OB Case

[Libertas]

---

Members don't see this ad.

Thought I'd post an interesting case for discussion.

Patient in her ~30s presents at 37w pregnant g1p0, with a mechanical mitral valve which was placed when she was <10yo. The valve may now be somewhat small for size. TTE shows severe mitral stenosis, moderate aortic regurg, severe LVH, PASP not obtainable. Before pregnancy, she was relatively asymptomatic, but currently she presents with functional limitations with even minor physical activity. She was on warfarin at home for anticoagulation but was admitted by OB to bridge to heparin gtt and for diuresis by cardiology. Plan by OB was to plan for vaginal delivery holding heparin at appropriate times for epidural placement and then restarting heparin and holding again as induction of labor progresses.

 

[Planktonmd]

Thought I'd post an interesting case for discussion.

Patient in her ~30s presents at 37w pregnant g1p0, with a mechanical mitral valve which was placed when she was <10yo. The valve may now be somewhat small for size. TTE shows severe mitral stenosis, moderate aortic regurg, severe LVH, PASP not obtainable. Before pregnancy, she was relatively asymptomatic, but currently she presents with functional limitations with even minor physical activity. She was on warfarin at home for anticoagulation but was admitted by OB to bridge to heparin gtt and for diuresis by cardiology. Plan by OB was to plan for vaginal delivery holding heparin at appropriate times for epidural placement and then restarting heparin and holding again as induction of labor progresses.

She is most likely not going to handle the demand on her heart needed for labor and vaginal delivery especially that her labor is likely going to be long since she is a primagravida. She should get an elective c section by an obstetrician who is able to perform the surgery quickly and without crazy blood loss.
She will need a new Mitral valve but hopefully this could be delayed until she recovers from her C section.

 

[Wiscoblue]

Pulmonary hypertension and RV failure will result from mitral stenosis. Usually the LV is protected from dilatation or hypertrophy. But you say she has severe LVH? It's probably more like severe LV dilatation without hypertrophy, from the AI.

I think she should have a C Section under general anesthesia. (I would be very reluctant to poke this woman in the back. A patient in heart failure like this will have large veins everywhere, even in the epidural space.)She might need to be on a vent and be diuresed for a few hours after. Once things settle, she needs to be evaluated for a double valve replacement to be done in a couple of weeks or a month.


Sent from my iPad using Tapatalk

 

[Noyac]

I think the question is about labor pain relief and not c/s. We know you must plan for c/s in this pt anyway.

I have a question for everyone though.

We all know what happens with labor in regards to blood volume and CO. We can all see where there may be trouble. So my question to this group is, how might a labor epidural help or hurt this situation?

This may be where the OP is headed.

 

[Aralc]

I think the question is about labor pain relief and not c/s. We know you must plan for c/s in this pt anyway.

I have a question for everyone though.

We all know what happens with labor in regards to blood volume and CO. We can all see where there may be trouble. So my question to this group is, how might a labor epidural help or hurt this situation?

This may be where the OP is headed.

OP said vaginal. This may be a naive question since the last time I dealt with a laboring patient was in medical school, but what is the point of making her labor if you are just going to end up in c/s anyways? I think that's why Plankton said elective c/s?

I will let others deal with your question, because it still may be interesting from a physiology POV.

 

[psychbender]

Plankton wasn't suggesting that she labor, then have c/s, but rather that she have a scheduled section at 38-39wks before she has the chance to labor, to avoid the CV changes associated with labor and delivery.

 

[urge]

Thought I'd post an interesting case for discussion.

Patient in her ~30s presents at 37w pregnant g1p0, with a mechanical mitral valve which was placed when she was <10yo. The valve may now be somewhat small for size. TTE shows severe mitral stenosis, moderate aortic regurg, severe LVH, PASP not obtainable. Before pregnancy, she was relatively asymptomatic, but currently she presents with functional limitations with even minor physical activity. She was on warfarin at home for anticoagulation but was admitted by OB to bridge to heparin gtt and for diuresis by cardiology. Plan by OB was to plan for vaginal delivery holding heparin at appropriate times for epidural placement and then restarting heparin and holding again as induction of labor progresses.

