Anaesthetic management of pregnant patients with cardiac implantable electronic devices: case reports and review.

Heart disease is a leading cause of maternal mortality and morbidity. Pregnant women with structural, conduction or degenerative cardiac disease who require rhythm control or who are at high risk of sudden cardiac death may carry a cardiac implantable electronic device or may occasionally require the insertion of one during their pregnancy. These women are now encountered more frequently in clinical practice, and it is essential that a multidisciplinary approach, beginning from the early antenatal phase, be adopted in their counselling and management. Contemporary cardiac rhythm control devices are a constantly evolving technology with increasingly sophisticated features; anaesthetists should therefore have an adequate understanding of the principles of their operation and the special considerations for their use, in order to enable their safe management in the peripartum period. Of particular importance is the potential adverse effect of electromagnetic interference, which may cause device malfunction or damage, and the precautions required to reduce this risk. The ultimate goal in the management of this patient subgroup is to minimise the disruption to cardiovascular physiology that may occur near the time of labour and delivery and to control the factors that impact on device integrity and function. We present the ante- and peripartum management of two pregnant women with an implantable cardioverter-defibrillator, followed by a review and update of the anaesthetic management of parturients with cardiac implantable electronic devices.

Anaesthetic management of parturients with univentricular congenital heart disease and the Fontan operation.

Women with a single ventricle circulation palliated with the Fontan operation require specialist multidisciplinary management. We report 14 such cases with successful pregnancies and detail the pathophysiology encountered. A combined obstetric and cardiac service between Chelsea and Westminster Hospital and Royal Brompton Hospital provides care for women with heart disease, and maintains a prospective database of referred women. We searched this database for women with a known Fontan circulation and reviewed the case notes and electronic patient records between January 1994 and December 2015. Eight women palliated with the Fontan operation delivered 14 live babies over the study period, with detailed peripartum management available for 11. Low-dose combined spinal-epidural or epidural labour analgesia was the intended mode of analgesia or anaesthesia for all deliveries (depending on clinical scenario and clinician preference), and was performed in 79%. Seven cases (50%) had a caesarean delivery. A neuraxial catheter technique was preferred (86%), whether or not vaginal delivery was attempted first. There were no deliveries under general anaesthesia. Fifty percent of cases were complicated by postpartum haemorrhage. Other peripartum complications included arrhythmias (29%), chest pain (14%) and intrauterine growth restriction (57%). Women with a Fontan circulation are increasingly encountered in obstetric practice. A good understanding of the underlying anatomy and its impact on physiology, coupled with meticulous care are essential to allow safe delivery for mother and baby. Multidisciplinary input into peripartum care is required, with anticipation of increased risk of complications such as haemorrhage and arrhythmias.

Marfan syndrome and pregnancy: maternal and neonatal outcomes.

OBJECTIVE: To report outcomes in a recent series of pregnancies in women with Marfan syndrome (MFS). DESIGN: Retrospective case note review. SETTING: Tertiary referral unit (Chelsea and Westminster and Royal Brompton Hospitals). SAMPLE: Twenty-nine pregnancies in 21 women with MFS between 1995 and 2010. METHODS: Multidisciplinary review of case records. MAIN OUTCOME MEASURES: Maternal and neonatal mortality and morbidity of patients with MFS and healthy controls. RESULTS: There were no maternal deaths. Significant cardiac complications occurred in five pregnancies (17%): one woman experienced a type-A aortic dissection; two women required cardiac surgery within 6 months of delivery; and a further two women developed impaired left ventricular function during the pregnancy. Women with MFS were also more likely to have obstetric complications (OR 3.29, 95% CI 1.30-8.34), the most frequent of which was postpartum haemorrhage (OR 8.46, 95% CI 2.52-28.38). There were no perinatal deaths, although babies born to mothers with MFS were delivered significantly earlier than those born to the control group (median 39 versus 40 weeks of gestation, Mann-Whitney U-test, P = 0.04). These babies were also significantly more likely to be small for gestational age (24% in the MFS group versus 6% in the controls; OR 4.95, 95% CI 1.58-15.55). CONCLUSIONS: Pregnancy in women with MFS continues to be associated with significant rates of maternal, fetal, and neonatal complications. Effective pre-pregnancy counselling and meticulous surveillance during pregnancy, delivery, and the puerperium by an experienced multidisciplinary team are warranted for women with MFS.

