How to predict peripartum Cardiomyopathy ? What is the ideal anesthetic technique?

1. How to predict peripartum Cardiomyopathy ? • What is the ideal anesthetic technique?

2. Peripartum Cardiomyopathy (PPCM) was first reported in the year 1849. • How to predict it is CM? • Development of cardiac failure in the last month of pregnancy or within 5 months of delivery. • Absence of a determinable etiology for the cardiac failure. • Absence of demonstrable heart disease before the last month of pregnancy.

3. The Heart Failure Association of the European Society of Cardiology defined it as “ Idiopathic Cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. It is a diagnosis of exclusion. The left ventricle may not be dilated but the ejection fraction is nearly always reduced below 45%."

4. Criteria for diagnosis of peripartumcardiomyopathy Risk factors: -Advanced maternal age. -Multiparity -Afro-American race. -Twin pregnancy -Pre-eclampsia -Gestational hypertension and diabetes. -Use of tocolytics -High sodium salt -Deficiency of certain micronutrients -Smoking during pregnancy

5. Pathophysiology: -Myocarditis has been shown to be associated with PPCM although the incidence spans a wide range -Changes in immune function during pregnancy exacerbated de novo infection or reactivated latent virus in the pregnant females viral myocarditiscardiomyopathy . -Activation of autoimmune response . Sera from PPCM patients contain high titres of autoantibodies against normal human cardiac tissue proteins that are not present in the sera of patients with idiopathic cardiomyopathy . -An abnormal cardiac response to hemodynamic changes associated with pregnancy. -A magnified decrease in left ventricle function in association with increase in cardiac output and decrease in systemic vascular resistance which occurs in late pregnancy can explain features of PPCM. -An accelerated myocyte death (apoptosis), increase in proinflammatory cytokines, excessive prolactin production and coronary microangiopathy. A few reports of familial association of the disease have also appeared which may warrant further evaluation for a probable genetic cause of the disease.

6. Drugs that should be avoided: -Calcium channel blockers: They have a negative inotropic effect ,except amlodepine, Amlodepine may be used if PPCM is associated with pre-eclampsia to control blood pressure. - ACE inhibitors: Both direct acting or receptor blockers, although the first line of drug for patients in heart failure due to any cause, are however, contraindicated in pregnant females due to the risk of fetal toxicity associated with them.

7. In Patient presents with acute failure -Patient should be managed in an intensive care unit: -Propped up position -Continuous hemodynamic and oxygenation monitoring -Central venous and arterial cannulation. -Pulmonary artery wedge catheter (high dose of multiple cardiac drug infusions). -Noninvasive ventilation with suitable positive end expiratory pressure (if oxygen by simple face mask fails to improve SpO2 more than 95%). N.B.In case invasive ventilation is required: Guard against aspiration in a pregnant patient should be taken. -Nitroglycerine: to decrease afterload if the systolic blood pressure is more than 110 mm Hg. Nitroglycerin (NTG) intravenous infusion should be titrated to effect starting from a dose of 10-20 μg/min up to a maximum of 200 μg/min. N.B.(Nitroprusside is relatively contraindicated in pregnant patients due to risk of thiocyanate and cyanide accumulation in the fetus). -Dobutamine, dopamine and milrinone can be used to provide inotropic support to the failing heart.

8. Levosimendan a cardiotropic agent that improves cardiac output by increasing the response of myofilaments to intracellular calcium unlike the above mentioned traditional inotropes that do so by increasing the intracellular calcium itself. Levosimendan is used as an intravenous infusion at the rate of 0.1-0.2 μg/kg/min in cardiac failure with or without a loading dose of 3-12 μg/kg over 10 minutes. Mechanical assist devices and extracorporeal membrane oxygenators have been used in these patients if medical therapy fails to improve cardiac status. These devices can be used as bridging therapy as in most of the patients partial or complete recovery can be expected within a year of delivery. Up to 11% of patients will eventually require cardiac transplantation. Intensive fetal monitoring : in hemodynamically unstable pregnant patients who are on multiple drugs with continuous evaluation by obstetricians to prevent fetal loss.

9. Cardiologists, Anesthetists, Intensivists and Neonatologists all actively involved in the obstetric management. Pregnancy reach term emergent delivery unless there is deterioration in the maternal or fetal well-being, there is no need for urgent or emergent delivery and the pregnancy is allowed to progress to term Mode of delivery vaginally C.S. according to obstetric parameters or??? patient's wish.

10. -Monitoring : continuous hemodynamic monitoring and even invasive monitoring -Effective labor analgesia is mandatory. - Pain and anxiety associated with labor increase sympathetic nervous system activity increase in cardiac output and peripheral vascular resistance increase in cardiac afterload decreases uteroplacental outflow

11. The hemodynamic goals of anesthesia are common IN all approaches: - Reduce cardiac preload and afterload - Prevent any decrease in the already compromised cardiac contractility. - Intravenous and local anaesthetic drugs should be carefully titrated. *Monitoring : Before commencement of anesthesia : -Invasive monitoring including blood pressure and central venous pressure - Pulmonary artery catheter and transesophageal echocardiography has been described in patients with severely depressed cardiac function [ Regional anesthesia (RA) combined spinal epidural (CSE) continuous spinal anesthesia (CSA) continuous epidural anesthesia(CEA) The method of choice as the sympathectomy associated with it causes a decrease in cardiac preload and afterload which is beneficial in patients with PPCM. -non-emergent cesarean section with relatively stable hemodynamics. -Use of a catheter gives freedom of titrability of the local anaesthetic drug both in epidural and intrathecal space. - RA, however, may be contraindicated in anticoagulated patients .

12. -General anesthesia( GA): • -In moderately symptomatic patients or parturients undergoing emergency surgery . • For any urgent or emergent lower segment caesarean section (LSCS) . -In patients with borderline cardiac decompensation , as even minor degrees of sympathetic blockade associated with RA may lead to fulminant cardiac failure . • Opioid-based anesthesia provides good hemodynamic control and obtundation of response to endotracheal intubation • but may require postoperative ventilatory support for both mother and neonate. • -Remifentanil was chosen for its efficacy in controlling intraoperative stress response and rapid recovery independent of duration of infusion.

13. Use of other non-anesthetic drugs intraoperatively should be done with caution: Ergometrineshould preferably be avoided oxytocin should be given as an infusion or slowly titrated to response. Autotransfusion after delivery can be countered by a small dose of furosemide just before delivery of the baby.

14. Favorable maternal and fetal outcome is not dependent on anesthetic technique BUT *Strict hemodynamic control * Meticulous cardiovascular Monitoring *Close coordination between various involved specialists.

15. Questions: 1-Best choice of anesthesia ?

16. - Continuous epidural technique

17. 2-Why ?

18. -To avoid the complications of GA. - decrease in cardiac preload and afterload

19. 3- Risks of GA ?

20. -Carries with it the risks of sympathetic stimulation during laryngoscopy. -Use of a multi drug regime. -Doubts about extubation.

21. 4-Why Subarachnoid block can be hazardous?

22. It can precipitate sudden and rapid reductions in systemic vascular resistance and there by preload.

23. Thank YOU