocol for the study was approved by The
Regional Medical Research Ethics Committee for

Southern Norway, and the patients gave written
informed consent. All pregnant women with a
cardiac diagnosis who delivered at Rikshospitalet
from November 2003 to April 2008 were included.
Parturients with only chronic hypertension or
pregnancy-induced hypertension were not in-
cluded. The database included information about
patient history, cardiac diagnosis and treatment,
functional classification according to the New York
Heart Association (NYHA), and echo cardiogra-
phy.4,9,10 The patients were classified as high, inter-
mediate, or low risk based on guidelines in the
publications by Siu and Colman,6 and Dob and
Yentis.11 The NYHA classification was based on a
standardized exercise test. The women walked up
a stairway, with continuous monitoring of heart
rate and oxygen saturation, and stopped when they
felt the need, due to dyspnoea. The exercise test
was repeated during the pregnancy in intermedi-
ate- and high-risk patients.
In the beginning, in November 2003, there was no
organized multidisciplinary group, but this devel-
oped during the survey period. From 2005, a multi-
disciplinary team of cardiologists, obstetricians,
obstetric anaesthetists, and a cardiac anaesthetist
have had regular meetings to discuss all pregnant
women with a cardiac diagnosis planned for deliv-
ery in our hospital. This group decided on the
individual recommendations for each patient in-
cluding whether the woman should have a planned
caesarean section or a vaginal delivery. This decision
was based on an individual assessment of the risk
group. Central in the evaluation of the recom-
mended method of delivery was the functional
classification according to NYHA. Our routine strat-
egy in most high-risk patients was to deliver by an
elective caesarean section with regional anaesthesia,
unless there were contraindications such as antic-
oagulation. Patients with a previous uncomplicated
vaginal delivery were considered for vaginal deliv-
ery, even in the high-risk group.
Standard routine monitoring for an elective cae-
sarean section was an arterial line in all high- and
intermediate-risk patients. In addition to invasive
blood pressure, we measured haemodynamic vari-
ables using LiDCOPlus (LiDCO Ltd, Cambridge,
UK), which is a monitor that provides continuous
haemodynamic measurements. This new mini-
mally invasive technique is based on two methods:
a continuous arterial waveform analysis system
(PulseCO) coupled to a single-point lithium indi-
cator dilution calibration system (LiDCO). For the
calibration to measure the actual cardiac output
Caesarean section in women with cardiac disease
(CO), lithium chloride 0.3 mmol is injected through
a peripheral line and the lithium is detected by a
lithium ion-sensitive external electrode connected
to a peripheral arterial line. The lithium dose has
no pharmacological effect on the woman or the
foetus.12 The LiDCOPlus gives continuous blood
pressure and a beat-to-beat measurement of CO,
stroke volume (SV), and systemic vascular resis-
tance (SVR).13 We started to use this monitor in our
anaesthetic department in 2005. The CO monitor
has been validated in other patient groups,14 and in
the last year there have been publications on its use
in pregnant women.15–17
A prophylactic low-dose phenylephrine infusion
and cohydration with crystalloids was part of a
standard protocol for preventing haemodynamic
instability during a caesarean section, based on
data from healthy women.17 Haemodynamic in-
stability was defined as a decrease in CO to levels
below 70% of the baseline, and systolic blood pres-
sure (SBP)o90 mmHg, until s
delivery of the baby.
Oxytocin (Syntocinon , Novartis, Copenhagen,
Denmark) used to be given as boluses of 5 U, which
was the standard dose in our department in 2003.
The use of oxytocin changed during the study
period. We reduced the dose to repeated boluses
of 0.5 U in the beginning of the study. Based on the
two studies by Carvalho and colleagues18,19, and
our own experience, we reduced the dose further to
0.1 U, repeated until there was an adequate effect
on uterine contractions.
We registered the mode of delivery and anaes-
thetic technique during a caesarean section, use of
phenylephrine, use of oxytocin, bleeding, haemo-
globin concentration pre- and post-delivery, need
for transfusion, and the maternal outcome in all
patients 6 months postpartum. The Apgar score
and umbilical venous and arterial pH were re-
corded for all the babies.
The haemodynamic data were stored in the LiD-
COPlus-monitor and downloaded as csv files (text
files) for each patient. Construction of the data set
was performed using MATLAB version R2007a (The
MathWorks, Natick, MA). Outliers were removed,
and the beat-to-beat data set was constructed using a
centred moving average of 30 observations.
Results
Patients
Our obstetric department at Rikshospitalet had
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

