1. Department of
Anaesthesiology
Combined Military Hospital
Dhaka, Bangladesh22 Apr 2017

2. • Name : Buly Akhter
• Spouse : Snk Shamim Mollah
• Age : 21 years
• Gender : Female
• Religion : Islam
• Marital Status : Married
• Hailing from : Borogoni, Chitolmari, Bagerhat
• Date of Admission : 4th November 2016
Particulars of the Patient

3. • Amenorrhea due to
pregnancy for 35+ weeks
• Lower abdominal pain for
3 days
• Watery vaginal discharge
for 2 days
Chief complaints

4. The patient had been amenorrhoic due to pregnancy
for 35+ weeks. She had complaints of lower
abdominal pain for last 3 days which was initially dull
and intermittent in nature, radiated towards back and
groins, not associated with hardening of uterus.
She also complained about per-vaginal discharge for
last 2 days, which was initially whitish and foul-
smelling then gradually watery in nature.
H/O Present illness

5. With these complaints, she got admitted to this CMH
in ORs’ Family Gynae ward. After 2 days of her
admission, she developed severe respiratory
difficulties in the ward which was treated by O2
inhalation, nebulisation and diuretics, but did not
improve significantly.
Then, she was shifted to PACU from the Gynae ward
immediately.
H/O Present illness (Continued)

6. There was NO history of -
• Diabetes Mellitus
• Systemic Hypertension
• Bronchial asthma
• Pregnancy Induced Hypertension
• Gestational Diabetes Mellitus
• Tuberculosis
• Rheumatic fever
H/O Past illness

7. Nothing contributory
Drug History
The patient was on Iron, Vitamin B complex &
Calcium supplementation during her pregnancy. She
was on irregular antenatal check up.
Treatment History
Nothing contributory
Family History
Low middle class
Socio-economic History

8. Married for : Two and half years
Para : 0
Gravida : Primi
Obstetric History
Menstrual period : 5 days
Menstrual cycle : 28 days
Menstrual flow : Regular
LMP : 3 Mar 2016
EDD : 10 Dec 2016
Menstrual History

9. • Appearance : Anxious
• Built : Average
• Nutritional status : Average
• Decubitus : Propped up
• Anaemia : Mild
• Cyanosis : Absent
• Jaundice : Absent
• Clubbing : Absent
General Examination

10. • Koilonychias : Absent
• Leukonychia : Absent
• Oedema : Absent
• Dehydration : Absent
• Pulse : 120 b/min
• BP : 130/80 mm of Hg
• Temperature : 98.4˚F
• Lymph node : Not palpable
• Thyroid gland : Not enlarged
General Examination (Continued)

11. Systemic Examination
Respiratory system:
Inspection Palpation Percussion Auscultation
• Shape: Normal
• Chest
movement:
symmetrical on
both side
• No visible scar
mark
• No visible
engorged vein
• Respiratory
rate: 28/min
• Trachea:
centrally placed
• Apex beat:
normal
• Chest
expansibility:
symmetrical on
both side
• Vocal fremitus:
normal
• Percussion:
Resonant
• Cardiac
dullness:
Normal
• Vesicular
breath
sound with
Bilateral
basal
crepitation
on both
lung

12. Systemic Examination (Continued)
Cardiovascular system:
Inspection Palpation Auscultation
• Not done • Apex Beat: Left
5th inter costal
space
• Thrill: Present in
apical & left
parasternal area
• 1st & 2nd heart
sound: Normal in
all areas
• Murmur: Mid
diastolic murmur in
mitral area and
Early diastolic
murmur in left
lower parasternal
area

13. Per-abdominal Examination:
Inspection Palpation Percussion Auscultation
• Normal in
shape
• Umbilicus:
Centrally
placed
• Relaxed
• Symphysio
fundal height:
Reveals 36
weeks of
pregnancy
• Abdominal
girth: 115 cm
• Fetal
movement:
present
• Normal • Fetal heart
rate: 148
beat/min
Systemic Examination (Continued)

14. Per-vaginal Examination:
• Cervix : Soft
• OS : 1.5 cm dilated
• Presentation : Cephalic
• Station : 0
• Movement : Regular
Systemic Examination (Continued)

15. Salient Features
A 21-years-old primi reported to Gynae OPD of CMH
Dhaka with the complaints of amenorrhea due to
pregnancy for 35+ weeks. She had complaints of lower
abdominal pain for last 3 days which was initially dull and
intermittent in nature, radiated towards back and groins,
not associated with hardening of uterus. She also noticed
per-vaginal discharge for last 2 days, which was initially
whitish and foul-smelling, then watery in nature.

