Sunil Jani, MD

A metaanalysis of epidural labor analgesia compared with nonepidural or no analgesia did not identify a difference in the risk for perineal trauma requiring suturing medications you cant take with grapefruit purchase oxybutynin 5 mg with visa. However symptoms after embryo transfer buy oxybutynin 2.5 mg on line, to our knowledge symptoms wheat allergy buy 5 mg oxybutynin, there is no evidence that epidural analgesia per se predisposes to pelvic floor injury treatment 20 buy oxybutynin from india. Controversy exists as to whether there is a cause-and-effect relationship between the use of these analgesic techniques and prolonged labor or operative delivery medications and pregnancy order generic oxybutynin canada. The understanding of this subject has been limited by the difficulty of performing controlled trials in which parturients are randomly assigned to neuraxial analgesia or a control group. Ideally, if one wants to study the effect of neuraxial analgesia on the progress and outcome of labor, the control group would receive no analgesia. However, such a study is not ethical, and even if it were and women volunteered to participate in it, the crossover rate would probably be high and the data consequently would not be interpretable. Therefore, controlled trials have randomly assigned parturients to receive neuraxial analgesia or an alternative form of pain relief, usually systemic opioid analgesia. However, even when the control group receives some type of analgesia, the crossover rate may be high because the quality of neuraxial analgesia is markedly superior to that of all other modes of labor analgesia. The investigators made the following comments389: Of 245 selected patients, 43 had to be removed from the trial after labour ensued. Most of the patients removed from the non-epidural group were apparently experiencing severe pain; they were usually primigravidae whose baby presented in the occipito-posterior position. The majority of patients removed from the epidural group were apparently normal and usually multigravidas; their labours were so rapid it was not possible to arrange for an epidural block. In other words, patients at low risk for operative delivery were excluded from the epidural group, and patients at high risk were excluded from the nonepidural group. Women who agree to participate in research trials may be inherently different from women who refuse to participate. Many women make a decision regarding labor analgesia well before the onset of labor and are unwilling to let chance randomization determine the type of labor analgesia. Thus, the study results may not be generalizable to the general obstetric population. Ironically, the effect of systemic opioids on the progress and outcome of labor has not been well studied. Conclusions about the effect of one technique on the progress of labor may not be applicable to other techniques (see later discussion). This is not possible for studies that compare neuraxial analgesia with another mode of analgesia, because of the marked difference in the quality of analgesia. Therefore, the potential for bias on the part of the parturient, nurses, and anesthesia and obstetric providers is substantial. Additionally, a number of factors are known to affect or to be associated with the progress and outcome of labor, including parity, artificial rupture of membranes, use of oxytocin, and payer status; these factors should be controlled in well-conducted studies. One factor known to markedly influence the outcome of labor is the obstetric provider. Five percent of patients in the clinic group and 17% of patients in the private group underwent cesarean delivery (P <. More striking was the difference between groups in the incidence of cesarean delivery for dystocia (0. Similarly, Guillemette and Fraser392 observed marked obstetrician variation in cesarean delivery rates, despite similarities in the use of oxytocin and epidural analgesia. Several groups of investigators have noted that the timing of cesarean delivery conforms to a "circadian" rhythm. In some cases, distinguishing between anesthesia administered for pain relief during labor and anesthesia administered in preparation for operative delivery is difficult. During the latent phase, higher levels of pain were predictive of longer latent and active phases of labor. Those women who reported "horrible" or "excruciating" pain during the latent phase were more than twice as likely to require instrumental delivery as women who only had "discomfort. Greater pain intensity during labor appears to be a risk factor for operative delivery. This fact will significantly bias observational studies of labor analgesia because women with greater pain intensity request analgesia, specifically neuraxial analgesia, at a higher rate than women with less intense pain. The rate of cesarean delivery for dystocia was 14% in women who self-administered 50 mg/h or more of meperidine, compared with 1. In a retrospective study of factors that predict operative delivery in laboring women, Hess et al. These findings may explain the observed association between neuraxial analgesia and operative delivery. Four prospective, randomized trials were