Anaesthetic technique
All elective caesarean sections were performed
with regional anaesthesia apart from three cases
on anticoagulation therapy. Standard doses of
spinal anaesthesia with bupivacaine plain 8–
10 mg and sufentanil 5 mg or fentanyl 20 mg were
administered using spinal or a combined spinal–
epidural (CSE) technique in 49 cases. One patient
had an epidural top-up for an emergency caesarean
section, and one patient with severe peripartum
cardiomyopathy had a spinal catheter for contin-
uous spinal anaesthesia. Eight patients had general
anaesthesia with Pentothal and Suxamethonium as
part of a rapid sequence induction.20 None of the
patients receiving regional anaesthesia needed con-
version to general anaesthesia. One patient with
CSE had a local anaesthetic skin infiltration and
fentanyl intravenous (i.v.) while waiting for the
epidural top-up to have effect.
Invasive haemodynamic monitoring
Arterial line monitoring of blood pressure was
used in 49 patients during a caesarean section, in
four vaginal deliveries, and in six abortions. Thir-
teen patients for a caesarean section had a central
venous catheter inserted. Six patients had a pul-
monary artery catheter. We used the LiDCOplus in
33 patients during a caesarean section. Hypoten-
sion was prevented and treated with an i.v. crystal-
loid solution and phenylephrine infusion. The
median requirement of phenylephrine in all cae-
sarean section patients peri-operatively was 140 mg
(0–1960 mg). Twenty of the 59 patients for a caesar-
ean section had no phenylephrine. The haemody-
namic changes during regional anaesthesia in 24
intermediate- and high-risk patients are shown in
Fig. 1. Two patients (patients 6 and 14) had an SBP
below 90 mmHg for a short period. Three patients
(patients 14, 20, and 24) had a decrease in CO
below 70% of the baseline. In patient 2, the changes
in CO and SBP at 18 min were due to an artefact
caused by temporary technical problems with the
arterial line. Seven low-risk patients, one inter-
mediate-risk patient with general anaesthesia, and
one intermediate-risk patient with technical pro-
blems with the arterial line are not displayed. The
haemodynamic changes in CO and SBP are pre-
sented after the start of regional anaesthesia when
the patient was positioned in the left lateral tilt and
until delivery of the baby, including the effects of
oxytocin. All patients tolerated the haemodynamic
Caesarean section in women with cardiac disease
changes induced by regional anaesthesia without
any clinical deterioration.
Use of oxytocin
Oxytocin decreases SVR and increases CO.21 In this
heterogenic patient group the haemodynamic ef-
fects of small doses of oxytocin will differ from
patient to patient, but given in small titrated doses,
the haemodynamic changes were minor and tran-
sient without aggravating any symptoms. Only one
patient (Fig 1; patient 3) had a short period of
dyspnoea after oxytocin 0.1 U. The haemodynamic
effects of oxytocin in 24 high- and intermediate-risk
patients are shown in Fig. 1. These patients were
administered boluses from 0.05 to 0.5 U oxytocin i.v.
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
an HOCM and pulmonary hypertension. She had
an emergency caesarean section due to circulatory
‘collapse’ in the operation theatre while inserting a
central venous catheter, during the preparation for
regional anaesthesia, and before inserting an arter-
ial line. Probably, the combination of anxiety, over-
night fasting, and inferior vena cava compression
resulted in bradycardia and unconsciousness. She
was dependent on a high heart rate of 120/min
with a low SV due to severe hypertrophic myocar-
dium (septum 43 cm). An emergency caesarean
section was performed under general anaesthesia
and both the mother and the baby survived. A
second patient with a subvalvular aortic stenosis
was haemodynamically stable during a caesarean
section with CSE anaesthesia (see Figs 1–3). She
died 7 months postpartum after a cardiac re-opera-
tion when she suffered a post-operative coronary
infarction with heart failure. A third patient, with a
severe heart failure due to peripartum cardiomyo-
pathy (ejection fraction 15–20%, left ventricle 9 cm,
heart rate 150/min), was haemodynamically stable
during a caesarean section using continuous spinal
anaesthesia (see Figs 1 and 2). This patient had,
prophylactically, an introducer for an intra-aortic
balloon pump (IABP), and an introducer for pul-
monary catheter. A pulmonary catheter was in-
serted post-operatively. On the first post-operative
day, she deteriorated and required treatment with
IABP and an i.v. infusion of nitroprusside. A
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)

