Table of Contents  
COMMENTARY
Year : 2014  |  Volume : 7  |  Issue : 6  |  Page : 783-786  

Anesthetic challenges in peri-partum cardiomyopathy: Still a long way to go!


1 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
2 Department of Obstetrics and Gynaecology, Gian Sagar Medical College and Hospital, Banur, Punjab, India

Date of Web Publication18-Nov-2014

Correspondence Address:
Sukhminder Jit Singh Bajwa
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Bajwa SS, Bajwa SK. Anesthetic challenges in peri-partum cardiomyopathy: Still a long way to go!. Med J DY Patil Univ 2014;7:783-6

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Bajwa SS, Bajwa SK. Anesthetic challenges in peri-partum cardiomyopathy: Still a long way to go!. Med J DY Patil Univ [serial online] 2014 [cited 2024 Mar 28];7:783-6. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2014/7/6/783/144882

Medical advancements, newer modalities, and better diagnostic facilities in the 21 st century have helped significantly in decreasing maternal mortality resulting from cardiac diseases. Better knowledge and understanding of various pathophysiological aspects related to cardiac diseases has provided a safe platform for the parturients.

In spite of all this progress, maternal morbidity and mortality remains higher in developing nations. [1],[2] The big question is "are we lacking somewhere in the diagnosis and management of co-morbid diseases, especially cardiac diseases like peri-partum cardiomyopathy (PPCM)"? The answer to these seems somehow complicated as morbidity and mortality is largely influenced by various other factors such as shortage of medical specialists, health care workers, meager resources, inadequate diagnostic and therapeutic facilities, poor mode of transportation, poverty, and lack of awareness specifically in remote areas. [1]

Peri-partum cardiomyopathy has been comprehensively defined by European society of Cardiology as "an idiopathic cardiomyopathy manifested as heart failure due to left ventricular systolic dysfunction toward the end of pregnancy or in the months after delivery when no other cause of heart failure is found. Thus, PPCM is a diagnosis of exclusion, suggesting that a broader definition would eliminate PPCM as a missed diagnosis." [3]

The incidence varies from 1:100 to 1:12000, but exact incidence is difficult to estimate because many risk factors vary from place-to-place, which are possibly implicated in development of PPCM. [4] Incidence is highly variable from 1:100 in Northern Nigeria to 1:299 in Haiti to 1:6000 per live birth in Japan to 1:1000 in South Africa and 1:4000 live births in US. The exact data from India is difficult to express as the reporting is not uniform and the available literature is largely possible due to isolated reported cases. The incidence of PPCM varies from nation to nation and various risk factors such as ethnic variation, preeclampsia, diabetes mellitus, apoptosis, pregnancy at advanced age, cytokine mediated inflammation, multiparity, gestational hypertension, multiple pregnancies, maladaptive response to hemodynamic stress of pregnancy, anti-oxidant deficiency, idiopathic causes and so on, are considered to be responsible in causation of PPCM. The role of immune mechanisms and viral infections has also been established at cellular levels. [5] As such early delivery is advocated to prevent symptoms of PPCM. [6]

Parturients during the last month of pregnancy or during the first 5 months of the post-natal period having signs and symptoms of cardiac failure should always be investigated for PPCM. [7] Sometimes the symptomatology may be vague mainly pertaining to generalized symptoms such as dizziness, chest pain, abdominal discomfort, vasovagal syncope, which can put the dilemma in the minds of the attending obstetrician. [8] The diagnosis can be established by the presence of dyspnea, pulmonary rales, pedal edema, hepatomegaly, raised jugular venous pressure, and appearance of new murmur. However, all efforts should be made to exclude the possibilities of other causes of heart failure also and should always be followed by echocardiography which is conclusive of diagnosis of PPCM. A case with these typical clinical findings of PPCM and the challenges encountered during its management is being reported in the current issue of the journal. Dilated left ventricle, ejection fraction of <45% and increase in end-diastolic anatomical parameters of the left ventricle on echocardiography successfully establishes the presence of PPCM.

Anesthesiologist should be involved during the last month of pregnancy besides involving cardiologist or physician if the patient comes for institutional delivery. Anesthesiologist may not get sufficient time for a thorough evaluation and optimization of cardiac status during emergency cesarean section (CS). However, during elective and if possible, during emergency CS measures should be directed at improving oxygenation and maintenance of cardiac output by decreasing both preload and afterload. [9],[10] Hydralazine and nitrates are good for decreasing afterload. In an emergency situation, β-blockers can be immensely helpful. Role of anticoagulants has gained wider acceptability in patients with PPCM and lower ejection fraction. Low molecular weight heparin is usually preferred as it does not cross the placenta. [11] Admission to intensive care is warranted if the severity of the disease is higher. However, the issue of delivery in Intensive Care Unit (ICU) is of paramount importance and facilities have to be available in ICU if the PPCM is severely affecting the maternal and fetal outcome. The concept of dedicated obstetric ICU is gaining popularity in our country also. [12] ICU management may involve but is not limited to hemodynamic monitoring, oxygenation, preferably noninvasive ventilation, pharmacotherapeutic measures (loop diuretics, nitroglycerine, dobutamine, dopamine, milrinone, levosimendan), avoidance depending upon individual profile and severity of the disease.