performed at the University of Texas Southwestern Medical Center, Parkland Hospital, in Dallas. In the first study, 1330 women of mixed parity were randomly assigned to receive either epidural bupivacaine/fentanyl or intravenous meperidine for labor analgesia. However, the investigators did not report an intention-to-treat analysis of these data; thus, it was unclear whether there was a higher incidence of cesarean delivery in the women randomly assigned to the epidural analgesia group. Subsequently, the investigators published a re-analysis of the data that included an intention-to-treat analysis (Table 23. These analyses support the conclusion that women who choose epidural analgesia have an inherent risk factor(s) for cesarean delivery and that the administration of neuraxial analgesia per se does not alter this risk. Only 5 of 357 women randomly assigned to the Cesarean Delivery Rate Randomized Controlled Trials A number of randomized controlled trials have studied the effect of neuraxial (primarily epidural) and systemic opioid (primarily meperidine) analgesia on the cesarean delivery rate. All but one of these studies found no difference in the rate of cesarean delivery between women randomly assigned to receive either neuraxial or systemic opioid analgesia. The studies comparing neuraxial with systemic opioid analgesia have been systematically reviewed in several metaanalyses. Parturients were randomly assigned to traditional epidural analgesia or to one of two "low-dose" neuraxial techniques (see text). Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Similarly, several other studies that compared traditional epidural analgesia (using bupivacaine 0. Impact Studies Some physicians have questioned whether prospective, randomized studies provide an accurate representation of the effect of neuraxial analgesia on the mode of delivery in actual clinical practice. They have suggested the possibility that prospective studies may introduce a Hawthorne effect (which may be defined as the appearance or disappearance of a phenomenon on initiation of a study to confirm or exclude its existence). An alternative study design is to assess obstetric outcome immediately before and after a sentinel event, such as the introduction of an epidural analgesia service. The results of these studies may be generalizable to the general population because patients have not chosen to participate in a study. It also eliminates the problem of treatment group crossover because epidural analgesia was not available in the control period. One limitation of this study design is that it assumes that there were no other changes in obstetric management in the "after" period. Because of relative homogeneity in socioeconomic status, universal access to health care, and the availability of dedicated health care providers in the population served by this hospital, its rate of cesarean delivery may not be subject to influences common to other hospitals. Before 1993, the rate of epidural analgesia was less than 1% at Tripler Army Medical Center. Department of Defense mandated on-demand availability of neuraxial labor analgesia in military hospitals. In nulliparous women in spontaneous labor with a singleton infant with a vertex presentation, the rate of epidural labor analgesia rose from less than 1% to approximately 80% in a 1-year period. The investigators concluded that the consistency of the operative delivery rates in each of 3 years with very different epidural rates suggests that epidural analgesia does not increase the cesarean delivery rate. First, they strongly encouraged a trial of labor and vaginal birth after cesarean delivery. Second, after the 1988 calendar year, they circulated data showing the cesarean delivery rate of every obstetrician to all obstetricians. Third, they recommended the active management of labor as the preferred method of labor management for term nulliparous women. The rates of total, primary, and repeat cesarean deliveries decreased from 27%, 18%, and 9% in 1986 to 17%, 11%, and 6%, respectively, in 1991 (P <. Meanwhile, the use of epidural analgesia rose from 28% in 1986 to 48% in 1991 (P <. The authors concluded that epidural analgesia is not an important causal factor for operative deliveries. Thus, the before-after impact studies support the results of randomized controlled trials-namely, that neuraxial analgesia does not cause an increase in the cesarean delivery rate. Obstetricians in the target group used epidural analgesia more often than obstetricians in the control group. In other words, the target group of obstetricians was able to achieve a lower cesarean delivery rate despite their greater use of epidural analgesia. Each pair of symbols shows data from one investigation (the left symbol is the epidural analgesia rate and cesarean delivery rate during the period of low epidural analgesia availability, and the right symbol is the epidural analgesia rate and cesarean delivery rate during the period of high epidural availability). The size of the plot symbol is proportional to the number of patients in the analysis. A number of randomized controlled trials have addressed the question of whether initiation of neuraxial analgesia