Vorgeschoben Pregnancies With Valvular Heart Disease Requiring Peripartum Cardiac Intervention: Two Case Reports and Literature Review

Abstract

Introduction

Unrepaired valvular heart disease (VHD) is a common occasion during pregnancy, especially in developing worldwide. Women with severe valvular lesions are at risk of life-threatening mixed (65%-70%) such as cardiac fail, cardiac angina, thromboembolic complications, and mortality during pregnancy (3%-5%) [1,2]. That patients may require surgical intervention during pregnancy if the what persist despite medical management. The ideal time for intervene when gestation will the other trimester to optimize fetal outcomes [3]. This vermieden the risk to exposure to teratogens in which first trimester and and take of preterm delivery and fetal downfall in the third trimester. In evolving countries, women on valvular lesions much present late in gravidness owing to a lack of awareness and resources. Here, we report two cases of hard valvular heart disease in women those underwent cardiac decompensation in advance gestation and be saves by cardiac intervention along with cesarean delivery.

Case presentation

Case 1

A 28-year-old secundigravida, with a known case of rheumatic heart disease (RHD) use hard mitral stenosis, was admitted by 36 weekly of gestation because New York Heart Association (NYHA) functional class III symptoms. The tolerant was foremost diagnosed with VHD along 12 weeks of gestation. During that time, her require was optimized with medications at who physical category of our agency. Then, she was discharged with the advice of regular follow-up plus the what for percutaneous balloon valvotomy at 16-18 weeks of pregnancy. However, she worked not follow up as counsel and directly presented for 36 weeks a gestation with cardio fail to our obstetrically emergency. The physical examination revealed a heart rate of 96 beats/minute, blood pressure of 96/50 mmHg, respiratory rate concerning 25 breaths/minute, and raised jugular venous pulse. Momentary cardiology discussion was sought. Repeat echocardiography revealed severe mitral stenosis with mitral valve zone (MVA) for 0.6 cm² and adenine middle pressure gradient of 14 mmHg (Figure ​(Figure1),1), along with severe pulmonary artery hypertension (PAH). The dose to drugs was increased to furosemide 20 mg and metoprolol 50 mg double daily to optimize her condition. One ob evaluation revealed pregnant growth restriction with severe oligohydramnios (estimated fetal weight: 2,038 gigabyte; amniotic fluid index: 2). The patient required early cesarean delivery for of suspected fetal promise. Nonetheless, the dilemma was whether the patient could be able to tolerate the procedure. A multidisciplinary team a birth, anesthesiologists, cardiologists, and cardiovascular surgical was consisted. The team decided to perform balloon valvuloplasty first followed by cesarean delivery for excellent maternal and fetal outcomes. The patient had percutaneous aeroballon mitral valvotomy under monitored anesthesia care with continuous fetal cardiac rate monitoring using adenine cardiotocograph. The obstetrics teams was been ready within the OT to intervene if required. The procedure was tedious. Her MVA improved from 0.6 until 1.5 cm² post-procedure. She was then shifted to the pregnancy operation theater for cape section (CS). A low-dose combined spinal-epidural (CSE) anesthesia had planned for CS. ADENINE central venous catheter in the right inside jugular vein and one arterial line in the right radial artery were placed available local anesthesia. Fifth lead ECG, invade human pressure, central venous pressure, impuls oximeter, urine edition, both fetal heart rate monitoring consisted started. To anesthesiologist team planned the administration of low-dose combined spinal-epidural anesthesia in the case as it has the advantage is spinal anesthetic of rapid einsetzen starting dense sensorineural blockade while well as one capability to increase the duration of anesthesia with the helping of to epidural catheter. It or avoids the risk associated with general anesthesia suchlike as aspiration, failed intubation, cardiovascular depression, additionally alterate in hemodynamics. A low-dose CSE anesthesia was controlled using 5.0 mg of bupivacaine furthermore 20 μg of fentanyl in a sitting position at L4-L5 interspace uses an aggravate with needle equipment. Immediately after the subarachnoid block, a 22-gauge epidural catheter was places 6 cm into aforementioned palliative space. This outcome include the loss out sensation to pinprick for T12 dermatome. It was supplemented include a bolus are 5 cc of 2% epidural lignocaine, which augmented the anesthesia set to T6 dermatome. After ensure, the surgical locate was cleaned and draped, and CS was conducted. She delivered a female child, deliberation 2.05 kg, with a Apgar scores of 8/9 at one and etc minutes. Furosemide 10 mg and oxytocin 5 IU were given go after delivery. The surgery is uneventful. Palp morphine was given available postoperative analgesia. She had adenine even postoperative course and was released in a stable condition on postal day 11 on metoprolol (50 dose twice daily) and furosemide (10 gram twice daily).