16. With those complaints, she got admitted in the ORs’
Family Gynae ward. After 2 days of her admission, she
developed severe respiratory distress in the ward which
was treated by O2 inhalation, nebulisation and diuretics;
but did not improve significantly.
Then, she was shifted from ward to PACU immediately.
The patient was thoroughly examined in PACU and was
found to have tachycardia and tachypnoea.
Salient Features (Continued)

17. Her CVS examination revealed thrill and mid-diastolic
murmur on apical area and early diastolic murmur on
parasternal area. On respiratory system examination,
there were basal crepitations on both lungs fields.
Her per-abdominal and per-vaginal examination revealed
36 wks of pregnancy with labour. Her other systems
shown no abnormality. Then, the patient was referred to
Cardiologist for further cardiac evaluation.
Salient Features (Continued)

18. Provisional diagnosis
Primi gravida with 35+ weeks of
pregnancy with PROM with preterm
labour with Valvular heart disease

19. Differential diagnosis
 Primi gravida with 35+ weeks of
pregnancy with PROM with preterm
labour with Fluid over load
 Primi gravida with 35+ weeks
of pregnancy with PROM with
preterm labour with Pneumonia

20. Investigations
Complete Blood count:
• Hb conc. : 11.00 gm/dl
• Total Red Blood cells : 3.75×1012/L
• Hct : 34.10%
• Total White blood cells : 13×109/L
• Differential Leucocyte count :
• Neutrophils - 80%
• Eosinophils - 01%
• Basophils - 00%
• Lymphocytes - 15%
• Monocytes - 04%
• Others - 00%

21. Investigations (Continued)
Complete Blood count:
• Platelets : 294.00×109/L
• ESR (Westergren) : 26 mm in 1st hour
Coagulation profile:
Prothrombin Time (PT):
• Patient : 17 second
• Control : 12 second
• INR : 1.44
Activated Partial thromboplastin time (APTT):
• Patient : 36 second
• Control : 31 second

22. Physical and Chemical
examination
Microscopic
Examination
Appearance:
Sp. Gravity:
Reaction:
Protein:
Glucose:
Bile salt:
Bile
pigments:
Light amber
Not done
Acidic
Nil
Nil
Not done
Not done
WBCs:
RBCs:
Epithelial
cells:
Casts:
Crystals:
Others:
2-3/HPF
Nil/HPF
4-6/HPF
Nil
Nil
Nil
Urine routine & microscopic examination:
Investigations (Continued)

23. Blood Sugar:
• Plasma Glucose Fasting : 5.0 mmol/L
• Plasma Glucose 2 hrs after
75 mg oral Glucose : 6.0 mmol/L
Blood group (ABO and Rh):
• B (BEE) +ve (positive)
VDRL (Qualitative):
• Non-reactive
HbsAg
• Negative
Investigations (Continued)

24. Ultrasonogram of Pregnancy profile:
Investigations (Continued)
 Uterus is gravid containing single living foetus with
regular cardiac pulsations and normal foetal movement
 Foetal presentation: Cephalic
 EDD: 4 Dec 2016 ± 1 week
 Placenta: Anterior, away from os
 Gestational age: 35 wks & 2 days

25. Figure: ECG tracing showing P mitralae with Tacycardia
Electrocardiogram:
Investigations (Continued)
 Sinus tachycardia
 P mitralae

26.  Rheumatic heart disease
 Moderate mitral stenosis (MS)
 Mitral vulve area: 1.2 cm2
 Moderate mitral regurgitation (MR)
 Mild to moderate aortic regurgitation (AR)
 Severe pulmonary hypertension (PASP: 68 cm of H2O)
 Good left ventricular function (LVEF: 60%)
Echocardiogram (bed-side):
Investigations (Continued)

27. Confirmatory diagnosis
Primi gravida with 35+ weeks pregnancy with
PROM with preterm labour with moderate MS
and MR with mild to moderate AR with severe
pulmonary hypertension

28. Decision of Emergency Surgery
Immediately after confirmation of the
diagnosis, decision of performing the
emergency Cesarean section was taken

29. Anaesthetic management

30. Anaesthetic considerations
 Anaesthetic management for an emergency
Caesarean section with double valve heart disease
which was diagnosed just prior to the operation.
 Administering anaesthesia in a compromised
patient with respiratory distress and basal
crepitations due to valvular heart disease and
pulmonary hypertension which were not
optimised by preoperative treatment.

31.  Prevention and management of intra-operative
complications due to pulmonary hypertension.
 As the mother was on preterm labour with
PROM, so there were great concerns of safety of
two lives on distress.
Anaesthetic considerations
(Continued)

32. Pre-anaesthetic assessment
 Pre-anaesthetic check-up was done with detailed
history, proper clinical examination and
assessment of the investigation reports.
 Immediately after the check-up in PACU patient
was shifted to Operation Theatre.

