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Positive Maternal and Foetal Outcomes After Cardiopulmonary Bypass Surgery

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Positive Maternal and Foetal Outcomes After Cardiopulmonary Bypass Surgery Case Study: Positive maternal and foetal outcomes after cardiopulmonary bypass surgery Positive maternal and foetal outcomes after cardiopulmonary bypass surgery in a parturient with severe mitral valve disease aMokgwathi GT, MBChB aLebakeng EM, MBChB, DA(SA), MMed(Anaes) bOgunbanjo GA, MBBS, FCFP(SA), MFamMed, FACRRM, FACTM, FAFP(SA), FWACP(Fam Med) aDepartment of Anaesthesiology, University of Limpopo (Medunsa Campus) bDepartment of Family Medicine and Primary Health Care, University of Limpopo (Medunsa Campus) Correspondence to: Dr GT Mokgwathi, e-mail: [email protected] Keywords: anaesthesia, cardiac surgery, parturient, cardiopulmonary bypass surgery, mitral valve replacement Abstract This case study describes the successful management of a parturient with severe mitral stenosis and moderate mitral regurgitation who underwent cardiopulmonary bypass (CPB) surgery. A healthy baby was delivered by Caesarean section 11 days later. The effects of CPB surgery and mitral valve replacement on parturient and foetus are discussed. Peer reviewed. (Submitted: 2011-01-04, Accepted: 2011-06-16) © SASA South Afr J Anaesth Analg 2011;17(4):299-302 Introduction she was classified as New York Heart Association (NYHA) class III and World Health Organization (WHO) heart Heart disease is the primary cause of nonobstetric mortality failure stage C. Her blood pressure was 90/60 mmHg in pregnancy, occurring in 1-4 % of pregnancies1-3 and and her heart rate was 82 beats per minute and regular. accounting for 10–15 % of maternal mortality in developed She had a tapping apex beat, loud first heart sound, loud countries.1,2 Cardiac disease contributes to 40.2% of pulmonary component of the second heart sound and a maternal deaths in South Africa.4 Soma-Pillay et al noted grade 3/4 diastolic murmur heard loudest at the apex. The that rheumatic valvular heart disease complicated 63.5% echocardiograph confirmed the diagnosis of severe MS of pregnancies in Pretoria.4 Mitral regurgitation (MR) and with a mitral valvular area of 0.88 cm², a mean gradient of mitral stenosis (MS) represent the most common causes 1.85 m/s or 15 mmHg, MR, right ventricular pressure of of valvular disorders requiring surgery during pregnancy, 42 mmHg and ejection fraction of 52%. with an incidence of 27.5% and 20.8%, respectively.4 Arnoni et al3 noted that 93% of cardiac surgeries during The patient was hospitalised until 33 weeks’ gestation. pregnancy were for valve disease, of which 70% were for During this period she was haemodynamically stable, mitral valve disease.1,5 Cardiovascular maternal morbidity maintaining blood pressures of 80/50 to 90/60 mmHg and mortality during pregnancy correlate strongly with and heart rates of 60–84 beats per minute, and she did maternal functional status.1,2,5 Pregnant women tolerate not develop heart failure. Management included bed rest cardiopulmonary bypass (CPB) surgery as well as non- and foetal monitoring by non-stress tests and ultrasound. pregnant women do,2,6 but foetal morbidity and mortality are Penicillin VK 250 mg was administered twice daily for high,2,5,6 due to increased uterine activity and contractions prophylaxis, and she was anticoagulated with enoxaparin that reduce placental perfusion.5,7 Untreated maternal heart 40 mg subcutaneous injection. disease also places the foetus at risk,2 and if open heart Although maximal physiological changes usually occur surgery is required, it is best undertaken in the second by 32 weeks and there were no signs of further functional trimester.2,6,8 This case study describes positive maternal deterioration, the patient’s functional status remained and foetal outcomes after CPB surgery in a parturient with very poor clinically with very limited exercise tolerance, severe mitral valve disease. independent of the echo result. This precluded a vaginal delivery, which would have significantly increased her Case study cardiac output and heart rate, exposing the patient to the A 17-year-old, 28 weeks’ pregnant patient with a body mass risk of haemodynamic compromise. Further multidisciplinary index of 22 kg/m² was admitted to the Dr George Mukhari discussions took into consideration that Caesarean section Hospital with a diagnosis of severe MS and moderate MR. does not relieve the haemodynamic stress of the pueperium, Being short of breath and complaining of easy fatiguability, with a potential for functional deterioration and relatively South Afr J Anaesth Analg 299 2011;17(4) Case Study: Positive maternal and foetal outcomes after cardiopulmonary