Sounds reasonable to me. I would put an a line along with the epidural. Titrate phenylephrine drip to desired bp.

 

[narcusprince]

A bigger issue is can the L and D nurses handle alines. Would this patient be better off in the icu with an obstetrician on standby to deliver in the icu. Either way she needs to be at a quaternary hospital delivery center. I would place the epidural early. No push gently titrated cardiac delivery. I would place the aline once we get a discreet vector of her progression as most of the hemodynamic issues occur during the active phases.

Sounds reasonable to me. I would put an a line along with the epidural.

 

[urge]

A bigger issue is can the L and D nurses handle alines. Would this patient be better off in the icu with an obstetrician on standby to deliver in the icu. Either way she needs to be at a quaternary hospital delivery center. I would place the epidural early. No push gently titrated cardiac delivery. I would place the aline once we get a discreet vector of her progression as most of the hemodynamic issues occur during the active phases.

I would leave her in L&D and go put my feet up in the lounge where i can watch the telemetry vital signs.

Send her to cardiac icu after delivery.

 

[PainDrain]

I think the question is about labor pain relief and not c/s. We know you must plan for c/s in this pt anyway.

I have a question for everyone though.

We all know what happens with labor in regards to blood volume and CO. We can all see where there may be trouble. So my question to this group is, how might a labor epidural help or hurt this situation?

This may be where the OP is headed.

I feel an epidural may actually help this patient for several reasons. It will drop afterload and decrease your regurg fraction from the AI, which will improve forward flow and potentially decrease wall stress on the LV. The epidural will also decrease the pain of labor which will decrease catecholamines and decrease HR and systemic pressure, which could help improve forward flow. With MS you want to decrease the HR to maximize filling and this could be improved with an epidural.

HR in pregnancy is maximal immediately after delivery and this could be the time where she crumps because you will have a blood loss to accommodate for and a HR that is increased.

 

[deleted171991]

The question here is not only what your plan for the delivery is, but what is your backup plan if she crashes? How will you resuscitate a severe MS with moderate AR and severe LVH (what's the reason for that?) if she goes into acute HF?

People will say: just keep her at her usual BP and HR, but that can be easier said than done, especially when the OB starts massaging a uterus full of blood during C-section. Same goes for vaginal delivery. She's in NYHA class III CHF even now. I don't see her tolerate a primigravida labor; she'll go into pulmonary edema way before delivering.

I think she should get an elective C/S with GA and a cardiac anesthesiologist, a PAC or TEE. It might be overkill... or it might save her life.

 

[Planktonmd]

The OP said she is now having symptoms with minimal effort, which means she is in CHF. How do we expect her to handle the increased demand during a prolonged labor and pushing the baby out???
Sure an epidural will make things relatively better but she still has to handle hours of labor and pushing with all the hemodynamic changes associated with that.
Starting labor and hoping she wouldn't crash is playing russian roulette that can be avoided with a planned elective C section.

 

[Aralc]

The OP said she is now having symptoms with minimal effort, which means she is in CHF. How do we expect her to handle the increased demand during a prolonged labor and pushing the baby out???
Sure an epidural will make things relatively better but she still has to handle hours of labor and pushing with all the hemodynamic changes associated with that.
Starting labor and hoping she wouldn't crash is playing russian roulette that can be avoided with a planned elective C section.

This. Although it seems that she can't get c/s immediately because of anticoagulation. So OB plan should be d/c coumadin, cards consult.

Optimize CV status, discuss case amongst cards/OB/anesthesia.

Likely go ahead with elective c/s without inducing labor after few days admission.

By the way, this forum is so much better than IM. It really blows over there.

 

[WholeLottaGame7]

The question here is not only what your plan for the delivery is, but what is your backup plan if she crashes? How will you resuscitate a severe MS with moderate AR and severe LVH (what's the reason for that?) if she goes into acute HF?

People will say: just keep her at her usual BP and HR, but that can be easier said than done, especially when the OB starts massaging a uterus full of blood during C-section. Same goes for vaginal delivery. She's in NYHA class III CHF even now. I don't see her tolerate a primigravida labor; she'll go into pulmonary edema way before delivering.

