Canadian Journal of Anaesthesia

, Volume 41, Issue 6, pp 502–512

Pulmonary hypertension and pregnancy: a series of eight cases

  • Kari G. Smedstad
  • Robert Cramb
  • David H. Morison
Clinical Reports

Abstract

This is the report of a series of eight patients with pulmonary hypertension (primary and secondary) who delivered at the McMaster University Medical Centre between 1978 and 1987. Seven of the eight patients delivered vaginally and had a successful outcome. The eighth patient was admitted as an emergency and died shortly after Caesarean section under general anaesthesia, performed to save the infant. The other seven patients were all managed by a team, including anaesthetists, cardiologists and obstetricians, from about 25 wk. The patients were hospitalized pre-partum and received oxygen therapy and anticoagulation with heparin. Analgesia in labour was managed, once anticoagulation was reversed, by low concentrations of epidural bupivacaine (0.125% – −0.375%) and fentanyl. The patients were monitored during labour and delivery with oximetry and arterial and central venous pressure lines. Pulmonary arterial lines were not used because of increased risk and questionable usefulness. Vaginal delivery was managed with vacuum extraction or forceps lift-out to minimize the stress of pushing. After delivery, all patients were monitored in an intensive care unit for several days, anticoagulation was restarted, and all patients were discharged home taking oral anticoagulant therapy. The successful management of pulmonary hypertension in pregnancy should include team management started early in pregnancy and controlled vaginal delivery utilizing epidural analgesia.

Key words

anaesthesia: obstetric lung: pulmonary hypertension 

Résumé

Ce travail porte sur une série de huit patientes souffrant d’hypertension pulmonaire (primaire et secondaire) qui ont accouché au centre médical de l’université McMaster de 1978 à 1987. Sept des huit patientes ont donné naissance par voie vaginale avec succès. La huitième a été admise en urgence et est décédée peu de temps après une césarienne sous anesthésie générale réalisée dans le but de sauver le foetus. Les sept autres ont été suivies à partir de la 25 semaine par une équipe qui comprenait des anesthésistes, des cardiologues et des obstétriciens. Elles ont été hospitalisées avant l’accouchement et ont reçu de l’oxygénothérapie et de l’héparine. Pendant le travail, une fois l’anticoagulation renversée, l’analgésie a été produite par de la bupivacaine 0,125%–0,375% et du fentanyl. Pendant le travail et l’accouchement, les patientes ont été monitorées par oxymétrie, tension veineuse centrale et pression artérielle sanglante. On n’a pas installé de cathéter artériel pulmonaire à cause du risque accru de complications et de son utilité douteuse. L’extraction vaginale a été réalisé par application de ventouse ou de forceps pour diminuer le stress de la poussée abdominale. Après l’accouchement, toutes les patientes ont été monitorées à l’unité de soins intensifs pendant plusieurs jours et anticoagulées de nouveau. Elles ont reçu leur congé de l’hôpital avec anticoagulothérapie. La gestion de l’hypertension pulmonaire de la femme enceinte doit être multidisciplinaire et l’accouchement doit s’effectuer sous contrôle, avec une anesthésie épidurale.