33. Pre-anaesthetic assessment
(Continued)
 Considering her preterm labour with PROM and
stat diagnosis of moderately advanced valvular
heart disease and severe pulmonary hypertension,
the patient was assessed as:
 NYHA classification : NYHA class - IV
 Airway assessment : Mallampati class - II
 ASA Grading : ASA Grade - IV (E)
 Patient was planned for emergency Caesarean
section.

34.  Propped up position
 O2 inhalation @ 2-4 l/min
 Airway management eqpt
 Different sized ET tube
 Gum elastic bougie
 Breathing circuits
 Drugs for GA and
emergency carts
Preparation for Anaesthesia

35.  Defibrillator
 Syringe pumps
 Large-bore 16 gauze I/V line was
established through left cephalic
vein
 Inj. Frusemide 20 mg I/V stat given
 Urinary catheterization was done
 Paediatric team was brought in the
OT.
Preparation for Anaesthesia
(Continued)

36.  A central venous catheter line was established
through the right internal jugular vein (IJV) with 7
Fr, 20 cm central venous catheter.
Preparation for Anaesthesia
(Continued)

37.  An intra-arterial line was established in the right
radial artery to monitor the continuous invasive
blood pressure.
Preparation for Anaesthesia
(Continued)

38.  Inj. Metoclopramide (10 mg)
 Inj. Ranitidine (50 mg)
 Inj. Ceftriaxone (1 gm)
 Inj. Fentanyl (100 mcg)
Premedication
 Medications given on the OT table before operation

39.  Induction was done by Inj.
Thiopentone Sodium
(300mg)
 Intubation was done after
adequate muscle relaxation
with Inj. Suxamethonium
(100mg)
Induction and Intubation
 The patient was reassured with compassion to allay
her fear and anxiety

40.  Anaesthesia was maintained with O2 and
intermittent Midazolam.
 Adequate analgesia was ensured with intravenous
Fentanyl (150 mcg)
 Adequate muscle relaxation was provided with
intermittent NMBA (Inj. Vecuronium Bromide)
 Intravascular volume was kept optimised by Inj.
Frusemide.
 Per-operatively, only 200 ml of Hartmann solution
was given.
Maintenance

41.  Control of HR & rhythm: By Inj Esmolol
 Maintaining CVP within 5-6 cmH2O by optimum
volume of IV Fluids (only 200 ml) and judicious use of
diuretics (Inj Frusemide 20 mg)
 Emergency medicines were kept ready to combat any
unforeseen complications which include - Inj GTN,
Adrenaline, Noradrenaline, etc.
Measures to overcome
Anesthetic challenges

42. Further deterioration of PAH was
managed by:
 100% O2 (to prevent hypoxia)
 Avoidance of Halothane and N2O
 Adequate analgesia by Inj. Fentanyl (150 mcg)
 Moderate hyperventilation (to prevent of acidosis)
 Low-dose infusion of Inj. Dobutamin to reduce
Pulmonary vascular resistance
Measures to overcome Anesthetic
challenges (Continued)

43.  Routine monitoring of
ECG and SpO2.
 Continuous ETCO2 was
monitored and kept below
30 mmHg to prevent
further deterioration of
pulmonary hypertension.
 CVP was monitored to
restore normal volume
status.
Intra-operative monitoring

44.  Beat-to-beat IBP was monitored through arterial line.
 Urine output was monitored (50 ml in 45 minutes).
 Per-operative ABG analysis was done and kept within
normal ranges.
Intra-op monitoring (Continued)

45. A male baby with 2 kg body weight was delivered per-
abdominally and after immediate resuscitation at the OT
by the attending Paediatric Team, the baby was shifted
to NICU for further evaluation and management.
Baby resuscitation

46. The conventional reversal and emergence usually
provokes tachycardia and agitation which are
considered as the detrimental factors for the patients
with VHD and PAH. Moreover, this patient needed a
less stress and pain free reversal. So, she was not
reversed on the OT table and kept on elective
mechanical ventilation, then shifted to CCC, with an
endotracheal tube in situ.
Issue of Reversal

47. Postoperative Management
 In the CCC, all invasive and non-invasive monitoring
were continued.
 MAP was kept within 70-90 mmHg.
 Cardiac output was monitored by flow trac module.
 Analgesia & sedation was provided with Inj Fentanyl
and Inj Midazolam.
 Fluid maintenance was ensured by 0.45% DNS @ 70
ml/hr
 The patient was on pressure-supported ventilation for
48 hours in the CCC with measured VT of 7 ml/kg.