I think she should get an elective C/S with GA and a cardiac anesthesiologist, a PAC or TEE. It might be overkill... or it might save her life.

Agree with all those who vote elective C/S. I presume this will be done in an academic center, in which case there should be some sort of "OB-fellowship-trained" person around. This sort of high-risk stuff should be right in their wheelhouse, otherwise I don't see what the point of a fellowship is. They can consult their cards buddy for a TEE read if they like.

 

[Aralc]

The cards consult is to manage fluid status while her anticoagulation is being reversed unless anesthesia typically follows these patients without an epidural. Or OB wants to do it on their own, which I highly doubt.

As for how to manage anesthesia for OR, clearly I have no idea but plan for GA/ Aline/ TEE all seem reasonable to me.

1) the way I see this case, seems like OB has consulted anesthesia, I guess as a heads up for a complicated case. Patient is not ready now for either epidural or c section because she is anticoagulated. Even if OB wanted to induce labor, it shouldn't be done until Coumadin is reversed. Seems like your job as a consultant is to tell OB that elective c section would be much safer for patient, and then to make plans for said c section which won't happen for a few days. But I personally would be glad that for the heads up even if patient does not currently need anesthesia services.

2) If I were the OB, I would undoubtedly call cards because I would not want to be the one making the call on whether the patient was optimized prior to said elective c section. Not saying that anesthesia should call them.

Agree with all those who vote elective C/S. I presume this will be done in an academic center, in which case there should be some sort of "OB-fellowship-trained" person around. This sort of high-risk stuff should be right in their wheelhouse, otherwise I don't see what the point of a fellowship is. They can consult their cards buddy for a TEE read if they like.

 

[Noyac]

What I'm getting at is the effects of an epidural on PHTN. This can lead to a death spiral if not done extremely cautiously. Without the adequate preload the left heart will fail to pump. I would rather a PAC in this case than a TEE as well. Why?

 

[deleted171991]

.

What I'm getting at is the effects of an epidural on PHTN. This can lead to a death spiral if not done extremely cautiously. Without the adequate preload the left heart will fail to pump. I would rather a PAC in this case than a TEE as well. Why?

Because the right heart is anterior and wrapped around the left ventricle, hence difficult to visualize and measure on TEE, while the PAC is the gold standard for PAP measurement, and can also measure CO, thus providing a good estimate of RV function. Plus one can measure PVR and get a mixed venous gas, too.

 

[Noyac]

.

Because the right heart is anterior and wrapped around the left ventricle, hence difficult to visualize and measure on TEE, while the PAC is the gold standard for PAP measurement, and also gives a CVP and CO reading, thus providing a good estimate of RV function. Plus one can measure PVR and get a mixed venous gas, too.

If the PAC is good for on thing that's continuous PAP and CVP monitoring (their difference being an estimate of RV forward output).

Bingo
And if we are doing an elective c/s as many have recommended here, then a PAC is better tolerated by the pt under epidural. (Sarcasm)

I'm also thinking about the meds I'm gonna use in this case to manage all this.
Phenylephrine before delivery
Vasopressin after delivery bc it is a potent uterine vasoconstrictor but may have pulmonary smooth muscle relaxant effects
And Epoprostenol if things go south.

 

[itwasalladream]

I don't recall ever seeing a pregnant woman on coumadin. I think all of them had been converted to Lovenox. I looked it up briefly, it appears that coumadin crosses the placenta causing fetal bleeding, and teratogenicity especially during first trimester. Maybe the second and third are safe, but seems risky to me. Anyway, just thought it was strange she was still on coumadin.

As an aside, theoretically would people be okay with restarting the heparin gtt while she has the epidural in as suggested in the OP? I would not. But in this case I wouldn't put an epidural in anyway.

Where I trained, we would usually do these types of cases as elective C/S in the CT OR under GA with a-line, PAC, TEE. CVICU afterwards. The few we did went well so perhaps you could argue it was overkill, but I don't think the OB anesthesiologists and OB anesthesia fellows were at all comfortable with the pathophysiology, especially with rescue management if things went south. A lot of you guys who do OB, general, and CT seem comfortable with it, but at the academic centers the OB guys sometimes haven't done hearts in a very long time.

