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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 29-30

Cesarean Section in Patients with Hypertrophy Cardiomyopathy done Under Epidural Anesthesia

1 MD Anaesthesia and Intensive care, Assistant Professor, IGIMS, Patna, India
2 MD Anaesthesia and Intensive care, Additional Professor, IGIMS, Patna, India

Date of Web Publication12-Feb-2016

Correspondence Address:
Swati Singh
Assistant Professor Department of Anesthesia, IGIMS
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Source of Support: None, Conflict of Interest: None

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Hypertrophic cardiomyopathy is characteristically associated with asymmetric hypertrophy of interventricular septum causing partial obstruction of the left ventricular outflow and reducing ejection fraction. Since Hypertrophic cardiomyopathy is the most common genetic cardiovascular disease, it is very commonly encountered by anesthesiologist during preoperative examination. Surgery and anesthesia often complicate the perioperative outcome if adequate monitoring and proper care are not taken. General anaesthesia is considered safer because of more cantrolled hemodynamics. Regional anesthesia is considered to be dangerous in these patients, especially in those with obstructive HCM, vasodilation associated with sympathetic blockade of the lower extremities may lead to a critical reduction of preload and afterload. Nevertheless, epidural anesthesia has been used safely for vaginal delivery in patients with HCM. Our report indicates that cesarean section also may be managed safely with epidural anesthesia in patients with HCM, by taking precaution.

Keywords: Hypertrophic cardiomyopathy, cesarean section, epidural anaesthesia

How to cite this article:
Singh S, Verma V K, Kumar A. Cesarean Section in Patients with Hypertrophy Cardiomyopathy done Under Epidural Anesthesia. J Indira Gandhi Inst Med Sci 2016;2:29-30

How to cite this URL:
Singh S, Verma V K, Kumar A. Cesarean Section in Patients with Hypertrophy Cardiomyopathy done Under Epidural Anesthesia. J Indira Gandhi Inst Med Sci [serial online] 2016 [cited 2022 Oct 2];2:29-30. Available from: http://www.jigims.co.in/text.asp?2016/2/1/29/303366

  Introduction: Top

The commonest genetic cardiovascular disease encountered in clinical practice is Hypertrophy cardiomyopathy (HCM). This disease has no age selection with equal incidence in male and female.[1] There is tremendous variation in presentation and progression of HCM. Some patients may develop abnormal heart rhythms (arrythmias) that may put them at increased risk for sudden cardiac death. Young patients coming for some other surgery may have incidental diagnosis of this condition and may pose considerable challenge for the Anaesthesiologists. In most cases, HCM patients had undergone vaginal delivery safely;[2],[3] however, cesarean section may be carried out for cardiac or obstetric indications. Anesthetic management has not been determined in these cases, but epidural anesthesia is relatively contraindicated because of vasodilation and reduction in central blood volume.

We report two cases of young female for elective LSCS who had diagnosis of HCM safely done under epidural anaesthesia.

  Case Reports Top

Case 1: A 25 year old woman, primigravida was a known case of HCM. HCM was diagnosed at 24 years of age after an episode of presyncope. She had uneventful pregnancy just with an episode of dyspnea on exertion at 32 weeks. Echocardiography was done where peak outflow gradient of 32 mmHg was found. The patient was then started on oral propranolol and diuretics. Cesarean section was planned for fetal indication at 37 weeks of gestation. Patient was asymptomatic before surgery with normal haemodyanamics. All precautions were taken and along with routine monitors central venous pressure (CVP) was planned. Opening CVP was 10 cm of H2O in supine position with left uterine displacement with wedge under left hip. Patient was given bolus of lactated ringers solution about 200 to 300 ml through peripheral line. Epidural catheter was placed in L3 - L4 interspace through 18guage touhy needle using loss of resistance technique. Patient was kept in supine position with wedge under right hip to avoid aorto-caval compression. Bupivacaine, 0.5%, in 4-ml increments over 20 min for a total volume of 16 ml (80 mg) bupivacaine, when a sensory anesthesia level of T5-S4 was reached. The patient was breathing 35% O2via a face mask achieving 100% oxygen saturation. Intraoperative analgesia was excellent, and surgery proceeded uneventfully. A 2,870-g female infant was born with Apgar score of 8/9 at 1 and 5 min, respectively. Systemic arterial pressure remained stable at 95-110/60 mmHg; With strict CVP monitoring and fluid control CVP ranged between 9 and 11 cm H2O before delivery of fetus. Though when we administered 5 U oxytocin an increase CVP was observed to 15 cm H20. During entire duration of surgery total fluid administration was 2 liters of Ringer’s lactate.