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

10 140
8 120
6 100
4 80
Oxy 0.1
2 60
CO (L\Min)
10 140 10 140
8 120 8 120
6 100 6 100
4 Oxy 0.1 80 4 80
Oxy 0.1
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
reflect that our hospital is a tertiary centre for
complicated pregnancies, and a national centre
for congenital heart disease.
International recommendations state that, with
few exceptions, these women should be planned
for a vaginal delivery.4,6,11 Our practice differs from
this with 82% C-sections in the high-risk group.
The arguments against a caesarean delivery are the
higher risk of infection, bleeding, and anaesthetic
complications. However, a vaginal delivery may
increase the cardiovascular stress, even when opti-
mal pain relief is offered.30 There is sparse litera-
ture concerning the haemodynamic changes
during vaginal delivery, especially during the sec-
ond stage, and this concern has not been a main
focus in previous papers discussing the mode of
delivery in these high-risk patients.
A planned caesarean section has, in our view,
many advantages in high-risk parturients, espe-
cially if the patient has not given birth before. One
can decide on a definite date during the daytime
with experienced staff, with sufficient time for
adequate monitoring, and for administering regio-
nal anaesthesia. The relative risk (RR) for mortality
in a vaginal delivery vs. an elective caesarean
section is 2.3. When a vaginal delivery is compared
with an instrumental vaginal delivery, the RR
increases to 3.6, and to 12 in case of an emergency
caesarean section.31 In the UK registry of high-risk
obstetric patients,32 only 50 out of 274 had a
spontaneously vaginal delivery. An emergency
caesarean section under general anaesthesia may
also carry a risk of intubation failure. It is often
performed by less experienced staff, at an incon-
venient time, and with less monitoring. A previous
publication shows that a high number of pregnan-
cies in high-risk cardiac patients attempting vagi-
nal deliveries ended up in an emergency caesarean
section.1,33 Deaths due to intubation failure are
rare, but the confidential enquiry 2000–20022 re-
ported six deaths due to general anaesthesia in
women with no cardiac disease. General anaesthe-
sia may also induce autonomic responses with
hypo- or hypertension and tachycardia, which
may be less controllable. Positive pressure ventila-
tion may be an important additional concern in
some patients. Unless a patient has a bleeding
disorder or is treated with high doses of antic-
oagulation drugs, we would recommend regional
anaesthesia for an elective caesarean section. In our
view, general anaesthesia should only be chosen
when there are contraindications to regional anaes-
52
thesia or in case of an emergency caesarean section
with no time for regional anaesthesia.
Blood loss during a caesarean section may be an
overestimated risk factor in the debate concerning
delivery. In this population, the median change in
pre-and post-operative haemoglobin was 1.1 g/dl.
In two trials where the patients were randomized
to a caesarean section or a vaginal delivery, there
were no statistically significant differences in
bleeding between the two groups.34,35
The use of oxytocin is controversial. Some
authors avoid i.v. oxytocin in pregnant women
with cardiac disease,36 and others administer oxy-
tocin as an infusion.11,36,37 However, the risk of
bleeding caused by uterine atony is also a major
concern. In this series we administered small in-
cremental doses of oxytocin until uterine tonus was
sufficient. We do not practice administering oxyto-
cin as an infusion, as recommended by others,11
because this may lead to an unnecessary volume
load after the delivery of the baby.38,39 For some
patients this may aggravate congestive heart fail-
ure. In addition, a prophylactic B-lynch suture to
prevent uterine atony and post-operative bleeding
may be indicated in some patients.
Carvalho and colleagues have shown in two
studies that the ED95% of oxytocin was 0.35 U in
an elective caesarean section, and 3.0 U if the
patient was in labour with oxytocin stimulation
before an emergency caesarean section.18,19
We find that the implementation of a minimally
invasive technique for haemodynamic monitoring
peri-operatively is useful, and suitable for high-risk
pregnant women. In contrast to blood pressure
alone, monitoring CO and SVR provides important
information to guide therapy (volume, vasoactive
medication). Continuing the monitoring post-opera-
tively, the individual patient can be given optimal
treatment, and complications may be prevented.
Even though our observational study is small, our
findings suggest that the haemodynamic changes
induced by regional anaesthesia are well tolerated
in intermediate- and high-risk patients. We find CO
monitoring useful in the high-risk patients both
during a caesarean section and post-operatively to
guide treatment. Further studies are needed to
verify the usefulness of this minimally invasive
technique in obstetric patients.
Conclusion
Our study suggests that pregnant women with a
high-risk cardiac disease may safely deliver the

baby by a planned caesarean section under regional
anaesthesia. There is no evidence of an increased
risk of bleeding compared with a vaginal delivery.
Oxytocin i.v. administered as small repeated doses
can be used with minimal haemodynamic effects.
Haemodynamic stability can be obtained by titrated
regional anaesthesia, i.v. volume, and phenylephr-
ine infusion guided by invasive monitoring.
Acknowledgements
The authors thank Tor H. Hauge (MSc, Oslo, Norway) for data
handling in MatLab, and Mike S. Dodgson (MB ChB FRCA,
Consultant Anaesthetist, Division of Anaesthesia and Intensive
Care Medicine, Rikshospitalet, Oslo, Norway) for linguistic
advice.
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Address:
Eldrid Langesæter
Division of Anaesthesia and Intensive Care Medicine
Oslo University Hospital
Rikshospitalet
N-0027 Oslo
Norway
e-mail: eldrid.langesaeter@rikshospitalet.no