Aja2011

Acta Anaesthesiol Scand 2010; 54: 46–54 Printed in Singapore. All rights reserved

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

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 diagnosis, 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 underregional 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 performed in 59 (52.2%) cases, with regionalanaesthesia in 51

patients (18 emergencies), general anaesthesia in eight patients (five emergencies), and a planned vaginal delivery 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 ofhaemodynamic 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 findings, haemodynamic stability can be obtained by titrated regional anaesthesia, intravenous (i.v.) volume, phenylephrine 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

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.2,3Maternal 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 delivery has been recommended,5,6 but arguments have been put forward for a more frequent use of a caesarean section.7 There have beena number of case reports, but only a few studies on the anaesthetic techniques, monitoring, and practical management of these high-risk patients have been conducted.4,8 No relevant randomized clinical trials have been published.

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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-riskpregnancy 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...