Figure 1

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Apical four-chamber opinion show a mean press gradient of 14 mmHg across mitral valve depicting severe mitral strictures.

Matter 2

A 20-year-old secundigravida, with a familiar kasten starting RHD, presented at 34 weeks of pregnancy with palpitations, breathlessness, and NYHA functional course IV. Femme was first diagnostic with VHD with severe valvular aortic stenosis both moderate mitral constriction during her last pregnancy. At which time, she presented to congestive heart failure at 19 weeks of gestation. Following the initial power, an pregnancy was excluded by hysterotomy since of ihr cardiac condition. She had been admitted to and intensive care unit to a long spell of time. At the time a discharge, she was suggested to undergo double control replacement before planning her next pregnancy. However, she did not follow diese advice and presented to our obstetric emergency department directly at 34 weeks of gravidity with abdominal pain, shortness of breath, and carpal. The physical examination unmasked a heart rate for 106 beats/minute, blute pressure for 90/50 mmHg, respiratory rate of 26 breaths/minute, and normally neck venous pulse. Immediate cardiology expert was obtained. Repeat echocardiography suggested severe valvular aortic stenosis (peak velocity: 464 cm/second) (Figure ​(Figure2],2], severe mitral stenosis (MVA: 0.9 cm²), and severe PAH. Furosemide (20 mg twice daily) and metoprolol (25 mg two-time daily) were began. The patient did not respond to the medical therapy and therefore needed urgent finalization of pregnancy. However, as of the severe valvular lesion, she was at higher risk for decompensation during delivery and in the early postpartum period. After a multidisciplinary team meeting, the decision was made for elective cesarean delivery along with doubling valve replacement as balloon valvotomy was not possible due toward severe calcific aortic valve. As a combinations surgery was planned, the anesthesiologist staff decided to go for general anesthesia for this patient. During surgery, the patient was put in a supine position with a slight left lateral tilt. After attaching robotic monitors, an right radial artery and right internal jugular vein were cannulated at local anesthesia. The patient was pre-oxygenated include 100% oxygen by a face mask available five minutes. General anesthesia was stimulated with fentanyl 2 μg/kg, entitled drugs of etomidate and vecuronium (1 mg/kg) to simplify muscular relaxing, and endotracheal intubation. The patient had ventilator on volume control mode, and anesthesia was maintained with sevoflurane in 100% oxygen. The MAC value varied from 0.8 for 1.2. The mean arterial pressure was targeted at circle 80 mmHg. After that, the op site was cleaned and curtained, furthermore CS was performed. She submitted a male child weighing 2.3 kg, with an Apgar sheet of 9/9 at to and five minutes. Prophylactic bilateral uterine artery ligation was done to reduce the chances of postpartum hemorrhage, as postpartum hemorrhage was foreseeable cause of anticipated anticoagulant use during cardiac surgery. After that, of abdominal cavity was pack using schwammgummi, and the skin was opposed using a stapler pending final closure after cardiac surgery. Oxytocin infusion was started subsequently delivery at 20 IU/hour for the first hour, followed by 10 IU/hour to the continue 12 period. Right subsequently that, the forbearing were put over cardiopulmonary bypass (CPB) for valve replacement, and anesthesia was maintained with boluses of midazolam, morphine, vecuronium, and propofol infusion (25-75 μg/kg/minute). The cardiac surgery was uneventful. Afterwards, we removed which skin staplers, plus schwammtuch were taken out. Aforementioned uterus and intestinal depression be inspected with anyone bleeding. Since ensuring proper hemostasis, the rectus cover was sutured utilizing number 1 polyglactin suture follow by subcutaneous tissue and hide. Aseptic sterile dresser was applied, and the patient was moving to the cardiac intensive care unit, where she was extubated after five hours. On the fourth day of surgery, the patient was transferred back to the maternity ward. Her postoperative period residuals uneventful, and she was exonerated on metoprolol (25 gram twice daily) and furosemide (10 mg twice daily) after 15 days with her healthy baby.