Anesthetic management for CS in patients with PPCM poses unique challenges as the decision for surgery involves interdisciplinary team work from obstetrics, anesthesiology, cardiology and pediatrics. However, the chunk of decision making lies with the attending obstetrician as team leader and the rest of the team helping her with specifically designed approach for individual patients based on their current medical status. The normal delivery can be taken up provided patient remains stable till term but facilities should be readily available for emergency CS. Afterload increase due to exaggerated sympathetic activity resulting from labor pain should preferably be dealt with epidural relief of pain so as to allow pain free delivery. [13] Other pain relief measures can be adopted provided that it does not impact APGAR score. Precautions during such cases include judicious use of anesthetic agents in just optimal doses, avoidance of drugs causing sudden decrease in systemic vascular resistance, use of invasive monitoring depending upon the type of health set-up in which delivery is being conducted. Oxytocin should be given slowly as rapid infusion can cause hypotension and tachycardia. [14] The choice of regional anesthesia (RA) over general anesthesia (GA) technique and vice versa involves consideration of merits and pitfalls of each technique and the associated co-morbidities. However, epidural anesthesia seems appropriate in the majority of such population. Neuraxial anesthesia can decrease both preload and afterload by achieving the sympathetic blockade. The control in achieving the level of anesthesia by titration of local anesthetic is another remarkable feature of RA, which helps in achieving precise control of hemodynamic parameters during vaginal delivery or CS. [15] Moreover, complications associated with GA such as difficult airway management, use of cardiac depressant drugs, titration of anesthetic levels and overall decreased cardiac morbidity can be avoided. However, GA should be administered in case of emergency and also in patients receiving anticoagulants. Opioids can be used as analgesics, but should preferably be administered after delivery of the baby.

Vigilance should be an exercise, while treating potential peri-operative complications which may include, but are not limited to hypotension, hypoxemia, atrial fibrillation, pulmonary edema, myocardial ischemia, thromboembolism and cardiac arrest. [16] During severely acute episode, parturient may not show response to even aggressive medical therapy and mortality can result from heart failure, thromboembolic phenomenon, and fetal cardiac arrhythmias. [17] Cardiac transplantation considered as a therapeutic option in the west is a dream beyond ground realities in a resource challenged nation. The successful management of present episode is not a guarantee for the nonoccurrence for a future episode and as such risk stratification is mandatory in all such cases.

The onset of PPCM can be easily masked by normal physiological changes of pregnancy resulting from increased blood volume, increased metabolic demands, mild anemia, and changes in intravascular resistance and increased cardiac output. Preanesthetic evaluation is highly essential and should include detailed but precise history taking and physical examination as it can help in appropriate diagnosis of PPCM by excluding other events responsible for heart failure. The following criteria are necessary for establishing the diagnosis of PPCM.

  • Appearance of new systolic dysfunction of the left ventricle on ECHO during the peri-partum period.
  • Signs and symptoms of heart failure during the last month of pregnancy and first 5 months post-partum.
  • Clear absence of definite cause of heart failure.
  • Absence of cardiac disease during the last month of pregnancy.


Cardiac resonance imaging can be complimentary to the diagnosis of PPCM established by ECHO. [18],[19] Differential diagnosis may include but is not limited to amniotic fluid embolism, severe preeclampsia, pericarditis, myocardial infarction, pulmonary thromboembolism, myocarditis, sepsis, drug toxicity, metabolic disorders, aortic dissection and so on.

Treatment pattern is largely symptomatic and subjective as no conclusive therapeutic regimen exists due to paucity of clinical data from any of the clinical trials. Whatever therapeutic options have been established is solely based on our knowledge of various pathophysiological bases and treatment of isolated reported cases. While carrying out aggressive treatment, attention should be paid to drug safety for fetus as the harmful metabolite can possibly be secreted through breast milk. [20] Bromocriptine has proved its utility by inhibiting prolactin secretion, preventing deterioration of the left ventricle systolic function. [21]

Endotracheal intubation should be done when parturients are not responding to conventional and noninvasive methods. Extreme care should be taken during the postpartum period as mortality is highest (75%) during this period particularly in the first 3 months postpartum. The survival of parturients with PPCM can be depressive as they are mainly advised not to bear pregnancy again. Besides, the bio-psychosocial perspectives involving patient centered approach has to be given priority during treatment of such patients. [22]

In our nation with meager resources and lack of awareness among poverty stricken population maternal mortality is higher and follow up of such patients can be extremely challenging. Women and patient empowerment is a distant dream in our nation particularly in population hailing from rural and sub-urban areas and slums of urban areas. The early screening and management of such cases require support from government agencies, social organizations, public awareness and participation of each and every individual related to parturients with PPCM.

 
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Sliwa K, Hilfiker-Kleiner D, Petrie MC, Mebazaa A, Pieske B, Buchmann E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: A position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010;12:767-78.  Back to cited text no. 3
    
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