We describe the anaesthetic management for an elective Caesarean section, of a parturient with severe mitral stenosis and severe pulmonary hypertension, using low dose of hyperbaric bupivacaine and for spinal block, supplemented with epidural lignocaine to achieve an adequate level. This patient was vulnerable to develop complications such as hypotension and tachycardia, should conventional regional anaesthesia be employed. This case reports highlights the haemodynamic stability using carefully titrated combined spinal-epidural anaesthesia in a patient with severe mitral stenosis

Ahuja, V

Gai, B

Kumar, M

English

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Case Study27SAJAA 2009;15(3) • Jun/JulLow dose combined spinal and epidural anaesthesiain a parturient with severe mitral stenosis and severepulmonary arterial hypertension for Caesarean sectionGai B, MD, DNBAhuja V, MDKumar M, MDDepartment of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, IndiaCorrespondence to: Dr Vanita Ahuja, e-mail: vanitaanupam@yahoo.co.inABSTRACTWe describe the anaesthetic management for an elective Caesarean section, of a parturient with severe mitral stenosis andsevere pulmonary hypertension, using low dose of hyperbaric bupivacaine and for spinal block, supplemented with epidurallignocaine to achieve an adequate level. This patient was vulnerable to develop complications such as hypotension andtachycardia, should conventional regional anaesthesia be employed. This case reports highlights the haemodynamic stabilityusing carefully titrated combined spinal-epidural anaesthesia in a patient with severe mitral stenosis.IntroductionThe pregnant patient with heart disease presents a difficultchallenge to the obstetrician and the obstetric anaesthesiologist.A decision on appropriate anaesthesia modalities requires anunderstanding of the parturient’s pathophysiology as well aspharmacological therapy, and the impact on patient care. Thepresence of clinically significant maternal heart disease duringpregnancy increases the risk of adverse maternal, fetal andneonatal outcomes.1 Rheumatic heart disease is the most commoncardiac disorder in pregnancy in developing countries, withmitral stenosis being the single most prevalent lesion. Anaestheticcare requires preoperative optimisation, constant intraoperativehaemodynamic stabilisation, and postoperative pain relief todecrease complications and ensure better maternal and fetaloutcomes. We describe the anaesthetic management for anelective Caesarean section in a 26-year-old parturient with severemitral stenosis and severe pulmonary hypertension, using a lowdose of 5 mg hyperbaric 0.5% bupivacaine and 25 μg fentanylfor spinal block, supplemented with epidural lignocaine toachieve an adequate level. The patient had excellenthaemodynamic stability and outcome.Case report A 26-year-old parturient (gravida 2, para 1, height 155 cm,weight 58 kg), with known chronic rheumatic heart diseasewas scheduled for elective Caesarean delivery at 36 weeks’gestation. Closed mitral valvotomy had been performed 10years previously for critical mitral stenosis. She had a normalin-hospital vaginal delivery two years previously. In her secondpregnancy, she experienced one episode of dyspnoea andpalpitations at 26 weeks’ gestation, for which digoxin 0.25 mgand furosemide 2 0mg daily, and diltiazem 30 mg 8 hourlywere commenced orally. At 36 weeks’ gestation she was NYHAclass 2 and had no palpitations or chest pain. On examinationshe was comfortable, her heart rate was 80 beats per minuteand regular; blood pressure was 110/64 mm Hg and jugularvenous pressure was elevated. There was a mid diastolicmurmur and opening snap at the cardiac apex. There was noevidence of pulmonary oedema, hepatomegaly or peripheraloedema.The electrocardiogram (ECG) showed sinus rhythm, 86/minute,with a right axis deviation, premature atrial complexes and leftposterior fascicular block. Her echocardiogram demonstratedsevere mitral stenosis (0.8–1.0 cm2), trivial mitral regurgitationand severe tricuspid regurgitation. The peak pressure gradientgradient across the mitral valve was 39 mmHg (mean of 24mmHg), the ejection fraction was 56% and left ventricular systolicfunction was normal. There was severe pulmonary arterialsystolic hypertension (51 mmHg). Her chest radiograph showedcardiomegaly with prominent bronchovascular markings. Herhaemoglobin was 12 gm%, potassium 4.8 meq/L and renalfunction was within normal limits.It was decided that she should undergo elective Caesareansection at 36 weeks’ gestation. Pre-operatively she receiveddiazepam 5 mg orally and aspiration prophylaxis (Tab ranitidine150 mg and Tab metoclopramide 10 mg). In addition, antibioticprophylaxis was given 30 minutes prior to