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Continuous Fetal Monitoring Using Umbilical Artery Doppler Flow Velocity Indices

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Continuous Fetal Monitoring Using Umbilical Artery Doppler Flow Velocity Indices Case Report Cardiac surgery during pregnancy: Continuous fetal monitoring using umbilical artery Doppler flow velocity indices Manisha Mishra, Ravindra Sawhney, Anil Kumar, Kumar Ramesh Bapna1, Vijay Kohli1, Harpreet Wasir1, Naresh Trehan1 Departments of Cardiaothoracic and Vascular Anesthesiology, 1Departments of Cardiaothoracic and Vascular Surgery, Medanta The Medicity, Gurgaon, Haryana, India ABSTRACT The fetal death rate associated with cardiac surgery with cardiopulmonary bypass (CPB) is as high as 9.5‑29%. We report continuous monitoring of fetal heart rate and umbilical artery flow‑velocity waveforms by transvaginal ultrasonography and their analyses in relation to events of the CPB in two cases in second trimester of pregnancy undergoing mitral valve replacement. Our findings suggest that the transition of circulation from corporeal to extracorporeal is the most important event during surgery; the associated decrease in mean arterial pressure (MAP) at this stage potentially has deleterious effects on the fetus, which get aggravated with the use of vasopressors. We suggest careful management of CPB at this stage, which include partial controlled CPB at initiation and gradual transition to full CPB; this strategy maintains high MAP and avoids the use of vasopressors. Maternal and fetal monitoring can timely recognize the potential problems and provide window for the required treatment. Received: 27‑04‑13 Accepted: 08‑10‑13 Key words: Cardiac surgery; Cardiopulmonary bypass; Fetal monitoring; Mitral valve disease; Pregnancy INTRODUCTION review.[4] This report documents the procedure details and outcome of cardiac surgery in The incidence of heart disease in pregnant two pregnant women in second trimester of women ranges from 1% to 4%, accounting for pregnancy with rheumatic mitral valve disease 10‑15% of maternal deaths, which is similar to at our tertiary care referral hospital. the non‑pregnant women undergoing similar cardiac procedures on cardiopulmonary CASE REPORTS bypass (CPB).[1] The fetal mortality in such patients has remained unchanged at Case 1 9.5‑29%, with an average of 19% over the A 33‑year‑old gravida III, para II was admitted [1‑3] Access this article online past 25 years. Arguably, perioperative to our hospital at 16‑week gestation with Website: www.annals.in management of pregnant women undergoing palpitation and acute shortness of breath (NYHA PMID: cardiac surgery with CPB should take the Class IV). Her medical history revealed history *** well‑being of both mother and fetus into of balloon mitral valvulotomy (BMV) at the DOI: 10.4103/0971-9784.124141 consideration; fetal and maternal monitoring age of 21 years for rheumatic mitral valve Quick Response Code: during cardiac surgery with CPB can allow stenosis (MS). The MS was diagnosed during the greatest control of risk in the pregnant first pregnancy when she became symptomatic patient. Although, successful valve repair at 20 weeks gestation. On examination, and replacements during pregnancy have she was found to be in atrial fibrillation been reported.[4‑6] Most of these studies are with fast ventricular rate of 146 beats/min. case reports, at times organized as literature Transthoracic echocardiography revealed Address for correspondence: Dr. Manisha Mishra, D-2, Front Portion, SF, Kalindi Colony, New Delhi-110065, India. E-mail: [email protected] 46 Annals of Cardiac Anaesthesia Vol. 17:1 Jan-Mar-2014 Mishra: Cardiac surgery during pregnancy and umbilical artery flow‑velocity indices monitoring a thickened, heavily calcified stenosed mitral valve vena cava cannulation, crystalloid prime, Capiox with an area of 0.6 cm2, moderately severe eccentric sx 18R hollow fiber membrane oxygenator (Terumo jet of mitral regurgitation and a clot in left atrial (LA) cardiovascular systems Inc., Elkton, MD 21921) and appendage, which ruled out BMV as a treatment 38 µ arterial filter (AFFINITY®, Medtronic, Inc. MN option. Hence, mitral valve repair/replacement was the 55432). Initially, to avoid precipitous decrease in treatment of choice. Obstetrical examination revealed mean arterial pressure (MAP), partial CPB with a positive fetal viability and an ultrasound demonstrated single venous cannula was established then gradually, normal development consistent with the gestational after ensuring hemodynamic stability, full CPB was age of 16 weeks. established. Thereafter, aorta was clamped, during clamping myocardium was protected by topical cooling Case 2 with ice slush and hyperkalemic, cold (4°C) blood A 26‑year‑old gravida II, para I was admitted with cardioplegia infused into the aortic root at 10 ml/kg complaints of breathlessness on exertion (NYHA body weight at 20 min interval. Systemic normothermia Class III) at 17 weeks of gestation. She had undergone at 35‑36°C was maintained. The MAP during CPB was BMV 3 years ago during her first pregnancy when aimed to be maintained at 70‑80 mmHg and the CPB she went into congestive