Management of Labor and Delivery in Cardiovascular Disease: Cardiologist Perspective

1. Management of Labor and Delivery in Cardiovascular Disease:Cardiologist Perspective Niloufar Samiei MD, FACC Associate Professor in Cardiology Rajaei Cardiovascular Medical and Research Center

2. Introduction • Hemodynamics of Labor • General Principles • Specific lesions

3. Introduction • Leading cause of maternal mortality in the developed world • Over a half of all maternal death can be eliminated • Increase the incidence of pregnancy in CHD • Acquired heart disease as the main cause of death • Team working( Obstetrician, Cardiologist, Anesthesiologist, Neonatalogist) • Individualized plan • Interdisciplinary communication and preparation

4. Hemodynamic changes of labor as unique time • Anxiety, fear and apprehension • Progressive increase in CO • Rise of CO 3-3.5 l/min during 2nd stage • Autotransfuison : 300-500 ml/contraction • Autotransfusion: postpartum 1000ml • Average blood loss 500cc/ NVD for a singleton, 100cc/ CS and vaginal twins • Other factors: anemia, preeclampsia, infection • Fluctuation of HR and SV • Early post partum: increased CO and SV, decrease of HR , stable mean arterial pressure

5. Hemodynamic changes of labor • NVD: within 10 min after delivery CO and SV increase 59% and 71% respectively • Persist for at least 1 hour • C/S: CO increase by 30-50% within 2 minutes • Persist for 10 minutes

6. General Principles • Risk stratification: choice of delivery, location • Pain control • Strict input/output • Continuous ECG monitoring • Oxygen supplementation • Intravenous filters if shunt is present • Arterial line • Patient positioning (semi recumbent/lateral tilt) • Fetal monitoring • Thrombosis/ endocarditis prophylaxis • Invasive monitoring

7. Risk Stratification • Prior Fontan procedure • Severe PAH • Cyanotic CHD • Complex repair CHD with residua • CHD with malignant arrhythmia • Severe AS • MS with NYHA class II to IV symptoms • AI or MR with NYHA class III or IV symptoms • AV or MV disease with severe LV dysfunction • Marfan syndrome • Prosthetic valves

8. Labor • Vaginal delivery is generally preferred • Scheduling labor instead of spontaneous form in women at high risk • Placement of monitoring devices, IV access and other preparation for analgesia and anesthesia before starting of contractions • Check of vital sign between contractions • Any sign or symptom of cardiac decompensation: indication for intensive medical care • If neuroaxial analgesia is not an option : route for delivery should be reconsidered

9. Vaginal “Cardiac Delivery” • Epidural analgesia • Fetal descent during the majority of the 2nd stage is accomplished exclusively by uterine contractions without the aid of maternal expulsive effort • Low or outlet operative delivery • Still controversial

10. Trial of pushing • Pulse oximetry waveform • Mostly on earlobe

11. Monitoring • Continuous ECG • Arrhythmias • Myocardial ischemia • A 5 lead ECG with computerized St segment trending • Specialized nursing care

12. External Defibrillator or Pacemaker Pads • Patients with history of poorly tolerated tachy arrhythmias • Patients with CIED reprogrammed for operation or deactivated in detection of tachy/ bradycardia by magnet

13. Pulse Oximetry • Continuous • Audible and visible waveform • Particularly in cyanotic CHD or right to left vascular shunt

14. Intra Venous Catheter Filters • Prevent paradoxical air emboli • Intracardiac shunts • Extracardiac shunts

15. Intra arterial catheter • Invasive monitoring of arterial BP • Hypotension can be detected promptly and treated • Analysis of uterine contractions and maternal expulsive effort on overall hemodynamics • Should be inserted before induction of anesthesia in unstable high risk patients undergoing CS • Also facilitates ABG and vasoactive drug administration

16. Central Venous Catheter • In unstable patients with high risk cardiovascular disease • For administration of vasoactive drugs • For monitoring of CVP • Should not be used as a sole guide for fluid management • Helpful when CVP values are either high or low

17. Pulmonary Artery Catheter • Rarely indicated • High risk for complication • Helpful in some situations • PAH requiring titration of pulmonary vasodilatory agents such as nitric oxide

18. Echocardiography • TTE or TEE • Determine the cause of any unexplained persistent or life threatening circulatory instability • During GA, TEE is the best method to assess volume status, regional and global cardiac function

19. Vasoactive Drugs • Should be prepared in advance • Syringes and infusions • Phenylephrine • Efedrine • Norepinefrine

20. Neuroaxial Analgesia • Reduction in CO peaks throughout labor • Should be placed early in labor • Epidural or low dose combined epidural-spinal • monitoring of systemic BP is necessary • Excellent analgesia • Dense analgesia can be achieved • Titration is possible • A passive 2nd stage • In case of urgent CS , surgical block can be established

21. Specific Lesions • Aortic rupture or disection risk • Fixed cardiac output lesions -avoid hypotension -avoid pulmonary edema • Shunts/ Eisenmenger syndrome/PH • PPM/ICD • IHD

22. Endocarditis Prophylaxis • Prosthetic cardiac valve or prosthetic material used for cardiac valve repair • Previous infective endocarditis • Congenital heart disease (CHD) • Unrepaired cyanotic CHD, including those with palliative shunts and conduits • Completely repaired CHD with prosthetic material or device either by surgery or catheter intervention during the first 6 months after the procedure[ • Repaired CHD with residual defects • Cardiac transplantation recipients who develop cardiac valvulopathy

23. Post Partum Period • Care should be given with bolus of oxytocine • Controlled intravenous infusion • Several days of close monitoring in patients with diminished LV function • Prophylactic diuretics and ACEI • Routine post delivery echo • Risk of thromboembolism • A short observation period (48Hours) for low risk patient • Lactation