during early labor adversely affects the mode of delivery. There was no difference between the two groups in the rate of cesarean delivery or in the rate of instrumental vaginal delivery. The size of the box at the point estimate for each study is proportional to the number of patients in the study. This revised opinion included the following statement: Neuraxial analgesia techniques are the most effective and least depressant treatments for labor pain. The American College of Obstetricians and Gynecologists previously recommended that practitioners delay initiating epidural analgesia in nulliparous women until the cervical dilation reached 4-5 cm. However, more recent studies have shown that epidural analgesia does not increase the risks of cesarean delivery. The choice of analgesic technique, agent, and dosage is based on many factors, including patient preference, medical status, and contraindications. The fear of unnecessary cesarean delivery should not influence the method of pain relief that women can choose during labor. Later randomized trials in nulliparous women in both spontaneous22 and induced441 labor, as well as a 2014 metaanalysis (nine randomized controlled trials; n = 15,752)23 replicated these results. The effect of neuraxial analgesia on mode of vaginal delivery has not been assessed as a primary outcome in randomized controlled trials, although it has been assessed as a secondary outcome in multiple trials. Interpretation of these results is clouded by the fact that most studies have not assessed the quality of analgesia during the second stage of labor. Further, most investigators did not define the criteria for the performance of instrumental vaginal delivery. In clinical practice, and in study interpretation, it is often difficult to distinguish "indicated" instrumental deliveries from elective instrumental deliveries. Indeed, we have observed that indications for instrumental vaginal delivery vary markedly among obstetricians. An obstetrician is more likely to perform an elective instrumental delivery in a patient with satisfactory anesthesia than in a patient without analgesia. For studies with no instrumental vaginal deliveries, the risk ratio could not be calculated. Instrumental vaginal deliveries performed for the purpose of teaching are more likely to be done in women with adequate analgesia. Multiple randomized, controlled studies comparing epidural analgesia with systemic opioid analgesia have assessed the rate of instrumental vaginal delivery as a secondary outcome variable. A systematic review of seven impact studies435 involving more than 28,000 patients did not identify a difference in instrumental vaginal delivery rates between periods of low and periods of high epidural analgesia rates (mean change, 0. Studies of early versus late initiation of neuraxial labor analgesia have not identified an increased risk for instrumental vaginal delivery in the early analgesia group. The contribution of these factors to the mode of vaginal delivery, and their interactions, are not well understood, and these factors have not been well controlled in many studies. Several studies have specifically assessed the effect of maintenance of neuraxial analgesia until delivery with regard to the duration and outcome of the second stage of labor. The effect of neuraxial analgesia on the outcome of the second stage of labor may be influenced by the density of neuraxial analgesia. High concentrations of epidural local anesthetic may cause maternal motor blockade, leading to relaxation of pelvic floor musculature, which in turn may interfere with fetal rotation during descent. Abdominal muscle relaxation may decrease the effectiveness of maternal expulsive efforts. The effects of specific analgesic techniques, concentration of local anesthetic, total dose of local anesthetic, and degree of motor blockade on the risk for instrumental vaginal delivery are overlapping and difficult to study. For example, some studies suggest that administration of epidural analgesia using higher concentrations of bupivacaine is associated with a higher risk for instrumental vaginal delivery compared with use of lower concentrations. In a meta-analysis of 11 studies (n = 1145) comparing maintenance of epidural analgesia with high-concentration (defined as bupivacaine concentration greater than 0. A 2017 meta-analysis453 compared parturients randomized to low-concentration epidural analgesia with nonepidural or no analgesia (earlier meta-analyses included studies using both high- and low-concentration solutions3). There was no difference in the duration of the second stage of labor (mean difference, 5. Taken together, these data suggest that the specific analgesia technique may influence the risk for instrumental vaginal delivery. In general, the dose of bupivacaine is significantly lower if epidural analgesia is maintained with an intermittent bolus technique rather than a continuous infusion technique (see earlier discussion). Most investigators have noted a difference in motor blockade between the two techniques; higher total bupivacaine doses. However, the relationship between motor blockade and instrumental vaginal delivery is inconsistent.

