a 25 y/o pregnant woman with acute heart failure
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A 25 y/o pregnant woman A 25 y/o pregnant woman with acute heart failurewith acute heart failure
RiRi 曾渥然曾渥然 /Ri/Ri 楊智勝楊智勝 /CR/CR康庭瑞康庭瑞 /VS/VS鄭鄭淳心淳心
Brief HistoryBrief History
25 y/o female patient25 y/o female patient GA 35GA 35++ weeks with twin pregnan weeks with twin pregnan
cycy BL: 155 cmBL: 155 cm BW: 47/62 kgBW: 47/62 kg Past history: deniedPast history: denied
OB/GYN historyOB/GYN history G2P0AA1G2P0AA1 LMP: 94.4.9LMP: 94.4.9 EDC: 95.1.16EDC: 95.1.16 Prenatal conditionPrenatal condition
GDM: negativeGDM: negative VDRL: non-reactiveVDRL: non-reactive HIV: negativeHIV: negative Blood type: B, Rh(+)Blood type: B, Rh(+) SMN carrier (-)SMN carrier (-)
Prenatal examinationPrenatal examination
94.11.14 (3194.11.14 (31+2+2 wks) wks) Urine sugar(-), Urine protein(-)Urine sugar(-), Urine protein(-) 59kg, 91/83 mmHg59kg, 91/83 mmHg
94.11.30 (3394.11.30 (33+5+5 wks) wks) 62kg, 121/97 mmHg62kg, 121/97 mmHg Urine sugar(-), Urine protein(2Urine sugar(-), Urine protein(2++))
94.12.14 ( 3594.12.14 ( 35+5+5 wks) wks) 66kg, 130/95 mmHg66kg, 130/95 mmHg Urine sugar(-), Urine protein(4Urine sugar(-), Urine protein(4++))
Clinical symptoms and signsClinical symptoms and signs
Exersional dyspnea for one weekExersional dyspnea for one week OrthopneaOrthopnea Vital signsVital signs
36.5/129/20, BP:135/108mmHg36.5/129/20, BP:135/108mmHg PEPE
Neck: JVE(+)Neck: JVE(+) Chest: bilateral basal cracklesChest: bilateral basal crackles Heart: RHB with systolic murmurHeart: RHB with systolic murmur Abd: ovoid, normactive BoSAbd: ovoid, normactive BoS Ext: edema (+)Ext: edema (+)
Cardiac Echo (12.14)Cardiac Echo (12.14)
Moderate to severe MRModerate to severe MR Moderate PR & TRModerate PR & TR LVEF: 43%LVEF: 43% LV dilatation (47mm)LV dilatation (47mm) Pulmonary hypertensionPulmonary hypertension
PG = 50mmHgPG = 50mmHg Small amount pericardial Small amount pericardial
effusioneffusion
12.14, 12.14, pre-C/Spre-C/S
Lab DataLab Data
CBCCBC WBCWBC
K/μL K/μL
RBCRBC
M/μLM/μL
HBHB
g/dLg/dL
HCTHCT
%%
MCVMCV
fLfL
PLTPLT
K/μL K/μL
941214941214 8.118.11 4.034.03 10.910.9 31.831.8 78.978.9 312.0312.0
BCSBCS T-bilT-bil
mg/dL mg/dL
D-bilD-bil
mg/dLmg/dL
ASTAST
U/LU/L
ALTALT
U/LU/L
941214941214 0.540.54 0.10.1 3232 1515
BCSBCS NaNa
mmol/Lmmol/L
KK
mmol/Lmmol/L
941214941214 133133 4.74.7
UNUN
mg/dL mg/dL
CRECRE
mg/dLmg/dL
19.519.5 0.80.8
PTPT PTTPTT
941214941214 10.810.8 28.328.3
ImpressionImpression
Twin pregnancy at 35Twin pregnancy at 35thth week s/p week s/p emergent Cesarean sectionemergent Cesarean section
PreeclampsiaPreeclampsia Maternal heart failure, suspecteMaternal heart failure, suspecte
d cardiomyopathyd cardiomyopathy
Anaesthesia RecordsAnaesthesia Records
Arterial lineArterial line Induction agentsInduction agents
AtropineAtropine EtomidateEtomidate SuccinylcholineSuccinylcholine
Under ETGA (6:50PM)Under ETGA (6:50PM) Inhalation of isofluraneInhalation of isoflurane Cis-atracurium for m. relaxantCis-atracurium for m. relaxant Midazolam for sedationMidazolam for sedation Fentanyl for pain controlFentanyl for pain control Central venous catheterCentral venous catheter
Delivery time: 7:03PMDelivery time: 7:03PM Twin A (vertex extraction)Twin A (vertex extraction)