surgery (Inj ampicillin2 g and Inj gentamycin 80 mg).In the operating room noninvasive blood pressure monitoring,5 lead ECG and pulse oximetry was attached and an 18Gintravenous line was secured. Her oxygen saturation on roomair was 97%, the blood pressure was 106/64 mmHg and heartrate was 96 beats per minute. Under local anaesthesia the leftradial artery and right internal jugular vein were cannulated.The initial central venous pressure was 3 mmHg, prompting theadministration of 300 ml of normal saline over 30 minutes, andan increase in CVP to 6 mmHg.The patient received combined spinal-epidural anaesthesia atthe L3-4 level. Loss of resistance was obtained using an 18GTuohy needle. Spinal anaesthesia was then performed usinga needle through needle technique, employing a 26G Quinckespinal needle. The patient received 5 mg of hyperbaric 0.5%bupivacaine and 25 μg preservative-free fentanyl in thesubarachnoid space. This resulted in loss of sensation topinprick to the T10 dermatome, which was supplemented with3 ml 2% epidural lidocaine. This resulted in a loss of sensationto pinprick to the T6 dermatome. A female infant of 2.5 kgwas delivered with Apgar scores of 9 at 1 and 5 minutes, andumbilical arterial pH of 7.28. Blood loss during surgery wasapproximately 300 ml. Furosemide 10mg and oxytocin 5IUwere given slowly IV after delivery. Intraoperative heart ratewas 70–80/min and systolic blood pressure was 100–120 mmHg.SAJAA 2009; 15(3) 27-2828SAJAA 2009;15(3) • Jun/JulCase StudyAn infusion of bupivacaine 0.125% with fentanyl 2.0 μg/ml at5.0 ml/hr via the epidural catheter was started at the end ofsurgery for postoperative analgesia, and the patient wastransferred to high dependency unit. Her postoperative arterialblood gas analysis, chest radiograph, ECG, and haemoglobinlevel were within normal limits. On the following day, theepidural catheter was removed and the patient was transferredto the general ward. She was discharged on the fourthpostoperative day.DiscussionThe haemodynamic alterations associated with pregnancy poseunique problems for the patient with mitral stenosis. This lesionis the most common valvular defect associated with maternaldeath in pregnancy.2 With severe disease, such women face apregnancy-related mortality of 5%.3 Labour, delivery and theimmediate puerperium appear to be the times of the maximalrisk.4 Pulmonary arterial hypertension carries a very high riskduring pregnancy (30–50% mortality).5 A recent five year reviewof practice in an Australian hospital found that six of sevenparturients with NYHA 4 symptoms received regional anaesthesia(three for Caesarean section and  three for labour) and 12 outof 17 with NYHA 3 symptoms received regional anaesthesia (sixfor Caesarean section and  six for labour).There is no evidence to support any particular technique, butcardiovascular stability is the goal.5 Our anaesthetic goals wereto achieve adequate level of blockade after combined spinal-epidural anaesthesia without producing hypotension andconsequent tachycardia. Hypotension in such patients mayproduce myocardial ischaemia, and tachycardia may increasemyocardial oxygen consumption and also decrease left ventricularfilling time, which is a critical factor in mitral stenosis. Our goalin fluid management was normovolaemia since hypervolaemiamay lead to pulmonary oedema and hypovolaemia would havedecreased her preload. Central venous pressure monitoring wasused for fluid management. We did not use a pulmonary arterycatheter in this patient as her status was NYHA 2 and she hadnot been in heart failure. Moreover, there are documented casesof pulmonary artery rupture and pulmonary artery thrombosiswhen floatation catheters were used in patients with severepulmonary hypertension, and their use has not been shown toimprove survival in these patients.6-7Low dose spinal anaesthesia given as part of a combined spinal-epidural (CSE) technique has been used effectively to provideanaesthesia for Caesarean section.8-9 It is important in clinicalsettings where hypotension may be poorly tolerated. Theincidence of hypotension following spinal anaesthesia is reportedto be as high as 94% in uncomplicated pregnancies.8 Nointerventions have been able to prevent hypotension completelybut its incidence decreased 31% when intrathecal isobaricbupivacaine 5 mg and fentanyl 25 μg were used.8Various combinations of low dose spinal anaesthesiasupplemented by epidural anaesthesia for Caesarean sectionhave been described in the literature. Fan et al concluded thatlow dose intrathecal hyperbaric bupivacaine (5 mg) incombination with 2% epidural lidocaine can provide effectiveand rapid anaesthesia for Caesarean section with minimumadverse effects in healthy term parturients.10Lim Y et al used ultra