In some cases medications 2 generic oxybutynin 2.5 mg fast delivery, physicians conclude that providing the requested care would present a personal moral problem-a conflict of conscience treatment zamrud oxybutynin 2.5 mg order with visa, which prompts them to refuse to provide the requested care treatment jones fracture discount oxybutynin 2.5 mg with mastercard. Conscientious refusals have become especially prevalent in the practice of reproductive medicine symptoms 24 hours before death discount oxybutynin 5 mg visa, an area characterized by deep societal divisions regarding the morality of contraception and pregnancy termination treatment kitty colds buy discount oxybutynin 2.5 mg on-line. The evolving clinical needs of both parturient and fetus require the coordinated efforts of obstetricians, midwives, nurses, anesthesia providers, and pediatricians. Birnbach and Salas have highlighted how coordinated care in the perinatal setting can benefit from the same team-building and teamtraining strategies that are inherent in other high-reliability organizations. There is increasing evidence that bringing clinical providers together, to practice the management of critical events or to debrief real events, helps ensure a more unified and effective therapeutic environment. For example, a recent simulationbased multidisciplinary obstetric team training exercise resulted in transiently improved management of real-life shoulder dystocia and obstetric hemorrhage. The investigators found that universal debriefings led to better communication among providers, and in particular, more providers chose to participate in debriefings and were more likely to speak up about patient care concerns. Intraprofessional team training on the labor floor also affects worker attitudes that can secondarily affect the patient experience. Developing strategies that support and engage all roles, and integrate the needs and contributions of all care providers, is a key component of a strong safety culture. In addition to bringing together the values of the patient and input of the clinicians, it requires that clinicians with varying experiences and perspectives also "be on the same page. Analysis of closed claim data has shown that communication barriers include hierarchy, intimidation, failure to function as a team, and failure to follow a chain of communication. In particular, they discussed the importance of closed-loop communication to confirm plans and directives, the value of having standardized hand-over language, and the benefits these simple techniques can have on fostering mutual support and minimizing burnout. Regularly scheduled intraprofessional safety rounds, including nurses, physicians, and other health care professionals, provide a standardized format with which to share information. This approach has been shown to foster a sense of "team," improve outcomes, align goals, and promote discussion, even when participants have competing priorities. One can imagine a situation in which, for example, a parturient with an unfavorable airway has expressed to the anesthesia provider a desire for natural childbirth, and the anesthesia provider could then share this information with the rest of the team during intraprofessional rounds. Then, if the obstetric provider was concerned about her nonreassuring fetal heart rate tracing, the team could approach the patient in a collaborative way to readdress the increased likelihood of an operative delivery and need for an anesthetic. In this not uncommon situation, the discussion would be focused not on choices for analgesia but on potential risks and benefits of surgical anesthesia. Generally this requires both effective systems for reporting and honest discussion of medical error. Of note, the peer review protection does not generally apply in federal court, which can result in information that was considered confidential being disclosed in certain federal matters, such as a patient race discrimination complaint. If the plaintiff is unable to prove even one of these elements, then the claim will fail as a matter of law. In a malpractice case, the "duty" that must be proven to have been "breached" is the duty to provide care that meets a minimum level of competence as determined by expert opinion on both sides of the case. It does not need to be the highest level of care, nor does it even need to be the level of care provided by most clinicians. However, it must not be beneath the minimum standard of care expected of a licensed provider. The standard of care is generally defined as "that care which a reasonable, similarly situated professional would have provided to the patient. If either the judge or jury determines that the standard of care was not met, then the plaintiff will still need to prove that there was an "injury" that was "caused" by the "breach. The use of standardized approaches such as checklists empowers members of the intraprofessional care team to cross-check clinical care for individual patients. Clear communication among providers and allied professionals has been shown to increase favorable outcomes, and certainly to increase the likelihood of meeting appropriate standards of care. The report specifically noted: "At the intersection of individual decision-making and team communication, teamwork training fosters development of a culture and structure for effective communication and decisive action. The evidence presented, including the expert testimony, must be significant and objectively strong. Some of the most common standards of care that are evaluated in a medical malpractice claim include whether an appropriate diagnosis was made, whether there was a surgical error, or whether pharmaceuticals have been prescribed and/ or administered appropriately. Sometimes, a physician makes a promise of a specific outcome to the patient, which could create a cause of action against the physician if such an outcome is not met. It is more often the case that the process of care is being evaluated, rather than the outcome. A physician is liable for a misjudgment or mistake only when it is proved to have occurred through a failure to act in accordance with the "care and skill of a reasonably prudent practitioner. Injured patients may serve notice of the intent to sue for malpractice as a strategy to find out what happened, and use legal procedures to require disclosure of the details of care that may otherwise be inaccessible. Statutes of limitations, legal time frames in which legal claims must be brought for such claims to be valid, vary