BBW:2016gmBBW:2016gm Apgar score: Apgar score: 5 5 8 8 Fetal anomaly: nilFetal anomaly: nil
Twin B (breech extraction)Twin B (breech extraction) BBW:2344gmBBW:2344gm Apgar score: Apgar score: 5 5 8 8 Fetal anomaly: nilFetal anomaly: nil
Placenta: intactPlacenta: intact EBL: 500mlEBL: 500ml
4FI treatment course(II)4FI treatment course(II)
MedicationMedication Albumin 2btls IV x 3 daysAlbumin 2btls IV x 3 days Lasix: 1 amp TIDLasix: 1 amp TID Perdipine titrationPerdipine titration MgSO4 in D5WMgSO4 in D5W Inderal(10) 1tab BIDInderal(10) 1tab BID
Ventilator settingsVentilator settings Mode: SIMV + PSMode: SIMV + PS FiO2:35%FiO2:35% PS/PEEP:8/4PS/PEEP:8/4 SpO2:96%SpO2:96%
Extubation at 12.16_10:45AMExtubation at 12.16_10:45AM
12/14 Send to 4 FI12/14 Send to 4 FI 12/16 ETT was removed12/16 ETT was removed 12/17 Transfer to general ward 12/17 Transfer to general ward 12/21 Discharge12/21 Discharge
Followed up cardiac echoFollowed up cardiac echo
12/1612/16 LVEF:62%LVEF:62% LVEDD:49mmLVEDD:49mm Moderate MRModerate MR TR, PG:44mmHgTR, PG:44mmHg
12/2012/20 LVEF:48%LVEF:48% LVEDD:55mmLVEDD:55mm Moderate to severe MRModerate to severe MR TR, PG:36mmHgTR, PG:36mmHg
DiscussionDiscussion
Maternal hemodynamic change Maternal hemodynamic change during pregnancyduring pregnancy
Recognition and management of Recognition and management of peripartum cardiomyoparthyperipartum cardiomyoparthy
Maternal hemodynamic changMaternal hemodynamic change during pregnancye during pregnancy
HeartHeart Cardiac outputCardiac output MAP and SVRMAP and SVR Venous returnVenous return Hemodynamic assessmentHemodynamic assessment
HeartHeart
Displacement of diaphragmDisplacement of diaphragm
- left and upward- left and upward
- apex is moved laterally- apex is moved laterally Expand of blood volumeExpand of blood volume
- LVEDD increase- LVEDD increase
- LA/RA diameter increase- LA/RA diameter increase
Cardiac output (CO=SV x HR)Cardiac output (CO=SV x HR)
Cardiac outputCardiac output
PositionPosition
- Increased: left lateral- Increased: left lateral
- Decreased: sitting, supine- Decreased: sitting, supine
MAP and SVRMAP and SVR
MAP and SVRMAP and SVR
Decreased SVRDecreased SVR
- Elevated progesterone level- Elevated progesterone level
- NO, prostaglandin, ANP- NO, prostaglandin, ANP Refractory to hypertensive effectRefractory to hypertensive effect
s of angiotensin IIs of angiotensin II
Venous pressureVenous pressure
Elevated in lower extremitiesElevated in lower extremities EdemaEdema Varicose veinsVaricose veins Deep vein thrombosisDeep vein thrombosis
Hemodynamic assessmentHemodynamic assessment
By arterial lines and Swan-Ganz catheterizationBy arterial lines and Swan-Ganz catheterization
Effect of labor and Effect of labor and immediate puerperiumimmediate puerperium
Elevated MAP and COElevated MAP and CO
- uterine contraction- uterine contraction
- pain and apprehension- pain and apprehension
- position- position
Diagnosis and evaluation of Diagnosis and evaluation of cardiac disease in pregnancycardiac disease in pregnancy
Detailed historical informationDetailed historical information
Physical examination:Physical examination:
murmur( grade 3/6) or radiate to ≧murmur( grade 3/6) or radiate to ≧
carotidcarotid→ pathologic→ pathologic
JVE, peripheral cyanosis, JVE, peripheral cyanosis,
clubbing, pulmonary crackleclubbing, pulmonary crackle