Case 2 : A 28 year old woman, gravida 3, a known case of HCM, presented at 38 weeks of gestation. She was diagnosed HCM at age of 12. Her previous 2 pregnancies were normal vaginal delivery without any complications. During current pregenancy at 10 week of gestation she became symptomatic with dyspnea and palpitation. Echocardiogram revealed a mild left ventricle (55mm) and left atrial (45mm) dilatation. Holter monitoring revealed 3 episodes of non sustained ventricular tachycardia. Patient was treated with sotalol and furosemide. Pre-operative BP was 95/70 mm of Hg and HR 78 beats per minute. The saturation of patient was maintainted 99 % on venturi mask with 35% FiO2. A peripheral 18 -guage intravenous catheter was placed in right upper limb. Central venous line catheter was placed in right internal jugular vein and opening CVP was 8 cm of H20. Fluid was administered under CVP guidance and slowly CVP was build up to 11 cm of H20. An epidural catheter was inserted through an 18 guage tuohy needle at the L3 - L4 space through loss of resistance technique. Bupivacaine was administered in 3 ml incremental dose (total 12 ml) and sensory anaesthesia of T4-S4 was achieved. Patient remain asymptomatic throughout the surgery, 2.970 kg female infant was extracted. After delivery of foetus there was a mild episode of hypotension with BP 85/60 mm of Hg, which was managed by fluids. She received approximately 800 ml lactated Ringer’s solution and 800 ml normal Saline solution.

  Discussion: Top

When during regional anaesthesia preload and afterload is reduced it has unfavourable effect on hemodynamics. During pregnancy the change in physiology results in decrease in systemic vascular resistance and an increase in blood volume. Further during third trimester aortocaval compression or major blood loss during labor and delivery may decrease preload drastically; moreover, pain and stress of delivery cause sympathetic stimulation, increasing heart rate and contractility and deteriorating the hemodynamic conditions of HCM.[1],[2] There are number of reviews published about how well pregnancy is tolerated in patients with HCM. In this review cesarean section was carried out for cardiac or obstetric indications in 11 of 56 patients. Information is not available regarding the type of anesthesia used forthe cesarean section.[2]

Most of the reviews on noncardiac surgery in HCM recommends general anesthesia.[3] Sympathetic blockade caused by regional anaesthesia can lead to critical reduction of preload and afterload.[4] Though safe vaginal delivery has been conducted under epidural anaesthesia in parturients suffering with HCM.[5]

We have conducted cesarean section safely with epidural anesthesia in patients with HCM, by using CVP monitoring and maintaining euvolemia or slight hypervolemia. Hypotension due to sympathetic blockade can be minimized by using drug in titration under strict preload and afterload monitoring.

This allows only slight hemodynamic changes that, if necessary, can be adjusted with fluid balance. Both our cases did not require vasoconstrictors for hypotension. Whenever hypotension is encountered it should be primarily managed by fluid, if patient is unresponsive to fluid phenylephrine could be preferred to increase afterload because of its shorter duration of action. As for oxytocin, since this drug has to be used it should be used in slow infusion because of its vasodilatory effects and the abrupt inflow of a large amount of blood into the systemic circulation as a result of uterine contraction that can adversely affect cardiac performance by increasing cardiac load.

Thus we conclude with adequate precautions epidural anaesthesia can be safely administered in parturients with HOCM.

  References Top

Maron BJ, Gardin JM, Flack JM, Gidding SS, Kurosaki TT, Bild DE: Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Echocardiographic analysis of 4111 subjects in the CARDIA Study. Circulation 1995;92:785-9  Back to cited text no. 1
Oakley GD, McGarry K, Limb DG, Oakley CM: Management of pregnancy in patients with hypertrophic cardiomyopathy. BMJ 1979; 1:1749-50  Back to cited text no. 2
Maron BJ. Hypertrophic cardiomyopathy: A systematic review. JAMA 2002;287:1308.  Back to cited text no. 3
Maron MS, Olivotto IBetocchi S, Casey SA, Lesser JR, Losi MA, et al. Effect of left ventricular outflow tract obs FiO2 truction on clinical outcome in hypertrophic cardiomyopathy. N Engl J Med 2003;348:295-303.  Back to cited text no. 4
Autore C, Brauneis S, Apponi F, Commisso C, Pinto G, Fedele F. Epidural anesthesia for cesarean section in patients with hypertrophic cardiomyopathy: A report of three cases. Anesthesiology 1999;90:1205-7.  Back to cited text no. 5


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