Also, not sure why you would need to choose PAC vs TEE but RV function is pretty easy to evaluate on TEE. TAPSE, S prime, dilation, eval of TR, RVSP calculations, interventricular septum evaluation, cardiac output calcs, etc. And even if you argue all those measurements are too academic, you can still eyeball the RV just fine in most patients. In my hands, if I had to choose I'd usually pick TEE over PAC. I think PACs are especially helpful (in certain pts) for post op management when you don't have continuous TEE.

 

[Aralc]

I don't recall ever seeing a pregnant woman on coumadin. I think all of them had been converted to Lovenox. I looked it up briefly, it appears that coumadin crosses the placenta causing fetal bleeding, and teratogenicity especially during first trimester. Maybe the second and third are safe, but seems risky to me. Anyway, just thought it was strange she was still on coumadin.

As an aside, theoretically would people be okay with restarting the heparin gtt while she has the epidural in as suggested in the OP? I would not. But in this case I wouldn't put an epidural in anyway.

Probably because of the mechanical valve. Patient may have been on LMWH earlier and transitioned at some point during her pregnancy. Although I don't know why they didn't start the process of transitioning back as an outpatient with a LMWH. May have saved a couple days in the hospital.

Because of the valve, she needs to be on heparin gtt in the hospital (except for critical moments such as surrounding possible epidural placement and delivery).

Uptodate actually has a monograph on management of pregnant patient with mechanical valve.

Interestingly, they say that vaginal delivery is preferred except in certain situations (one of them being advanced heart failure). So then you are stuck with possible epidural management in patient needing anticoagulation.

I am now curious to see what you all will say about that. Also makes me wonder does patient need a hem as well as cards consult?

 

[psychbender]

Probably because of the mechanical valve. Patient may have been on LMWH and transitioned at some point during her pregnancy.

She needs to be on heparin gtt in the hospital. She has a mechanical valve.

Uptodate actually has a monograph on management of pregnant patient with mechanical valve.

Interestingly, they say that vaginal delivery is preferred except in certain situations (one of them being advanced heart failure). So then you are stuck with possible epidural management in patient needing anticoagulation.

I am now curious to see what you all will say about that.

For this patient, we are not stuck with epidural management in a patient needing anticoagulation. Epidurals are elective procedures. For this patient, she has severe mitral stenosis with advanced heart failure that will only get worse with labor and delivery. As many of the posters her have said, her best option is an elective cesarean prior to the onset of labor, with appropriate cardiac monitoring and post-op intensive care.

Now, for an routine patient with a mechanical mitral valve, with no significant MS or heart failure, the situation is much different. That patient gets a conversation with her cardiologist regarding briefly coming off anticoagulation for delivery. I am not putting a neuraxial catheter in a patient, then letting someone run full-dose heparin unless there is a damn good reason, and labor analgesia isn't a good enough reason. The risks of epidural hematoma (and emergent decompression or paralysis) outweigh the benefit of better pain control. Either her valve can go for a few hours to a day without anticoagulation, or she can manage labor without an epidural.

 

[Aralc]

For this patient, we are not stuck with epidural management in a patient needing anticoagulation. Epidurals are elective procedures. For this patient, she has severe mitral stenosis with advanced heart failure that will only get worse with labor and delivery. As many of the posters her have said, her best option is an elective cesarean prior to the onset of labor, with appropriate cardiac monitoring and post-op intensive care.

Now, for an routine patient with a mechanical mitral valve, with no significant MS or heart failure, the situation is much different. That patient gets a conversation with her cardiologist regarding briefly coming off anticoagulation for delivery. I am not putting a neuraxial catheter in a patient, then letting someone run full-dose heparin unless there is a damn good reason, and labor analgesia isn't a good enough reason. The risks of epidural hematoma (and emergent decompression or paralysis) outweigh the benefit of better pain control. Either her valve can go for a few hours to a day without anticoagulation, or she can manage labor without an epidural.

I think this is the right answer.

Reading the OP again, the patient definitely was helped by an anesthesia and cards consult if the OB was asking for epidural and vaginal delivery. This is not a dig at the OB.

