Obstetric Anesthesia and Heart Disease: Practical Clinical Considerations

Marie-Louise Meng, M.D.; Katherine W. Arendt, M.D.

Disclosures

Anesthesiology. 2021;135(1):164-183. 

In This Article

Abstract and Introduction

Abstract

Maternal morbidity and mortality as a result of cardiac disease is increasing in the United States. Safe management of pregnancy in women with heart disease requires appropriate anesthetic, cardiac, and obstetric care. The anesthesiologist should risk stratify pregnant patients based upon cardiac disease etiology and severity in order to determine the appropriate type of hospital and location within the hospital for delivery and anesthetic management. Increased intrapartum hemodynamic monitoring may be necessary and neuraxial analgesia and anesthesia is typically appropriate. The anesthesiologist should anticipate obstetric and cardiac emergencies such as emergency cesarean delivery, postpartum hemorrhage, and peripartum arrhythmias. This clinical review answers practical questions for the obstetric anesthesiologist and the nonsubspecialist anesthesiologist who regularly practices obstetric anesthesiology.

Introduction

Maternal mortality is increasing in the United States, and cardiovascular disease is now the leading cause.[1,2] According to the Centers for Disease Control and Prevention, cardiovascular disease is currently responsible for one-quarter of maternal deaths in the United States and similar trends are occurring in other high-income countries.[2–4] These trends may be a result of an increasing average age of maternity during the last 4 decades, compounded by increases in known risk factors for cardiovascular disease such as diabetes, hypertension, and obesity.[5–7]

With improvements in the surgical and medical management of congenital heart disease, the number of women with congenital heart disease who survive to childbearing years and present to labor and delivery units in the United States has increased.[8] The European Society of Cardiology's Registry of Pregnancy and Cardiac Disease has recorded more than 5,700 pregnancies in women with cardiovascular disease, 57% of whom had congenital heart disease. Based on the Registry of Pregnancy and Cardiac Disease data, patients with congenital heart disease with appropriate cardiac and obstetric care do well, with relatively low rates of morbidity and mortality compared to other types of heart disease.[3] In contrast, patients at the highest risk of cardiovascular complications and death in pregnancy are women who are older, identify as Black or African American, acquire heart disease in pregnancy, and/or have unrecognized cardiovascular disease and become pregnant.[1,9–11]

There are little data to guide the anesthetic management of women with cardiac disease. Statements by the American Heart Association (Dallas, Texas), European Society of Cardiology (Sophia Antipolis Cedex, France), Society of Maternal–Fetal Medicine (Washington, D.C.), and American College of Obstetricians and Gynecologists (Washington, D.C.) provide valuable guidance regarding the diagnosis and management of cardiovascular disease preconception, in pregnancy, and in the peripartum and postpartum periods.[12–14] These guidelines recommend that a "pregnancy heart team" care for pregnant patients with complex cardiovascular disease. Such a team is defined as cardiologists, obstetricians, perinatologists, and anesthesiologists. Through a nonsystematic literature review with incorporation of national and international guidelines, this Clinical Review answers practical questions for the obstetric anesthesiologist and the nonsubspecialist anesthesiologist who regularly practices obstetric anesthesiology. Besides society statements and guidelines, many of the suggestions in this review are based on hemodynamic and physiologic extrapolation and advice from other experts.

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