from state to state but are generally 2 to 3 years. If a plaintiff can show that she would have been aware of an injury if not for fraudulent concealment by the provider, then the time frame may be extended to take such fraudulent behavior into account. Disclosure of Unanticipated Outcomes and Medical Errors Most practitioners strive to provide the highest quality of care, but even with the growing focus on patient safety, unintended consequences-including patient injury and death-do occur. Unfortunately, most physicians remain largely unprepared to engage patients and their families in a timely, truthful, and candid manner in the aftermath of such events. Although many providers and medical malpractice insurers might want potential breaches of the standard of care to go unnoticed or unrecognized, emerging evidence suggests that timely disclosure may reduce legal risk. Transparency, as well as a culture of accountability that includes providing apologies after such events, can mitigate distrust between the patient and provider, and ameliorate the desire to find someone to blame. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention and improvement strategies and for appropriate compensation for injured parties. This concern is reflected in a 2008 survey that indicated that as many as 75% of obstetricians felt that caring for a patient with an unanticipated stillbirth exacted a large toll on them, with almost 10% of those affected considering giving up their obstetric practice. Experts advise to limit disclosure to factual information that is known at the time of the discussion, and state that discovery is ongoing and information may evolve as the discovery process unfolds. It is important to maintain open dialogue with the patient and family as information is clarified, but this requires careful coordination among different members of the health care team. Conflicting information and speculation, especially speculation that places blame on other members of the health care team, can raise concerns that the entire team may be hiding the truth. If possible, it is best to obtain consent early in labor, before the onset of severe pain. When the patient is competent, the health care providers should attempt to resolve treatment conflicts through additional patient education and discussion. Rarely, it may be advisable to seek a court order to resolve competency or medical treatment issues. Ethical aspects of informed consent in obstetric anesthesia­new challenges and solutions. The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis. The relationship with malpractice claims among primary care physicians and surgeons. Surgical decision making: challenging dogma and incorporating patient preferences. Preferences for shared decision making in chronic pain patients compared with patients during a premedication visit. Implementation of shared decision making in anaesthesia and its influence on patient satisfaction. Patient-provider communication during the emergency department care of children with asthma. The effects of physician communications skills on patient satisfaction; recall, and adherence. Issues of consent for regional analgesia in labour: a survey of obstetric anaesthetists. Does labor pain and labor epidural analgesia impair decision capabilities of parturients. 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Expectations of pregnant women of Mexican origin regarding their health care providers. An anthropological analysis of the perspectives of Somali women in the west and their obstetric care providers on caesarean birth. Appropriateness of language used in patient educational materials from 24 national anesthesiology associations. The effect of a preanaesthetic information booklet on patient understanding and satisfaction. The effect of detailed, video-assisted anesthesia risk education on patient anxiety and the duration of the preanesthetic interview: a randomized controlled trial. Spanish and English video-assisted informed consent for intravenous contrast administration in the emergency department: a randomized controlled trial. Patient satisfaction and information gain after the preanesthetic visit: a comparison of face-to-face interview, brochure, and video. Clinicians may not administer life-sustaining treatment without consent: civil, criminal, and disciplinary sanctions. But it does not follow that they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves. The innovation imperative: scaling freestanding birth centers, centering pregnancy, and midwifery-led maternity health homes. South Carolina Supreme Court reverses 20-year homicide conviction of Regina McKnight. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women. Treatment versus criminalization-physician role in drug addiction during pregnancy. Managing care of an intrapartum patient with agitation and psychosis: ethical and legal implications. Does the effect of one-day simulation team training in obstetric emergencies decline within one year The brief debrief: improving communication and patient safety culture on labor and delivery. Improving safety on labor and delivery through team huddles and teamwork training [25h]. Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. Building comprehensive strategies for obstetric safety: simulation drills and communication. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. A comprehensive obstetric patient safety program reduces liability claims and payments. Advances in Patient Safety: New Directions and Alternative Approaches (Vol 3: Performance and Tools). York: information is not tangible personal property for the purpose of waiving sovereign immunity. The statute of limitations governing medical malpractice claims: rules, problems, and solutions. Statutes of limitation for medical malpractice claims vary by state, but generally span from two to three years. How physicians cope with stillbirth or neonatal death: a national survey of obstetricians. It occurs in 5% to 9% of pregnancies in developed countries1 and is responsible for 75% to 80% of all neonatal deaths and significant neonatal morbidity. For example, in 2005, in the United States the cost associated with preterm birth was at least $26. In lower-income countries, the preterm birth rate is 12% with a mortality rate greater than 90% in those born extremely preterm (less than 28 weeks). The United States has a slightly higher neonatal mortality rate than Europe (4 versus 3 per 1000 births, respectively), which reflects the higher preterm birth rate in the United States.