Would you be OK with labor epidural (for mechanical valve in patient without HF) if cards said OK to go without anticoagulation? I mean clearly she is going to need to be off for at least a few hours for delivery, and if vaginal is planned, then I guess she would need to be off as she labors. Or is the risk still too much because of restarting post-partum?

Actually, more reading suggests that full reversal is not necessary for delivery.

Would you also be thinking about reversal if patient crashes for whatever reason while still anticoagulated?

Also, what is the cutoff for "advanced heart failure" where you would prefer the elective c-section? I guess the reason vaginal would be preferred is because of hemorrhagic complications.

 

[Aralc]

Also, my first post was not in response to Plankton, but to Noyac who was considering a labor epidural while planning for a c-section.

 

[urge]

Also, not sure why you would need to choose PAC vs TEE but RV function is pretty easy to evaluate on TEE. TAPSE, S prime, dilation, eval of TR, RVSP calculations, interventricular septum evaluation, cardiac output calcs, etc. And even if you argue all those measurements are too academic, you can still eyeball the RV just fine in most patients. In my hands, if I had to choose I'd usually pick TEE over PAC. I think PACs are especially helpful (in certain pts) for post op management when you don't have continuous TEE.

What are the normal values for S'?

 

[dutchmaster]

This should be an elective c/s under GA all the way. No labor. No neuraxial. Consider TAP blocks for post-op pain. Letting this woman labor is not wise.

 

[Aralc]

I have a question. Let's say this goes for c/s.

How prepared do you want to be for all the worst case scenarios? The other worst case scenario I don't think has been brought up is a valve thrombosis.

 

[deleted171991]

I have a question. Let's say this goes for c/s.

How prepared do you want to be for all the worst case scenarios? The other worst case scenario I don't think has been brought up is a valve thrombosis.

You can't fix or perfectly avoid valve thrombosis. When there is risk of bleeding (e.g. surgery), that takes priority.

One would like to be prepared for anything. That's what anesthesiology is about: backup plan to backup plan to backup plan... What if..., what if..., what if...? Just look at the motto on the seal of the ASA:

 

[Aralc]

I was really surprised when I read that full anticoagulation was not necessary for either vaginal delivery or c section.

Would anybody really consider delivering without her fully reversed?

It seems like this was more for an emergency situation, but that's why I was asking if you would be considering ahead of time your game plan for a potential crash c section. The preferred strategy was to stop anticoagulants prior to planned delivery, but if emergent delivery was necessary, they had various recommendations on reversal.

Anyways, thanks for tolerating me here.

The uptodate monograph really answers almost all these questions except for how to handle the patient in failure; and also whether an epidural is acceptable if the choice was to attempt a vaginal delivery.

It seems to me that for a patient who is not in failure, and if you are inducing a vaginal delivery while stopping anticoagulation - and the plan is not to restart until after birth, an epidural may be acceptable.

 

[Hoya11]

Thought I'd post an interesting case for discussion.

Patient in her ~30s presents at 37w pregnant g1p0, with a mechanical mitral valve which was placed when she was <10yo. The valve may now be somewhat small for size. TTE shows severe mitral stenosis, moderate aortic regurg, severe LVH, PASP not obtainable. Before pregnancy, she was relatively asymptomatic, but currently she presents with functional limitations with even minor physical activity. She was on warfarin at home for anticoagulation but was admitted by OB to bridge to heparin gtt and for diuresis by cardiology. Plan by OB was to plan for vaginal delivery holding heparin at appropriate times for epidural placement and then restarting heparin and holding again as induction of labor progresses.

lets not forget that GA puts time pressure on OB surgeons in a possibly semi anticoagulated patient, and intubation has its own hemodynamic consequences including PPV which increases chest pressures worsening her CV status or at least challenging it. This approach would be my plan B as it is not the best plan for the baby.

i agree no labor, but i would try the epidural approach. id stop anticoagulation now, put the catheter in when possible per guidelines, slowly dose it up with 2% lido to a T6ish level with aline and neo/fluid to guide and keep pressure stable. Use PPV on aline to guide fluids. Keep mom awake. Keep numbers normal. Keep baby without propofol inside it. Proceed with CS with GA backup. Pull catheter at the end of case.