References

  1. 1.
    Gleicher N, Midwall J, Hochberger D, Jaffin H. Eisenmenger’s syndrome and pregnancy. Obstet Gynecol Surv 1979; 34: 721–41.PubMedGoogle Scholar
  2. 2.
    Jones AM, Howitt G. Eisenmenger syndrome in pregnancy. BMJ 1965; 1: 1627–31.PubMedGoogle Scholar
  3. 3.
    Stoddart P, O’Sullivan G. Eisenmenger’s syndrome in pregnancy: a case report and review. International Journal of Obstetric Anesthesia 1993; 2: 159–68.PubMedCrossRefGoogle Scholar
  4. 4.
    Breen TW, Janzen JA. Pulmonary hypertension and cardiomyopathy: anaesthetic management for Caesarean section. Can J Anaesth1991; 38: 895–9.PubMedGoogle Scholar
  5. 5.
    Dawkins KD, Burke CM, Billingham ME, Jamieson SW. Primary pulmonary hypertension and pregnancy. Chest 1986; 89: 383–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Gummerus M, Laasonen H. Eisenmenger complex and pregnancy. Ann Chir Gynaecol 1981; 70: 339–41.PubMedGoogle Scholar
  7. 7.
    Slomka F, Salmeron S, Zetlaoui P, Cohen H, Simonneau G, Samii K. Primary pulmonary hypertension and pregnancy: anesthetic management for delivery. Anesthesiology 1988; 69: 959–61.PubMedCrossRefGoogle Scholar
  8. 8.
    Nelson DM, Main E, Crafford W, Ahumada GG. Peripartum heart failure due to primary pulmonary hypertension. Obstet Gynecol 1983; 62: 58S-63SPubMedGoogle Scholar
  9. 9.
    Johnson MD, Saltzman DH. Cardiac disease.In: Datta S (Ed.). Anesthetic and Obstetric Management of High-Risk Pregnancy. St. Louis: Mosby — Year Book, Inc, 1991; 237: 245–51.Google Scholar
  10. 10.
    Pollack KL, Chestnut DH, Wenstrom KD. Anesthetic management of a parturient with Eisenmenger’s syndrome. Anesth Analg 1990; 70: 212–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Wille-Jϕrgensen P, Jϕrgensen LN, Rasmussen LS. Lumbar regional anaesthesia and prophylactic anticoagulant therapy. Is the combination safe? Anaesthesia 1991; 46: 623–7.CrossRefGoogle Scholar
  12. 12.
    Spinnato JA, Kraynack BJ, Cooper MW. Eisenmenger’s syndrome in pregnancy: epidural anesthesia for elective cesarean section. N Engl J Med 1981; 304: 1215–7.PubMedGoogle Scholar
  13. 13.
    Garber SZ, Choi HJ, Tremper KK, Fujita RA. Use of a pulse oximeter in the anesthetic management of a pregnant patient with Eisenmenger’s syndrome. Anesthesiology Review 1988; 15: 59–63.Google Scholar
  14. 14.
    Rocke DA, Rout CC, Orlikowski CEP. Anesthesia and coexisting maternal disease.In: Norris MC (Ed.). Obstetric Anesthesia. Philadelphia: JB Lippincott Company, 1993: 451–4.Google Scholar
  15. 15.
    Mangano DT. Anesthesia for the pregnant cardiac patient.In: Shnider SM, Levinson G (Eds.). Anesthesia for Obstetrics. 3rd ed. Baltimore: Williams & Wilkins, 1983; 502–8.Google Scholar
  16. 16.
    Robinson S. Pulmonary artery catheters in Eisenmenger’s syndrome: many risks, few benefits. (Letter). Anesthesiology 1983; 58: 588–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Devitt JH, Noble WH, Byrick RJ. A Swan-Ganz catheter related complication in a patient with Eisenmenger’s syndrome. Anesthesiology 1982; 57: 335–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Schwalbe SS, Deshmukh SM, Marx GF. Use of pulmonary artery catheterization in parturients with Eisen-menger’s syndrome. (Letter). Anesth Anaig 1990; 71: 442–3.CrossRefGoogle Scholar
  19. 19.
    Rich S. Primary pulmonary hypertension. Prog Cardiovasc Dis 1988; 31: 205–38.PubMedCrossRefGoogle Scholar
  20. 20.
    Roessler P, Lambert TF. Anaesthesia for Caesarean section in the presence of primary pulmonary hypertension. Anaesth Intensive Care 1986; 14: 317–20.PubMedGoogle Scholar
  21. 21.
    Roberts NV, Keast PJ. Pulmonary hypertension and pregnancy — a lethal combination. Anaesth Intensive Care 1990; 18: 366–74.PubMedGoogle Scholar
  22. 22.
    Sϕrensen MB, Korshin JD, Fernandes A, Secher O. The use of epidural analgesia for delivery in a patient with pulmonary hypertension. Acta Anaesthesiol Scand 1982; 26: 180–2.CrossRefGoogle Scholar
  23. 23.
    Robinson DE, Leight CH. Epidural analgesia with low-dose bupivacaine and fentanyl for labor and delivery in a parturient with severe pulmonary hypertension. Anesthesiology 1988; 68: 285–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Feijen HWH, Hein PR, van Lakwijk-Vondrovicova EL, Nijhuis GMM. Primary pulmonary hypertension and pregnancy. Eur J Obstet Gynecol Reprod Biol 1983; 15: 159–64.PubMedCrossRefGoogle Scholar
  25. 25.
    Takeuchi T, Nishii O, Okamura T, Yaginuma T. Primary pulmonary hypertension in pregnancy. Int J Gynecol Obstet 1988; 26: 145–50.CrossRefGoogle Scholar
  26. 26.
    Abboud TK, Raya J, Noueihed R, Daniel J. Intrathecal morphine for relief of labor pain in a parturient with severe pulmonary hypertension. Anesthesiology 1983; 59: 477–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Power KJ, Avery AF. Extradural analgesia in the intrapartum management of a patient with pulmonary hypertension. Br J Anaesth 1989; 63: 116–20.PubMedCrossRefGoogle Scholar
  28. 28.
    Gilman DH. Caesarean section in undiagnosed Eisen-menger’s syndrome. Anaesthesia 1991; 46: 371–3.PubMedCrossRefGoogle Scholar
  29. 29.
    Atanassoff P, Alon E, Schmid ER, Pasch Th. Epidural anesthesia for cesarean section in a patient with severe pulmonary hypertension. Acta Anaesthesiol Scand 1989; 33: 75–7.Google Scholar
  30. 30.
    Batson MA, Longmire S, Csontos E. Alfentanil for urgent Caesarean section in a patient with severe mitral stenosis and pulmonary hypertension. Can J Anaesth 1990; 37: 685–8.PubMedGoogle Scholar
  31. 31.
    Shime J, Mocarski EJM, Hastings D, Webb GD, McLaughlin PR. Congenital heart disease in pregnancy: short-and long-term implications. Am J Obstet Gynecol 1987; 156: 313–22.PubMedGoogle Scholar

Copyright information

© Canadian Anesthesiologists 1994

Authors and Affiliations

  • Kari G. Smedstad
    • 1
  • Robert Cramb
    • 1
  • David H. Morison
    • 1
  1. 1.Department of AnaesthesiaMcMaster UniversityHamilton

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