Compared imaging of the rheumatoid cervical spine: prevalence study and associated factors medicine emblem 5 mg oxybutynin purchase. Acquired laryngeal deviation associated with cervical spine disease in erosive polyarticular arthritis medicine 2015 buy cheap oxybutynin 2.5 mg. Ankylosing spondylitis: lateral approach to spinal anaesthesia for lower limb surgery medications via peg tube order oxybutynin overnight delivery. Total spinal anaesthesia following epidural test dose in an ankylosing spondylitic patient with anticipated difficult airway undergoing total hip replacement treatment hypothyroidism 2.5 mg oxybutynin purchase free shipping. Failed epidural analgesia in a parturient with advanced ankylosing spondylitis: A novel explanation medicine to induce labor order oxybutynin 5 mg on line. Updated national birth prevalence estimates for selected birth defects in the United States, 2004-2006. 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There are limited published data on specific neurologic and neuromuscular disorders in pregnant women. In most cases, the obstetrician should 1160 obtain early antepartum consultation from an anesthesia provider. Early consultation allows accurate antepartum documentation of the extent and pattern of the neurologic deficit as well as discussion and formulation of the anesthetic plan with the patient, her obstetrician, and a neurologist or neurosurgeon. Because patients with a wide variety of neurologic disorders will present for preoperative evaluation, the following thought process will assist the clinician with completing a proper evaluation and formulating an anesthetic plan. The potential for progression of the disease after delivery will depend on the pattern of progression and underlying pathophysiology, and on the effect of pregnancy on disease progression. A basic physical examination should be conducted to document existing deficit patterns, including cognitive dysfunction. Motor and sensory deficits are classified as mild, moderate, or severe, with a description of the affected area. In most cases, specific laboratory testing will not influence anesthetic management and outcome. However, pulmonary function testing should be considered in patients with neurologic disorders that result in significant respiratory compromise; the findings may assist the anesthesia provider in making recommendations about anesthetic management. For example, central core disease is associated with a risk for malignant hyperthermia. Can treatment be initiated antepartum or before delivery that will improve outcome For most rare neurologic disorders, there is limited evidence on which to base decisions about anesthetic management. Encouraging the obstetrician to send these patients for early antepartum consultation will enable the anesthesia provider to obtain formal input from a neurologist or other consultant if necessary. A multidisciplinary discussion that includes the patient and her family may be necessary to weigh the risks and benefits of specific obstetric and anesthesia plans. A team approach to peripartum care in patients with complex neurologic disorders is essential. Will the intrapartum anesthetic management or postpartum analgesia management influence outcomes Some conditions, such as multiple sclerosis, can have significant implications for the postpartum period. The anticipated progress of the disease and planned postpartum management should be discussed with the patient in the antenatal period. In all cases, accurate documentation of the responses to the previous questions will greatly assist the team providing peripartum care for these patients. Some of the more common neurologic conditions are addressed in this chapter, and the existing literature is surveyed relative to the peripartum management of these patients. This knowledge allows the anesthesia provider an opportunity to formulate a safe and rational anesthetic plan as well as enable an appropriate discussion with the patient regarding the risks and benefits of anesthetic options. Most relapses reproduce previously experienced neurologic deficits, which can manifest as pyramidal, cerebellar, or brainstem symptoms. It is estimated that about onehalf of affected individuals with exacerbating remitting disease will eventually convert to chronic progressive. The more common symptoms include motor weakness, impaired vision, ataxia, bladder and bowel dysfunction, and emotional lability. Although there is no cure, over the last two decades relapsing/remitting multiple sclerosis has become a treatable disease as a result of advancements in disease-modifying therapies. In contrast, administration of intravenous immunoglobulin or plasmapheresis for severe relapses has no known