EchocardiographyEchocardiography
The possible etiology of heart The possible etiology of heart failure in this patientfailure in this patient
Previously undiagnosed congenital oPreviously undiagnosed congenital o
r rheumatic diseaser rheumatic disease
Embolic disease or ischemic heart diEmbolic disease or ischemic heart di
seasesease
CardiomyopathyCardiomyopathy
Previously undiagnosed valvular disePreviously undiagnosed valvular dise
asease
Recognition and management of Recognition and management of peripartum cardiomyoparthyperipartum cardiomyoparthy
Maternal death due to cardiac Maternal death due to cardiac diseasedisease
Br J Anaesth 2004;93, 428-39Br J Anaesth 2004;93, 428-39
Peripartum cardiomyopathyPeripartum cardiomyopathy
Incidence: 1:1500~1: 4000Incidence: 1:1500~1: 4000
It is associated with It is associated with older older
maternal age, greater parity, maternal age, greater parity,
black race and multiple black race and multiple
gestation…gestation…
The etiology remains unclear. The etiology remains unclear.
Clinical definition of peripartum caClinical definition of peripartum cardiomyopathyrdiomyopathy
Heart failure within Heart failure within last month of pregnancy last month of pregnancy
or five months postpartumor five months postpartum
Absence of prior heart diseaseAbsence of prior heart disease
No determinable causeNo determinable cause
Strict echocardiographic indication of LV dyStrict echocardiographic indication of LV dy
sfunctionsfunction Ejection fraction < 45%Ejection fraction < 45%
And/orAnd/or
Fraction shortening < 30 %Fraction shortening < 30 %
End-diastolic dimension >2.7 cm per mEnd-diastolic dimension >2.7 cm per m2 2 BSA BSA
The recognition of peripartum The recognition of peripartum cardiomyopathycardiomyopathy
The diagnosis as a challengeThe diagnosis as a challenge S/S that should raise the suspicion of S/S that should raise the suspicion of
HF, including HF, including paroxysmal nocturnal dyspnea, chparoxysmal nocturnal dyspnea, ch
est pain, new regurgitant murmur, pulmonary crackles, est pain, new regurgitant murmur, pulmonary crackles,
JVE, hepatomegalyJVE, hepatomegaly…… EKG: usually NSR or sinus tachycardiaEKG: usually NSR or sinus tachycardia
A high index of suspicion and low threA high index of suspicion and low thre
shold of cardiac echoshold of cardiac echo
Treatment of peripartum cardioTreatment of peripartum cardiomyopathymyopathy Salt restriction and the use of diureticSalt restriction and the use of diuretic
ss If systolic dysfunction, the use of vasIf systolic dysfunction, the use of vas
odilators to reduce afterloadodilators to reduce afterload ACEIACEI→ teratogenicity, neonatal anuric renal failure → teratogenicity, neonatal anuric renal failure (co(co
ntraindicated)ntraindicated) Hydralazine: the drug of choice prepartumHydralazine: the drug of choice prepartum
Atrial arrhythmias should be treated Atrial arrhythmias should be treated with with digoxin.digoxin. Class 3(amiodarone) and class 4(verapamil) ageClass 3(amiodarone) and class 4(verapamil) age
nts have side effects: fetal hypothyroidism, premnts have side effects: fetal hypothyroidism, premature delivery, fetal bradycardia… ature delivery, fetal bradycardia…
Treatment of peripartum cardiTreatment of peripartum cardiomyopathy (Cont.) omyopathy (Cont.)