 

[deleted171991]

As a sidenote: one cannot use the PPV on the A-line to guide fluid resuscitation in a spontaneously breathing patient.

I think that playing with epidural anesthesia for C/S in a patient with severe MS, who is also in stage III CHF and moderate AR at baseline, who will get a bunch of blood coming from that uterus after the baby is born, would be very interesting.

 

[Aralc]

.

 

[itwasalladream]

What are the normal values for S'?

Under 10cm/s is generally considered abnormal.

Hoya - my vote is still GA, prioritizing mom over baby.

So if they get the baby out, and she suddenly develops flash pulm edema from her MS how are people going to manage it? I suspect flolan and iNO won't do anything due to elevated LA pressures being the main problem. Inotropes might just push more volume into the lungs, but may be required if her systemic pressures are tanking. NTG? Maybe. I don't know.

But this scenario is one other possible reason to do this in a CVOR - last resort ECMO would be a lot faster in that setting.

 

[OB1🤙]

I generally hate NTG, but this is the kind of patient it helps once the baby is out. Milrinone also good if you see the RV struggle. If you need systemic tone, vasopressin is your friend. Increases SVR but not PVR.

I would favor elective CS under GETA. I think everything will likely go fine, to be honest. I'd probably put in a pre-induction a-line. Good IVs. If she had good surface windows I'd use a VScan to guide therapy. If not, then TEE if hemodynamics get shady.

Septal geometry and RV function would be what I'd watch on echo, especially once baby is out and the uterus is autotransfusing her. If these were fine by the end of the case, I'd do TAP blocks, extubate and she'd go to some closely monitored unit depending on where I could trust the RNs. If not, I'd keep her intubated, put in a PAC, and send her to the cardiac ICU.

Mitral stenosis isn't fun, but if this valve accommodated her pre-pregnancy physiology and she's not in florid pulmonary edema at rest, she'll be a'ight I bet. We do a lot of gnarly mitral stenosis cases and TBH they tolerate anesthesia pretty well.

 

[Planktonmd]

I generally hate NTG, but this is the kind of patient it helps once the baby is out.

How about the effect of NTG on the uterus tone???

 

[cincincyreds]

what criminal obstetrician told the patient it is okay to get pregnant in the first place? And where do they think it is okay for this patient to labor? Is this a real story. Are these people really this stupid?

This is a case that can end real bad real fast.

 

[PainDrain]

Conclusion?????

 

[OB1🤙]

How about the effect of NTG on the uterus tone???

Yeah, that's a potential concern. But if she ends up in florid pulmonary edema, you do what you have to do.

If the bleeding is refractory, they should do a hysterectomy. The patient should be informed of this possibility and consent to it. She really shouldn't be getting pregnant again.

 

[Aralc]

What if they fix her valves? Remember OP said at the start of her pregnancy, she was asymptomatic.

If her valves are fixed, at that point you are dealing with the thrombotic/ hemorrhagic issues only, and not the hemodynamic/cardiac ones.

I bet if you all get her through this delivery, which several here have said that you could, she would be willing to gamble again.

In retrospect, she should have fixed the valves before getting pregnant, but hindsight is always 20/20.

 

[22031 Alum]

what criminal obstetrician told the patient it is okay to get pregnant in the first place? And where do they think it is okay for this patient to labor? Is this a real story. Are these people really this stupid?

This is a case that can end real bad real fast.

From personal experience, it tends to be a cardiologist who told the patient "You can't get pregnant," which she interpreted as meaning she was infertile and didn't need contraception. Though I have known of some unscrupulous REIs who would assist patients with similar medical problems...

 

[Aralc]

IDK. If there is an entire monograph on the management of a pregnant patient with a prosthetic valve in UTD (not even some academic review article), the cardiologist might have been OK with proceeding if she was doing well at baseline.

Give them some credit.

 

[deleted171991]

IDK. If there is an entire monograph on the management of a pregnant patient with a prosthetic valve in UTD (not even some academic review article), the cardiologist might have been OK with proceeding if she was doing well at baseline.