adverse effects on pregnancy outcome. Findings from a prospective study in Finland suggest that multiple sclerosis is associated with increased requirement for assisted reproductive techniques. In one study of women with multiple sclerosis undergoing assisted reproductive techniques, failed assisted reproductive attempts were associated with increased annual relapse rates. Pregnancy and obstetric outcomes in women with multiple sclerosis are likely no different from individuals without disease. One cohort study compared 198 affected women with 1584 healthy women; the number of maternal complications was not higher in women with multiple sclerosis. A 2017 United Kingdom case-controlled study of 181 pregnancies in 98 mothers with multiple sclerosis and 244,573 pregnancies in 124,830 mothers without multiple sclerosis did not find any associations with neonatal birth weight, gestational age at birth, mode of delivery, stillbirth, or neonatal death. Data from prospective studies suggest that the rate of relapse increases during the first 3 months postpartum in comparison with the year before pregnancy. Stress, exhaustion, infection, the loss of antenatal immunosuppression, and the postpartum decline in concentrations of reproductive hormones may account for the higher postpartum relapse rate. Rather, at least one study has suggested that parturition may have a slightly favorable effect on long-term disease activity. Historically, the optimal mode of anesthesia in patients with multiple sclerosis has been controversial. Many anesthesia providers have been reluctant to administer neuraxial anesthesia because the effect of local anesthetic drugs on the course of the disease is unclear. Some anesthesia providers have expressed concern that neuraxial anesthesia may expose demyelinated areas of the spinal cord to potentially neurotoxic effects of local anesthetic agents. Several animal studies have investigated the histologic effects of local anesthetic agents on the normal spinal cord. In one study, subarachnoid injection of small doses of a local anesthetic agent produced no histologic changes in the spinal cord or meninges. Two small reports have implicated spinal anesthesia in the exacerbation of multiple sclerosis. The relationship of these relapses to spinal anesthesia or other postoperative conditions. There are few published data on the use of epidural anesthesia in patients with multiple sclerosis. An alternative explanation is that women who require a higher concentration of neuraxial local anesthetic may have more stressful labor. However, these observations suggest that anesthesia providers should use a dilute solution of local anesthetic for epidural analgesia during labor, when possible. The administration of neuraxial anesthesia for cesarean delivery is considered safe. The 2013 record linkage study from British Columbia compared spinal anesthesia use in cesarean deliveries in 128 women with multiple sclerosis and 846 women in the general population, and did not find a link between spinal anesthesia and increased disability. In light of the significant benefits of neuraxial techniques for intraoperative anesthesia and postoperative analgesia, either spinal or epidural anesthesia is the principal anesthetic technique used for cesarean delivery in patients with multiple sclerosis in many institutions, including our own. In summary, published data do not contraindicate the use of neuraxial anesthetic techniques for labor analgesia or operative anesthesia. The patient should be aware that there is a higher incidence of relapse during the postpartum period, even without the use of neuraxial analgesia or anesthesia. In addition, when anesthetic techniques are used, the type of anesthesia selected does not appear to influence the relapse rate. Neither pregnancy nor anesthesia appear to have a negative influence on the long-term course of the disease. The willingness of anesthesia providers to use neuraxial techniques in pregnant patients with multiple sclerosis is reflected in a survey of obstetric anesthesia providers published in 2006. Tension headaches, migraine headaches, and headaches associated with hypertensive disorders of pregnancy are commonly observed during pregnancy. All imaging modalities may be used to assist in the diagnosis of secondary headaches in pregnancy, although measures should be taken to minimize maternal and fetal exposure to ionizing radiation. Although the etiology is unknown, this type of headache is believed to be associated with stress rather than hormonal changes. These headaches are more common in women, are frequently associated with anxiety, and may be a symptom of postpartum depression. Butalbital is sometimes prescribed for treatment of