low dose spinal bupivacaine (2.5 mg),fentanyl 25 μg and morphine 100 μg, with 3 ml of 1.5% epidurallidocaine for Caesarean delivery in an obese, preeclampticpatient.11Hamlyn EL et al used a low-dose CSE technique in an obstetricpatient with mitral stenosis, employing intrathecal hyperbaricbupivacaine 5 mg with fentanyl 20 μg, followed by 5.0 mlepidural normal saline. During surgery, anaesthesia wassupplemented by three, 2.0 ml increments of 0.5 % bupivacaineand one bolus of 25 μg fentanyl.12Turker et al used continuous spinal analgesia (CSA) over-the-catheter technique (reduces risk of postdural puncture headache)in five parturients having moderate to severe mitral stenosiswith pulmonary arterial hypertension. Initially, spinal fentanyl25 μg and thereafter increments of fentanyl 10 μg providedeffective analgesia during first stage of labour but during thesecond stage, 0.5% heavy bupivacaine 2.5 mg with saline 0.5ml was used to supplement analgesia. This technique allowedmaternal cardiovascular stability with analgesia for labour andno significant fetal heart rate abnormalities.In our parturient, a combination of the reliability of intrathecalblockade with the flexibility of an epidural catheter providedtitratable, haemodynamically stable anaesthesia. CSE using lowdose intrathecal bupivacaine and fentanyl with epidural lignocainesupplementation was adequate for the performance of anuncomplicated Caesarean section with minimal side effects andgood fetal outcome. In the early postoperative period, patientswith mitral stenosis are at risk of developing pulmonary oedema,precipitated in part by auto transfusion from the contractinguterus. This may be exacerbated by the cessation of epiduralanalgesia and the return of sympathetic vascular tone.14 Wecommenced an epidural infusion in the postoperative periodand the patient had an uneventful recovery.DeclarationThe authors declare that they have no financial or personalrelationship(s) which may have inappropriately influenced themin writing this paper.References:1. Siu SC, Colman JM, Sorensen S, et al. Adverse neonatal and cardiac outcomesare more common in pregnant women with cardiac disease. Circulation .2002May;105(18):2179–84.2. Hibbard LT. Maternal mortality due to cardiac disease. Clin Obstet Gynecol1975 Sep;18(3):27.3. Ueland K. Rheumatic heart disease and pregnancy. In: Elkayam U, GleicherN, eds. Cardiac problems in pregnancy. New York: Alan R. Liss, 1982:81.4. Ueland K. Intrapartum management of the cardiac patient. Clin Perinatol1981Feb; 8(1);155.5. Burt CC, Durbridge J. Management of cardiac disease in pregnancy. ContinuingEducation in Anaesthesia, Critical Care & Pain.2009 Mar;9(2):44–7.6. Barash P, Nardi D, Hammond G, Walker-Smith G, Capuano D, Laks H, et al.Catheter-induced pulmonary artery perforation. Mechanisms, management,and modifications. J Thorac Cardiovasc Surg. 2005 Sep;130(3):899–900.7. Monnery L, Nanson J, Charlton G. Primary pulmonary hypertension in pregnancy:a role for novel vasodilators. Br J Anaesth .2001Aug;87(2);295–8.8. Ben-David B, Miller G, Gavriel R, Gurevitch A. Low-dose bupivacaine-fentanylspinal anesthesia for cesarean delivery. Reg Anesth Pain Med. 2000 May-June;25(3):235–9.9. Vercauteren MP, Coppejans HC, Hoffmann VL, et al. Small-dose hyperbaricversus plain bupivacaine during spinal anesthesia for cesarean section. AnesthAnalg .1998 May;86(5):989–93.10. Fan SZ, Susetio L, Wang YP, Chang YJ, Liu CC. Low dose of intrathecalhyperbaric bupivacaine combined with epidural lidocaine for cesarean section-a balance block technique. Anesth Analg. 1994 Mar;78(3):474–7.11. Lim Y, Loo CC, Goh E. Ultra low dose combined spinal and epidural anesthesiafor cesarean section. Int J of Obstet Anesth. 2004 Jul;13(3);198–200.12. Hamylyn EL, Douglass CA, Platt F, Crowhurst JA, Stocks GM. Low-dosesequential combined spinal-epidural: an anesthetic technique for cesareansection in patients with significant cardiac disease. Int J of Obstet Anesth.2005 Oct;14(4):355–61.13. Turker G, Gurbet A, Aksu HA. Continuous spinal analgesia in parturients withsevere heart disease. Int J of Obstet Anaesth .2007 Feb;16(3):297–9.14. Ngankee WD, Shen J, Chiu ATO, Lok I, Khaw KS.Combined spinal-epiduralanalgesia in the management of laboring parturients  with mitral stenosis.Anaesth Intensive Care. 1999 Mar;27(5):523–6.

Low dose combined spinal and epidural anaesthesia in a parturient with severe mitral stenosis and severe pulmonary arterial hypertension for Caesarean section

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Low dose combined spinal and epidural anaesthesia in a parturient with severe mitral stenosis and severe pulmonary arterial hypertension for Caesarean section

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