Spinal anaesthesia for caesarean section in the presence of respiratory failure and spinal metastases from a soft tissue clear cell sarcoma.

Spinal metastases occur in up to 70% of all patients with cancer. However, only 10% are symptomatic. Before considering central neuraxial blockade in patients with malignancy, a history of back pain should be excluded. Anaesthetists should be aware that intrathecal and epidural injections could cause paraplegia if metastases are impinging on the spinal cord. Failure to achieve adequate sensory anaesthesia after central neuraxial blockade or presentation with postoperative paraplegia may indicate the presence of asymptomatic vertebral canal metastases. In this report, the anaesthetic management of a patient with respiratory failure and spinal metastases from a soft tissue sarcoma, requiring caesarean section is described. Sensory anaesthesia extending above a level of imminent cord compression was achieved despite loss of cerebrospinal fluid signal on magnetic resonance imaging.

Practical management of the parturient with congenital heart disease.

Cardiac disease is becoming more common in women presenting for maternity care and is a major cause of maternal mortality in the UK. We present a review of the management of parturients with congenital heart disease, focusing on practical aspects and the problems that may be expected.

Evaluation of high fidelity patient simulator in assessment of performance of anaesthetists.

BACKGROUND: There is increasing emphasis on performance-based assessment of clinical competence. The High Fidelity Patient Simulator (HPS) may be useful for assessment of clinical practice in anaesthesia, but needs formal evaluation of validity, reliability, feasibility and effect on learning. We set out to assess the reliability of a global rating scale for scoring simulator performance in crisis management. METHODS: Using a global rating scale, three judges independently rated videotapes of anaesthetists in simulated crises in the operating theatre. Five anaesthetists then independently rated subsets of these videotapes. RESULTS: There was good agreement between raters for medical management, behavioural attributes and overall performance. Agreement was high for both the initial judges and the five additional raters. CONCLUSIONS: Using a global scale to assess simulator performance, we found good inter-rater reliability for scoring performance in a crisis. We estimate that two judges should provide a reliable assessment. High fidelity simulation should be studied further for assessing clinical performance.

UK registry of high-risk obstetric anaesthesia: arrhythmias, cardiomyopathy, aortic stenosis, transposition of the great arteries and Marfan's syndrome.

The UK registry of high-risk obstetric anaesthesia was set up in late 1996 to collect reports of high-risk pregnancy, pool them into a central database and disseminate the results. At the time of analysis for this paper (December 31, 2001) 308 cardiorespiratory reports had been received. The five most common conditions, occurring in 125 cases (41% of the total), were arrhythmias (43 cases), cardiomyopathy (26 cases), aortic stenosis (24 cases), transposition of the great arteries (18 cases) and Marfan's syndrome (14 cases). We describe the features and management of these cases.

The anaesthetic management of a parturient with polymorphic catecholamine-sensitive ventricular tachycardia.

Polymorphic catecholamine-sensitive ventricular tachycardia is an uncommon but potentially life-threatening condition. There are few reports of this condition in pregnancy. It is one of five types of polymorphic ventricular arrhythmia, the others being long-QT syndrome, short coupled variant of torsade de point malignant disease, idiopathic ventricular fibrillation with normal ECG and Brugada syndrome. Exercise and stress can precipitate ventricular tachyarrhythmias in patients with polymorphic catecholamine-sensitive ventricular tachycardia and it is important to avoid increases in plasma catecholamine levels. We report on the anaesthetic management of a parturient with this condition, for elective caesarean section and discuss the stress response in parturients receiving regional and general anaesthesia.