Give them some credit.

No offense, but what's your specialty?

Statistically speaking, the last time a cardiologist gave bad/useless anesthesia-related advice was probably the last time s/he saw a patient preop.

The difference between a cardiologist/internist and an anesthesiologist is that we actually take care of people intraop. It's like we actually fight the bad guys while they sing Imagine.

 

[sethco]

Don't think I have even seen it done, but I do wonder if a balloon valvuloplasty had been considered during the course of her pregnancy. The fact that it is a prosthetic certainly doesn't help that though. Mechanical vs Bioprosthesis?

As an aside, for those that don't do much Cards in practice and/or do much TEE, how comfortable would you be doing this case without backup?

For those, saying GETA, what is your induction plan? Severe mitral stenosis patients can be tricky

 

[Aralc]

No offense, but what's your specialty?

Statistically speaking, the last time a cardiologist gave bad/useless anesthesia-related advice was probably the last time s/he saw a patient preop.

The difference between a cardiologist/internist and an anesthesiologist is that we actually take care of people intraop. It's like we actually fight the bad guys while they sing Imagine.

For sure, I already mentioned that I was internal medicine. Anyone can look at my postings and figure out what I do (which is neither obstetrics nor cardiology).

It just seems to me that if there is literature regarding management on pregnant patient with prosthetic valve, that proceeding with a pregnancy can't be that crazy in a patient who was asymptomatic at baseline. (There is also literature on preconception counseling for patient with mitral stenosis and AI with outcomes; seems the question about valvuloplasty is right on). The recommendation is Coumadin after first trimester, switch to heparinoid when baby comes to term, reverse anticoagulation and proceed to vaginal delivery unless patient is in advanced heart failure.

Maybe if you all didn't do your jobs so well, and outcomes were poorer, the obstetrician/ cardiologists wouldn't be so quick to trust you for a good outcome? The NA and European MS series had no maternal deaths. In contrast, maternal mortality in Africa was 30%. Clearly you must be doing something right. Take that as a compliment, because it is. Maybe that is the problem - we are all victims of our own success.

Several folks have already said that they think the outcome of the case would be Ok even now with symptoms of failure with elective c section, GA and close monitoring.

As long as patient is apprised of risks and willing to accept those risks, I don't see why you have to badmouth other specialties.

If you want to help them out in making these decisions which occur more than 9 months before you see the patient, help them figure out what degree of preconception cardiac/valvular compromise seriously increases risks during delivery.

Who knows, maybe the cardiologists did do a crappy job of preconception counseling... I think the kindest thing to do would be to point them to their own society guidelines which are fairly specific with respect to mitral stenosis.

Ok, leaving now, sorry to interrupt.

 

[deleted171991]

It's mechanical 99.99%, based on the age at implantation.

Induction plan? Opiate-heavy, inhalational etc. pick your favorite type of slow cardiac induction.

 

[Aralc]

Don't think I have even seen it done, but I do wonder if a balloon valvuloplasty had been considered during the course of her pregnancy. The fact that it is a prosthetic certainly doesn't help that though. Mechanical vs Bioprosthesis?

As an aside, for those that don't do much Cards in practice and/or do much TEE, how comfortable would you be doing this case without backup?

For those, saying GETA, what is your induction plan? Severe mitral stenosis patients can be tricky

Mechanical per OP.

 

[sethco]

It's mechanical 99.99%, based on the age at implantation.


Induction plan? Opiate-heavy, inhalational etc. pick your favorite type of slow cardiac induction.

So opiate-heavy? I take it you don't plan on extubating at the end? Any RSI precautions you plan to take? Worried about the high dose opiate crossing the placental barrier?

I would sooner agree with breathing her down with Sevo while watching her hemodynamics, but that could take a while.

As an aside, has anybody done a true "cardiac induction" in the past few years? You know high dose opiate/benzo only induction? I have never done one in residency, fellowship, or practice. Curious if anyone has.

Don't mean to pick on you, but curious what are your thoughts

 

[deleted171991]

For sure, I already mentioned that I was internal medicine. Anyone can look at my postings and figure out what I do (which is neither obstetrics nor cardiology).

