Peripartum Cardiomyopathy (PPCM): anesthetic and obstetric monitoring, management and medico-legal aspect

Baldini D.

Del Rio A.

Negro F.

English

Archivio della ricerca- Università di Roma La Sapienza

3551Dear Editor,The incidence of Peripartum Cardiomyopathy (PPCM) during pregnancy has increased over the past few decades, partly because of rising average maternal age. Causative factors commonly associated with higher rates of age-related conditions are obesity, diabetes mellitus, hypertension, and cardiovascular problems. There are some important medico-legal implications related to early diagnosis and treatment of cardiovascular complications during pregnancy, delivery, and postpartum. Firstly, it should be considered that the onset of cardiomyopathy can easily be overlooked and missed. Hence, women of advanced maternal age need to be closely monitored throughout their pregnancies. It is advisable for such patients to give birth by cesarean section (CS)1. The outcome is likely to be closely related to maternal and fetal complications. Prior to anesthesia and CS, these patients need to go through preanesthetic assessment, in order to minimize the risk of cardiovascular complications stemming from CS2,3.Invasive hemodynamic monitoring (of the kind previously carried out by the Vigileo hemodynamic monitor) or non-invasive monitoring techniques (e.g. Impedance cardiography) and the administration of low drug doses are paramount, because the cardiac reserve is generally reduced in such high-risk patients. The degree of hemodynamic stability, a satisfactory sensory block and rapid mobilization provided by low drug doses may be particularly advantageous in those patients4-7. Monitoring during anesthesia for CS and in postpartum period has to be provided in PPCM patients in light of the high rates of high morbidity and mortality linked to that segment.When high drug doses are used in single shot spinal anesthesia for CS, cardiac functions may get worse, leading to lower Systemic Vascular Resistance (SVR), Stroke Volume (SV) and Cardiac Output (CO). These effects of drugs may also decrease, in such a way, placental perfusion, thus negatively affecting maternal and fetal well-being5. In case of PPMC patients, in order to avoid the administration of high drug doses for neuraxial anesthesia during CS, it is important to use combined spinal epidural (CSE) techniques; single shot spinal anesthesia is not indicated. By using the CSE technique, we can administer low drug doses (LDLA), and inject some pain control drugs, if necessary (e.g. paracetamol)8-10.Malvasi et al11 confirm that Low-Dose Neuraxial Anesthesia (LDLA), a CSE technique with reduced dose of drugs, usually lipophilic opioids and local anesthetics, can provide a rapid and effective analgesia with minimal hemodynamic effects, maintaining leg mobility. In the two groups of patients that were observed, 5 ml of levobupivacaine (LB) 0.15% were administered, with a 5 mcg of sufentanil in the former group, vs. 4 ml of LB 0.125% with 5 mcg of sufentanil both into the spinal space, and a tuohy 18-g needle, 3-7 mL of xylocaine carbonate 0.5% plus 1 mcg/ml of sufentanil in the latter group. If needed, an epidural catheter was used for top-up during CS and for postoperative analgesia. In case of complications during CS and post-partum arising in such patients, fetal distress (brain sparing) owing to placental hypoperfusion and maternal cardiovascular complications (cardiac failure, myocardial infarction or cardiac arrest) may occur9.For those PPCM patients, a cardiologic, obstetric and anesthesiological multi-disciplinary approach needs to be put in place during pregnancy, CS and in postpartum. Such approach arguably constitutes a good practice in medicine and it is of utmost importance for a favorable maternal and fetal outcome.European Review for Medical and Pharmacological Sciences 2019; 23: 3551-3552Corresponding Author: Alessandro Del Rio, MD; e-mail: alessandrodelrio50@gmail.comPeripartum Cardiomyopathy (PPCM): anesthetic and obstetric monitoring, management and medico-legal aspectsD. Baldini, F. Negro, A. Del Rio 3552In case of maternal and fetal complications, tort lawsuits aimed at seeking compensation are common, and overall, the litigation risk is high. Compliance with guidelines and good practices grounded in institutional recommendations and medical evidence, as for other aspects of childbirth12, certainly represents an adequate, cautious stance that can shield operators from malpractice allegations2,13. Moreover, this approach can help reduce liability insurance costs in a field where compensatory damages can be extremely high for doctors and health care facilities, making it difficult to find suitable insurance coverage14-16.Conflict of interestThe authors declare no conflicts of interest.References 1) D’Ambrosio A, spADAro s, mirAbellA l, NAtAle C, CotoiA A, De CAprAris A, meNgA r, sAlAtto p, mAlvAsi A, brizzi A, tiNelli A, DAmbrosio m, CiNNellA g. The anaesthetic and recovery profile of two concentrations (0.25% and 0.50%), of intrathecal isobaric levobupivacaine for combined spinal-epidural (CSE) anaesthesia in patients undergoing modified Stark method caesarean delivery: a double blinded randomized trial. Eur Rev Med Pharmacol Sci 2013; 17: 3229-3236. 2) KuCzKowsKy Km, beCK r. Anesthesia in labor and delivery. In: Di Renzo GC, Bergella V, Malvasi A. Good practice and malpractice in labor and delivery. Milan, Italy, EDRA 2019; pp.131-142. 3) [No Authors listeD]. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016; 124: 270-300. 4) beCK r, milellA l, lAbellArte C. Continuous non-invasive measurement of stroke volume and cardiac index in infants and children: comparison of Impedance Cardiography NICaS® vs CardioQ® method. Clin Ter 2018; 169: e110-e113. 5) D’Ambrosio A, CotoiA A, beCK r, sAlAtto p, zibAr l, CiNNellA g. Impedance cardiography as tool for continuous hemodynamic monitoring during cesarean section: randomized, prospective double blind study. 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Beijing Da Xue Xue Bao Yi Xue Ban 2012; 44: 804-807.10) tittArelli r, pellegriNi m, sCArpelliNi mg, mAriNelli e, bruti v, Di luCA Nm, busArDò fp, zAAmi s. Hepatotoxicity of paracetamol and related fatalities.  Eur Rev Med Pharmacol Sci 2017; 21: 95-101.11) mAlvAsi A, tiNelli A, stArK m, poNtrelli g, brizzi A, wetzl rg, beNhAmou D. Low-dose sequential combined spinal-epidural anaesthesia in elective Stark caesarean section: a preliminary cohort study. Eur Rev Med Pharmacol Sci 2010; 14: 215-221.12) mAlvAsi A, moNtANAri vergAllo g, tiNelli A, mAriNelli e. “Can the intrapartum ultrasonography reduce the legal liability in dystocic labor and delivery?” J Matern Fetal Neonatal Med 2018; 31: 1108-1109.13) moNtANAri vergAllo g, zAAmi s. Guidelines and best practices: remarks on the Gelli-Bianco law. Clin Ter 2018; 169: 82-85. 14) zAAmi s, mAlvAsi A, mAriNelli e. Fundal pressure: risk factors in uterine rupture. The issue of liability: complication or malpractice? J Perinat Med 2018; 46: 567-568.15) zAAmi s, moNtANAri vergAllo g, mAlvAsi A, mAriNelli e. Uterine rupture during induced labor after myomectomy and risk of lawsuits. Eur Rev Med Pharmacol Sci 2019; 23: 1379-1381.16) mAlvAsi A, zAAmi s, tiNelli A, trojANo g, moNtANAri vergAllo g, mAriNelli e. Kristeller maneuvers or fundal pressure and maternal/neonatal morbidity: obstetric and judicial literature review. J Matern Fetal Neonatal Med 2019; 32: 2598-2607.D. Baldini1, F. Negro2, A. Del Rio2 1Centro di Procreazione Medicalmente Assistita MOMO’ fertiLIFE, Bisceglie, Italy2Department of Anatomical, Histological, Forensic and Orthopedic Sciences, “Sapienza” University of Rome, Rome, Italy

Peripartum cardiomyopathy (PPCM): anesthetic and obstetric monitoring, management and medico-legal aspects

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Peripartum cardiomyopathy (PPCM): anesthetic and obstetric monitoring, management and medico-legal aspects

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