bypass surgery Case Study: Positive maternal and foetal outcomes after cardiopulmonary bypass surgery poor outcomes associated with premature foetuses in our Inotropic support with dobutamine infusion at 5 µg/kg/ institute. The risk-benefit ratio in our setting was therefore minute and 500 ml of salvaged blood was administered after weighted towards performing a mitral valve replacement weaning from CPB surgery and continued postoperatively in (MVR) prior to delivery. Informed consent for an MVR was the intensive care unit. Foetal bradycardia was noted during provided by the patient’s mother, as the parturient was a the initiation of CPB surgery, which resolved with restoration minor. of maternal temperature and normalising of circulation. Preoperatively the patient was haemodynamically stable During sternal closure, heparin was neutralised with 180 with a blood pressure of 112/69 mmHg and a heart rate of mg of protamine. The duration of anaesthesia and surgery 101 beats per minute. Ultrasonography showed a viable was three hours and 30 minutes. The patient was extubated foetus of 33 weeks’ gestation and an estimated weight of after six hours in the intensive care unit, after which she 1 900 g. Premedication consisted of diazepam 5 mg, received oxygen by facemask and a six-hourly regimen of sodium citrate 30 ml orally and intravenous metoclopromide subcutaneous enoxaparin 60 mg was begun. She remained 10 mg. After preoxygenation, general anaesthesia was haemodynamically stable and the foetal heart rate varied induced with the patient supine and with left lateral tilt between 130 and 140 beats per minute. Postoperative to avoid aortocaval compression, using intravenous recovery was uneventful and the postoperative monitoring fentanyl 5 µg/kg for three to five minutes, followed by data are summarised in Table II. etomidate 0.3 mg/kg. Tracheal intubation was facilitated with suxamethonium 1.5 mg/kg. Anaesthesia was Table II: Postoperative parameters for the mother and foetus maintained using a continuous fentanyl infusion at a Value 0 h 12 h 24 h 48 h rate of 0.1 ug/kg/hour supplemented with midazolam a 0.2 mg/kg, vecuronium 20 µg/kg, sevoflurane 1%, and air MAP (mmHg) 78 70 75 70 bCVP (mmHg) 10–14 14–18 8–13 8–13 and oxygen at FiO2 of 0.7. Intraoperative monitoring included c electrocardiography, pulse oximetry, end-tidal carbon PaO2 (kPa) 60.6 14.1 22.6 14.1 d dioxide measurement, rectal temperature probe, urinary PaCo2 (kPa) 3.6 4.98 3.07 4.94 catheter for fluid balance, intra-arterial blood pressure pH 7.43 7.43 7.42 7.42 monitoring and central venous pressure measurement. eBE -1.1 -1.2 -5.5 -01 Foetal heart rate was monitored using cardiotocography. Potassium (mmol) 3.6 5.1 5.9 4.1 Perioperative monitoring data are summarised in Table I. Lactate (mmol) 3.8 1.5 1.8 1.2 After administering heparin 1 800 IU, we monitored the Haemoglobin (g/dl) 8.4 9.8 8.1 10.3 patient’s anticoagulation status using activated clotting Glucose (mmol) 3.1 7.0 5.9 5.9 times. The mitral valve was replaced in a CPB surgery fFHR (beats/ time of 50 minutes and an aortic cross-clamp time of 115–120 110–130 110–144 130–150 minute) 39 minutes. Perfusion flow rates ranged between a= mean arterial pressure, b= central venous pressure, c= partial oxygen pressure, 2 o 3.6-4.1 l/m /minute. Rectal temperature was 32.5–35.6 C. d= partial carbon dioxide pressure, e= base excess, f= foetal heart rate Table I: Perioperative parameters for the mother and foetus Pre-induction Post-induction Pre-aCPB CPB Post-CPB Conclusion bMAP/flow rate 80 85 72 60–100/3.6-4.1 65 60 cHR (beats/minute) 101 90 76 106 100 dCVP (mmHg) 5 5 12 16 16 17 e FiO2 (%) 1.0 0.7 0.7 0.7 0.7 0.7 f SaO2 (%) 99 99 99 99 99 g PaO2 (kPa) 39.0 39.0 39.0 37.6 h EtCO2 (mmHg) 36 36 28 28 32 Temperature (·°C) 37 36 36 32.5–35.6 35.7 35.5 pH 7.43 7.43 7.38 7.42–7.55 7.47 7.47 jBE -3.6 -3.6 -5.0 -0.4–2.0 0.5 0.5 Potassium (mmol) 4.7 4.7 4.8 5.7–8.7 4.7 4.7 Haemoglobin (g/dl) 11.5 11.5 11.2 6.6–8.7 8.0 8.0 kACT(seconds) 114 386 405–480 116 116 lFHR (beats/minute) 110–120 110–120 110–120 50–70 130–145 130–140 a= cardiopulmonary bypass, b= mean arterial pressure, c= heart rate, d= central venous pressure, e= fraction of inspired oxygen, f= oxygen saturation, g= partial oxygen pressure, h= end-tidal carbon dioxide, j= base excess, k= activated clotting time, l= foetal heart rate South Afr J Anaesth Analg 300 2011;17(4) Case Study: Positive maternal and foetal outcomes after cardiopulmonary bypass surgery Case Study: Positive maternal and foetal outcomes after cardiopulmonary bypass surgery Eleven days postoperatively, the non-stress test indicated increase by one NYHA class.12 Patients presenting with probable foetal distress and an emergency Caesarean severe symptoms (i.e.
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