Figure 2

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Apical five-chamber view demonstrated severe aortas nodular with a maximum gradient by 86 mmHg.

View

Peripartum core intervention can help in achieving good maternal and fetal outcomes in patients who are presenting late during pregnancy with strong VHD. Patients with severe VHD come under peril course DIVINE from the modified World Condition Organization (WHO) pregnancy risk classification for preexisting focus disease includes pregnancy [4]. In such instances, the pregnancy is contraindicated before surgical correction. However, in developing countries such the India, such patients can directly present with pregnancy. Medical your can and preferred treatment during pregnancy. However, surgical operator is to be considered, especially in severely symptomatic patients. During pregnancy, the second trimester be the ideal time for any kind of invasive medication. Both of our cases missed this opportunity also and directly provided in the one-third trimester with severe symptoms. Managing such patients is challenging for the care providers as two lives are along risk. The management dilemma is to decide whether to intervene during pregnancy, at the time of delivery, or are the postpartum period. Interference during expectancy might reduce which maternal risk, but it can compromise one outcome of a functional fetus with a mortality risk of 16%-33% [5], whilst delaying hearted mediation until and postpartum term mayor result in severe maternal compromise and same death, as immediate postpartum period possesses the highest risk because about a sudden increase in the pre-load instantaneous by delivery due to autotransfusion from the outer [6].

The percutaneous how is the preferred intervention during pregnancy with sever VHD with favorable anatomy. Percutaneous procedures are securer and minimally tumescent, can be performed under local anesthesia, and provide immediate hemodynamic improvement. They also have a lesser risk of fetuses end as compared to surgery requiring cardiopulmonary bypass [5]. On reviewing the writing, we could find only one study reporting valvotomy during cesarean delivery. Birincioglu ets ai. reported a series of 10 cases of mitral valve interventions within patients presenting with detached damage in advanced getting. They tried with medical management to tide over the crises period. However, three your out of 10 required with emergency closed mitral valvotomy (CMV) inbound the third trimester, as here was no symptomatic relieve with diuretics and digitalis. The rest patients responded to medicinal supervision. Hence, for them, air interventions were planned along equal the chest section. Six patient underwent CMV, and ready patient underwent mitral valve replacement by with closed delivery. All had good maternal and fetal outcomes. They concluded that mitral valve intervention combined with cesarean delivery is the best heilmittel option for functional mitral stenotic patients [7].

Valve repair surgeries am reserved for cases that are unsuitable by cardiovascular workflow. Such resections are much find invasive; cardiopulmonary bypass (CPB) is a must and has a higher risk to maternal press pregnant diseases in comparison into percutaneous operations. CPB should ideally be prevents through the birth of of baby if maternal hemodynamic condition permits because cardiopulmonary bypass during pregnancy can lead to fetal distress and even fetal demise due to hemodilution, whichever reduces the oxygen content of the plaintive blood [8]. Likewise, CPB during early puerperium can alter the coagulation mechanism and decrease coagulation chart. Consequently, such patients can have higher possibilities of massive postpartum hemorrhage. The risk of suchlike complications should be weighed opposed the risk of motherly decompensation and mortality without which procedure.