48. Postoperative Management
(Continued)
 On 2nd POD, she was
extubated and shifted to Post-
Anaesthesia CU from CCC.
 On 5th POD, a follow-up
Echo was done & her cardiac
status was found comparable
with the pre-existing
condition.
 On 6th POD, the patient was
shifted from Post-Anaes CU
to Gynae ward.

49. Postoperative Management
(Continued)
 On 7th POD, the stitches of the surgical wound were
removed.
 On the same day, Cardiologist visited the patient and
prescribed Tab. Furosemide+Spironolactone, Tab.
Metoprolol, Tab. Bosentan & Tab. Phenoxymethyl
Penicillin and she was advised to come for follow-up
after 4 weeks.
 On the same day, the patient was discharged from CMH
Dhaka.

50. Discussion

51. Parameter
Average changes from
non-pregnant values (%)
Plasma volume +45
Cardiac output +40
Heart rate +15
Stroke volume + 30
Systemic vascular resistance -15
Oxygen consumption +20
Renal blood flow and GFR -50
Haemodynamic changes in
normal pregnancy

52.  Increases significantly by 5 weeks gestation.
 At the end of 1st trimester : CO increases by 40%
 At the end of 2nd trimester : Increases by 50%
 Immediately postpartum : Increases by 75%
 Overall, cardiac output get increased by 40% during
pregnancy period from non-pregnant values.
 It has a significant effect on maternal physiology and
pharmacology during anaesthetic procedure.
Critical periods
Cardiac output

53.  Incidence of valvular heart disease in developed
country is 2.5%, amongst all valvular heart
disease.
 Mitral valve prolapse is most common affecting
1% to 2.5% of all population of developed
countries.
 Most commonly women of child bearing ages are
affected.
Incidence of Valvular Heart
Disease

54. Pregnancy can cause following cardiac complication
in a patient with valvular heart disease:
 Atrial fibrillation
 Pulmonary oedema
 Pulmonary hypertension
 Right ventricular failure
 Congestive cardiac failure
 Bacterial endocarditis.
Effect of Pregnancy on
Valvular heart disease

55. Effect of Valvular heart disease
on Pregnancy
Valvular heart disease has some detrimental effect on
pregnancy it includes:
 Abortion
 Preterm labour
 Intra uterine growth retardation
 Congenital heart disease in baby – 5%
 Intrauterine fetal death

56. Anaesthetic challenges
(Mitral stenosis)
Challenges Management
Sinus tachycardia, atrial fibrillation
Cardioversion or IV administration
of Beta blockers, Ca++ channel
blockers, digoxin
Marked increase in central blood
volume
Judicious use of IV fluid
Drug induced decrease in systemic
vascular resistance
Use of sympathomimetic drug
(Phenylephrine)
Pulmonary Hypertension and right
heart failure
Avoidance of hypoxaemia and
hypercarbia, Ionotropes,
Pulmonary vasodilating drugs.

57. Anaesthetic challenges
(Mitral & Aortic regurgitation)
Challenges Management
Bradycardia Avoid volume overload
Increased systemic
vascular resistance
After load reduction with a
vasodilator(Nitroprusside)with or
without inotropes, maintenance of
cardiac output by modest increase in
heart rate.
Myocardial depression Judicious use of drugs.

58. Anaesthetic challenges
(Pulmonary Hypertension)
Challenges Management
Right heart
failure
• Reduce RV after load
• Avoid hypoxemia, hypotension and
inadequate RV preload
• Continuous use of pulmonary
vasodilator s (Ca channel blockers,
Inhaled NO, GTN)
Pulmonary
Oedema
Use of diuretics.
Hypoxia,
Hypercarbia,
acidosis
Use of 100% oxygen and judicious use of
inhalation anesthetics and sedatives

59. Choice of Anaesthesia
Condition Choice of Anaesthesia
NYHA class 1 & 2
Normal vaginal delivery, forceps
delivery with epidural analgesia
NYHA class 3 & 4 LUCS under G/A
It is better to avoid spinal anaesthesia except MR

60. Postoperative Care
Risk of:
 Sudden death in early postoperative period due to
worsening of pulmonary hypertension
 Pulmonary oedema and Right heart failure
 Pulmonary thromboembolism and Dysrhythmias
 Hypoxaemia, hypercarbia and respiratory acidosis due
to pain & hypoventilation

61. Postoperative Care (Continued)
These can be managed by:
 Intense cardiovascular monitoring
 Proper oxygenation, mechanical ventilation (if
necessary).
 Maintenance of hemodynamic variables at acceptable
levels
 Optimal pain control

62. Surgical and Anaesthetic management of a patient with
diseased heart is always challenging. Specially it sweats
more when the issue is PREGNANCY.
It demands skillful and sophisticated handling of the
patient. Moreover, when the finding is incidental, a
single break of concentration can be fatal.
Conclusion