cardiac failure at 24 weeks flow was kept between 2 and 2.5 L/m2/min. If MAP gestation. At present, she was in normal sinus rhythm was lower than 70 mmHg; initially, the CPB flow with a heart rate of 112 beats/min. Echocardiography was increased, vasoconstrictors were used sparingly. demonstrated severe MS with an area of 0.8 cm2, Hematocrit was maintained between 25‑30% and moderate tricuspid valve regurgitation and moderate PaO 2 at 400 mmHg. Pulsatile flow was maintained pulmonary artery hypertension. Surgery was the only throughout CPB, using Terumo Sarns™ Modular option at this stage of gestation. Perfusion System 8000 (Terumo CVS‑Ann Arbor MI 48103). Case 1 underwent mitral valve replacement Both families were counseled about the risks of the with 27 mm (Epic™ St. Jude Medical Minnesota 55117 procedure. Progesterone 100 mg intramuscular was USA) bioprosthesis along with removal of LA clot and started a day prior to surgery. Services of a dedicated ligation of LA appendage. Case 2 underwent mitral obstetrician and a ultrasonologist were ensured inside valve replacement with similar 25 mm bioprosthesis the operating room to monitor fetal heart rate (FHR) along with tricuspid valve repair. Aortic cross clamp and interpret umbilical artery flow‑velocity waveform time was 30 min in Case 1 and 48 min in Case 2. After throughout the procedure. As both cases are similar in unclamping of the aorta, cardiac activity resumed their clinical profile and surgery was performed within after a single defibrillation with 10 joules in Case 1, an interval of 2 months following similar technique, whereas it returned spontaneously in Case 2. Both hence the anesthetic and CPB management are being the patients were weaned from CPB without any discussed together. Baseline FHR and rhythm were inotropic support; the CPB times were 38 min and recorded before induction of anesthesia. Anesthesia 55 min, respectively [Table 1]. After the patients were was induced with etomidate and fentanyl; vecuronium weaned off CPB, protamine was administered and 0.1 mg/kg was administered to facilitate endotracheal hemostasis completed. In both the cases after bypass, intubation. Anesthesia was maintained with O2: Air the FHR gradually increased (over 15 min) to 135‑150 mixture (50:50), isoflurane 1‑1.5%, fentanyl 5 µg/kg, beats/min. Patients were shifted to intensive care unit and incremental doses of vecuronium. During surgery, and continuous maternal and fetal monitoring was the patients were monitored with radial artery continued. Patients were extubated 6 h and 8 h after pressure, a pulmonary artery catheter placed through surgery. Post‑operative course was uneventful. the right internal jugular vein, and transesophageal echocardiography. Additionally, FHR and umbilical MAP, FHR and umbilical artery Doppler flow‑velocity indices artery flow‑velocity waveforms were continuously at the initiation of CPB and during CPB monitored by transvaginal ultrasonography (Siemens, Progressive deceleration of FHR was noted with the ACUSON X300™ ultrasound system and transvaginal onset of CPB in both the cases [Figure 1]. In Case 1, the ultrasound probe 9‑14 MHz) and analyzed in relation initiation of CPB was accompanied by fetal bradycardia, to events of the CPB. Heparin, 4 mg/kg was given the FHR decreased to 80 beats/min; the CPB flow was for anticoagulation and activated clotting time was increased to 3.5 L/m2/min, which led to an increase maintained at >550 s.[4] CPB management was in FHR to > 100/min. The FHR recovered completely standard and included aortic and two separate within 15 min of separation from CPB. In Case 2, Annals of Cardiac Anaesthesia Vol. 17:1 Jan-Mar-2014 47 Mishra: Cardiac surgery during pregnancy and umbilical artery flow‑velocity indices monitoring Table 1: Summary of cardiac procedures done on both pregnant patients Variables Case 1 Case 2 Maternal Age (yrs) 33 26 BSA (m²) 1.7 1.4 Fetal gestation (wks) 16 15 Diagnosis RHD with RHD with Mitral stenosis mitral stenosis and LA Clot and Tricuspid Regurgitation Indication for surgery Cardiac failure Symptomatic severe MS Surgical procedure MVR MVR+Tricuspid repair Aortic clamp 30 48 time (min) CPB time (min) 38 55 Lowest Temperature 35.2° C 35.5° C Figure 1: Graphic depiction of fetal and maternal vital signs during surgery Hospital stay 6 days 10 days Fetal outcome Term, normal Fetal demise baby up, the resistive index (RI) increased to 1.96 and the Maternal outcome Good Good pulsatility index (PI) was 6.2 [Figure 3], which indicates RHD: Rheumatic heart disease, MVR: Mitral valve replacement, an increased utero‑placental resistance. Interestingly, MS: Mitral stenosis, LA: Left atrium the arterial blood gases remained normal throughout the CPB and did not indicate any problem with the the FHR decreased to 40 beats/min after initiation of fetal circulation. CPB; this decrease in FHR was accompanied by a fall in MAP to 46 mmHg and responded transiently to an Outcome of pregnancy increase in pump flow rates. The MAP increased in a Case 1 recovered uneventfully and was discharged few minutes to 65 mmHg after the administration of from the hospital on the 6th post‑operative day.
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