Patient with poor cardiac output Patient with poor cardiac output (LVEF<35%)(LVEF<35%) Anticoagulation is indicated for the risk oAnticoagulation is indicated for the risk o
f thromboembolism. f thromboembolism. Unfractionated or LMW heparin are the Unfractionated or LMW heparin are the
choice during pregnancy.choice during pregnancy.
The use of The use of ββ- blocker- blocker Carvedilol for dilative cardiomyopathyCarvedilol for dilative cardiomyopathy The application in peripartum cardiomyoThe application in peripartum cardiomyo
pathy is unclear.pathy is unclear.
Cardiomyopathy during pregnCardiomyopathy during pregnancyancy
Delivery of the fetus Delivery of the fetus ↓ ↓ the hemothe hemo
dynamic stress on the heart.dynamic stress on the heart.
The mode of deliveryThe mode of delivery Based on Based on obstetric indicationobstetric indication
Effective pain management is nEffective pain management is n
ecessary.ecessary.
Anesthetic consideration in Anesthetic consideration in this patientthis patient
In patients undergoing GA, the pIn patients undergoing GA, the principles are as for any patient wrinciples are as for any patient with cardiac failure.ith cardiac failure. Maintenance of normal to low heart rate Maintenance of normal to low heart rate
to to ↓O↓O22 demand demand Prevention of large swings in BPPrevention of large swings in BP
The hypertensive response to inThe hypertensive response to intubation can be obtunded by the tubation can be obtunded by the use of alfentanil. use of alfentanil.
Anesthetic implication for stage-C Anesthetic implication for stage-C heart failureheart failure
Two principal cardiovascular Two principal cardiovascular
events:events: Myocardial depressionMyocardial depression
Peripheral vasodilatationPeripheral vasodilatation
The patients with impaired LV The patients with impaired LV
function are dependent onfunction are dependent on the preload the preload
increased sympathetic toneincreased sympathetic tone
Anesthetic consideration in Anesthetic consideration in this patient (Cont.)this patient (Cont.)
Careful monitoring of fluid balanceCareful monitoring of fluid balance Arterial lineArterial line
CVP lineCVP line
Early critical care referral for unstablEarly critical care referral for unstabl
e patiente patient
Critical patients will require Critical patients will require Swan-GaSwan-Ga
nz monitoring, artificial ventilation annz monitoring, artificial ventilation an
d inotropic supportd inotropic support..
Severe myocardial dysfunctionSevere myocardial dysfunction
The use ofThe use of IABP IABP or a or a left left ventricular assisted deviceventricular assisted device needed as a bridge until needed as a bridge until myocardial recovery or cardiac myocardial recovery or cardiac transplantation is performed. transplantation is performed.
The prognosis of peripartum cThe prognosis of peripartum cardiomyopathyardiomyopathy
The mortality rate: 25~50%The mortality rate: 25~50%
Death due to progressive CHF, Death due to progressive CHF,
arrhythmia, or thromboembolism.arrhythmia, or thromboembolism.
Within 6 months:Within 6 months: Half of patient have resolution of LV dilatHalf of patient have resolution of LV dilat
ion.ion.
If not, 85% will die within the next 4~5 yIf not, 85% will die within the next 4~5 y
earsears..
Thank you for your attention!Thank you for your attention!
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