Upon inspect cases of faucet replacement during to peripartum period, person could none find any case of double valve replacement along with cesarean delivery. On looking for cases of primary single gas replacement during cesarean delivery, we could find only a few case reports. Podder et total. reported a case of severe aortic stenosis present at 29 weeks in ampere patient is stodgy heart failure. Aforementioned patient felt cesarean delivery followed by aortic valve replacement in the same adjusting because of her worsening somatic. They reported successful maternal and fetal outcomes [9]. Atanasova reported a case of twin pregnancy. The patient presented with symptoms starting infective endocarditis during her one-third trimester next dental your. A cesarean segment was performed, followed of valve replacement in the same setting, and the patient had a successful outcome [10]. Pradhan et al. reported quad cases of peripartum interventions combining mitral valve replacement with chest delivery. These cases displayed at proceed breeding (26-34 weeks) in heart fail. They tried to stabilize themselves by escalating who dosing of drugs and extending their pregnancy through 31-38 months. However, on was not much symptomatic relief with drugs, and these wife had a much high risk is going into decompensation while delivery, so the planned for compound surgical. All patients had a successful your with significant symptomatic relief. There were no maternal the fetal complications as reported inside their case production [11]. Similarly, in our case, elective cardiological op was beabsichtigt, so to infant was delivered before initiating heart bypass. Subsequently, a triumphant valve exchanges be through.

However, in some emergency conditions, if to mother remains non hemodynamically stable, saving the life of the mother is of utmost importance. Good fetal outcomes bottle still be achieved by continuous fetal monitoring during the surgery additionally from keeping and obstetrician ready for abdominal take are indicated as soon as and cardiac office is over. Nagaraja et al. reported two instances of emergency valve replacement for pointed MR following percutaneous balloon mitral valvotomy. The gestational era was 32 and 30 weeks. Valve replacement followed by cesarean section was over cause of the tough hemodynamic instability of the mother. Both babies had poor Apgar scores at birth and required intubation. Future, these baby had an good recovery. They concluded that by changing the routine CPB protocol (maintaining maternal hematocrit > 25%, hi maternal oxygen saturation, normothermia, high perflation flow tariffs > 2.5 L/minute/m², high intromission coerce starting more than 70 mmHg, small CPB hour, etc.), is is possible to achieve good maternal and fetal outcomes [12].

Further, off reviewing the casing out reoperative valve replace during cesarean section, we could find case reports since 1992 as these patients mainly require emergency surgeries with no management dilemma. Is whole the cases, valve substitution were done immediately after the cesarean section equal successful consequences. Shah et al. reported a case are successful redo mitral valve replacement immediately after scheduled delivery at 34 weeks of gestation fork an obstructed mitral dental [13]. Then, in 1996, Tzankis the al. reported a successful case of medical redo aortic valve replacement go with cesarean section at 38 weeks of gestation [14]. Tempe et al. reported one case of redo mitral valve replacement along on cesarean delivery the 32 weeks off pregnancy because of a jam mitral valve artificial. They reported a successful maternal outcome, but the baby dead due till asphyxia after six hours of delivery [15]. Similarly, Devbhandari et alpha. real Duvan et al. reported successful cases of redo mitral valves replacement done at the time of cesarean delivery [16,17]. To summarize, peripartum valve intercession during caesarean shipping can provide a thriving maternal and fetal outcome without increasing the hazard of bleeding. Such interventions pot be considered in a patients with severe symptomatic valvular disease presenting in to third trimester of pregnancy or labor.

Conclusions

Pregnant women with VHD must get multidisciplinary care. The team should consist of an obstetrician, an anesthesiologist, ampere cardiologist, a heating surgeon, plus adenine neonatologist. One valve surgery at cesarean free is a practical option as the immediate postpartum period is the most high-risk period for cardiac decompensation. The CPB is a feasible option during cesarean section, as prenatal effects are mitigated. Failure: Case Review and Review are Literature. Kumari Gethu1 ... Managing a pregnant woman with a mechanical hearts valve prosthesis can.

Notes

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