Top Things to Know: Statement on the anesthetic care of the pregnant patient with cardiovascular disease

Published: February 13, 2023
  1. Cardiovascular disease is the leading cause of maternal mortality in the United States, accounting for over 25% of maternal deaths.
  2. Maternal morbidity and mortality disproportionately affect Black patients evidenced by rates 3- to 4-fold higher than non-Hispanic white patients, in part due to structural and societal disparities, that cause Black patients to enter pregnancy with higher rates of cardiovascular risk factors such as obesity, diabetes, and hypertension.
  3. The anesthesiologist is crucial to the safe delivery of peripartum care. This statement provides a practical framework for coordinating the anesthetic care of a cardio-obstetric patient undergoing delivery or management of miscarriage.
  4. The Pregnancy Heart Team refers to the team of specialists with expertise in cardiology, obstetrics, gynecology, maternal fetal medicine, primary care, hematology, critical care obstetric nurses, pharmacy, and anesthesiology that works together to develop an individualized antepartum, labor/delivery, and postpartum care plan for patients with cardiovascular disease.
  5. Obstetric anesthesiologists have expertise in the anesthetic care of pregnant patients and cardiothoracic anesthesiologists can help with patients who sustain or are at risk for acute cardiovascular decompensation, potentially requiring peripartum cardiothoracic surgery, mechanical support or extracorporeal membrane oxygenation (ECMO).
  6. The Modified World Health Organization (mWHO) Pregnancy Risk Classification and the CARPREG II risk score, in conjunction with a patient’s current clinical status, can be used to assess maternal risk and care requirements of the obstetric patient with heart disease. Patients with mWHO classification III or IV are recommended to deliver at Maternal Level IV Care Centers, tertiary care centers with the ability to provide cardiac surgery, specialized critical care cardiology, and involvement of an appropriate cardiac subspecialist.
  7. Vaginal delivery with effective neuraxial analgesia is the preferred mode of delivery in most patients, as it decreases risk of obstetric complications (e.g., bleeding, thrombosis and infection) and allows for more gradual hemodynamic changes at the time of delivery. Cesarean delivery is reserved for obstetrical indications or patients who are at a very high risk of decompensation at the time of delivery.
  8. Neuraxial anesthesia is typically preferred for cesarean delivery, including for patients with mWHO class III or IV lesions. To avoid spinal epidural hematoma, neuraxial techniques should be timed according to the anticoagulation medication drug and dose as recommended by the American Society of Regional Anesthesia (ASRA) Guidelines and the Society for Obstetric Anesthesia and Perinatology (SOAP) Consensus Statement.
  9. ECMO on standby for select cardio-obstetrics patients is a useful strategy for cardiopulmonary support when medication therapy is inadequate. Deployment of ECMO early in a maternal cardiac arrest is lifesaving.
  10. The postpartum period, specifically the first 24–48 hours after delivery, is associated with significant hemodynamic changes and fluid shifts which may precipitate heart failure and arrhythmia. Managing patients in intensive care units may be necessary for thorough hemodynamic optimization.
  11. The wide range of maternal cardiovascular disease states, with heterogeneity in optimal hemodynamic parameters, highlights the importance of individual assessments when making anesthetic plans for pregnancy, labor, and delivery. Safe pregnancy can be achieved for most cardio-obstetric patients under the care of a Pregnancy Heart Team which includes anesthesiologists who recognize patients at high cardiovascular risk, and who formulate safe delivery and post-delivery plans.

View the summary for Anesthetic Care of the Pregnant Patient With Cardiovascular Disease

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Citation

Meng ML, Arendt KW, Banayan JM, Bradley EA, Vaught AJ, Hameed AB, Harris J, Bryner B, Mehta LS; on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; and Council on Peripheral Vascular Disease. Anesthetic care of the pregnant patient with cardiovascular disease: a scientific statement from the American Heart Association [published online ahead of print February 13, 2023]. Circulation. doi: 10.1161/CIR.0000000000001121

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