It just seems to me that if there is literature regarding management on pregnant patient with prosthetic valve, that proceeding with a pregnancy can't be that crazy in a patient who was asymptomatic at baseline. The recommendation is Coumadin after first trimester, switch to heparinoid when baby comes to term, reverse anticoagulation and proceed to vaginal delivery unless patient is in advanced heart failure.

Maybe if you all didn't do your jobs so well, and outcomes were poorer, the obstetrician/ cardiologists wouldn't be so quick to trust you for a good outcome? Take that as a compliment, because it is.

Several folks have already said that they think the outcome of the case would be Ok even now with symptoms of failure with elective c section, GA and close monitoring.

As long as patient is apprised of risks and willing to accept those risks, I don't see why you have to badmouth other specialties.

If you want to help them out in making these decisions which occur more than 9 months before you see the patient, help them figure out what degree of preconception cardiac/valvular compromise seriously increases risks during delivery.

Ok, leaving now.

You asked @22031 Alum to give some credit to cardiologists. All I did was point out why we usually don't. If you read as many bad cardiac preops as we do, you would probably have the same skeptical attitude. I love especially when I am told what type of anesthesia I am supposed to do on the patient, which is about as hilarious as me telling a surgeon what suture to use. Which is not far from what you were doing on this thread, by the way.

I tend to agree with 22031 that the main reason this patient got pregnant was because nobody told her, in no uncertain terms, that pregnancy will worsen her heart disease, and might even kill her. Any physician with common sense would expect a valve implanted when less than 10 years old to be way too small for adult size, even if the patient is asymptomatic with usual activities.

 

[deleted171991]

So opiate-heavy? I take it you don't plan on extubating at the end? Any RSI precautions you plan to take? Worried about the high dose opiate crossing the placental barrier?

I would sooner agree with breathing her down with Sevo while watching her hemodynamics, but that could take a while.

As an aside, has anybody done a true "cardiac induction" in the past few years? You know high dose opiate/benzo only induction? I have never done one in residency, fellowship, or practice. Curious if anyone has.

Don't mean to pick on you, but curious what are your thoughts

I have seen only one opiate-benzo induction in the OR, done by an oldie cardiac anesthesiologist. He used a lot of Versed and fentanyl (3-5 times the usual doses). I did not see the patient postop, though.

You are right about respiratory depression in the baby and emergence, so breathing the patient down would be a much better method. I think RSI is not the priority here, given the bad heart. In an elective C-section, with long NPO and the patient not in labor, the risk of aspiration should be very low.

 

[Aralc]

yeah I just need to know when to keep my mouth shut. 🙄

But if you guys get this patient through the case, I don't think you will ever convince the cardiologist (who presumably specializes in congenital heart disease and is working with MFM and anesthesiology at a quaternary referral center and has seen this before although you never know) that they made a poor recommendation or the patient they made a poor decision. They just won't know how close they skated the edge and how heroic your efforts were.

Like I said, victims of your own success.

 

[deleted171991]

In our culture, it's so much easier not to tell a colleague that s/he was wrong. Especially if we are not close.

Occasionally, I feel really bad for internists being expected by surgeons to "clear" a patient for surgery, when those internists don't really know (where from?) what anesthesia and surgery do to the body. I actually like a lot when somebody writes that the patient is optimized as much as possible, or at her baseline, and avoids "clearing" the patient for surgery.

In this particular situation, I don't think there is much a cardiologist could help with, except optimizing the patient's cardiac status for an elective C-section, including a plan for optimal interruption of anticoagulation. An experienced cardiologist or obstetrician might offer some valuable patient optimization or anesthesia-related insight (that we don't already know), based on past experiences, but that would be a surprise for me.

Unfortunately for us, we have made anesthesia so safe that, if anything happens to the patient it's our fault, and if everything goes well that's the surgeon's merit. Very few people outside of anesthesia understand how much effort, knowledge and planning it takes sometimes. Also, people don't realize that we are probably the best at managing a patient during, and closely before and after surgery.

The whole system is screwed up, because most patients are seen preop mostly by surgeons and internists, and not by anesthesiologists (as in Europe, for example).