migraine and tension headaches, but its appropriateness has been questioned given increased risks for abuse, overuse headache, and withdrawal. Emerging data from the National Birth Defects Prevention Study, an ongoing case-control study, suggest that butalbital exposure in pregnancy is associated with an increased risk for congenital heart abnormalities, including tetralogy of Fallot, pulmonic stenosis, and atrial septal defect. Although a 2013 review did not find evidence that first-trimester exposure to benzodiazepines is associated with an increased risk for congenital malformations,33 these drugs are not usually used to treat headache during pregnancy. Opioids have a long record of safe use during pregnancy, but because of escalated use and abuse, and their association with neonatal opioid withdrawal syndrome with long-term maternal exposure, their prescription during pregnancy and the puerperium is undergoing increased scrutiny. Although earlier studies reported links between tricyclic antidepressant use during pregnancy and congenital malformations, most subsequent larger studies have been negative. Most investigators favor neurovascular vasospasm, followed by cerebral vasodilation, as a cause of these headaches; a primary vascular disorder or a disturbance in the noradrenergic nervous system also may be involved. Hormonal influences have a strong association with these headaches; estrogen withdrawal is associated with an exacerbation of symptoms. After delivery, the reduction in hormonal concentrations coincides with an increase in migraine symptoms. Pregnant women with migraines are at four times higher risk for developing preeclampsia, as well as at higher risk for stroke during pregnancy and the puerperium. Although there are no published data on the relationship between intrapartum anesthesia and postpartum migraine headaches, one cohort study suggested that patients with a prior history of migraine may be more likely to present with atypical symptoms of post­dural-puncture headache, including nonpostural headache; cervical, thoracic, or lumbar vertebral stiffness and pain; and vertigo. Patient disability and residual function depend on the anatomic location of the injury. Affected patients have relaxed perineal muscles, and women with such injuries experience labor pain. Patients with a lesion above T6 have varying levels of respiratory compromise and are at risk for autonomic hyperreflexia (see later discussion). Spinal shock, defined as immediate and temporary areflexia/hyporeflexia and transient sensorimotor dysfunction resolving within 24 to 48 hours after injury, may develop in about one-half of spinal cord­injured patients.

Based on observational studies 2 medications that help control bleeding discount oxybutynin 5 mg buy, current guidelines recommend that women with Marfan syndrome who are planning pregnancy undergo replacement of the ascending aorta and the aortic root if the diameter is greater than 4 symptoms glaucoma order 2.5 mg oxybutynin fast delivery. In addition symptoms 3 days after embryo transfer buy oxybutynin 2.5 mg low cost, visceral and iliac aneurysms treatment lung cancer generic oxybutynin 5 mg with amex, arterial tortuosity symptoms kidney failure order oxybutynin 2.5 mg with visa, and early-onset joint abnormalities may be present. In a cohort of 17 patients and 34 pregnancies, no maternal mortality or aortic dissection was observed. Cesarean delivery was performed for mainly obstetric indications without increased bleeding complications. Current guidelines are based on expert opinion, case reports, and current standard of care (level C evidence) (Box 41. All recommendations are Level of Evidence C (very limited populations have been evaluated, and recommendations are based on consensus opinion of experts, case studies, or standard of care). Not infrequently, women with an atrial septal defect may become symptomatic during pregnancy. The most common defect is the secundum-type atrial septal defect (80%), whereas the primum, sinus venosus, and coronary sinus types of atrial septal defect are less common. Right ventricular overload leads to pulmonary hypertension and Eisenmenger syndrome in less than 5% of patients with an atrial septal defect. In women with both an atrial septal defect and Eisenmenger syndrome, pregnancy carries a significant risk for both maternal and fetal mortality, and is not recommended. Cardiac complications are similar in women with unrepaired and repaired atrial septal defects. Preeclampsia, fetal demise, and small-for-gestational-age infants are more common in pregnant women with an unrepaired atrial septal defect than in the general obstetric population. Both neuraxial and general anesthesia are appropriate for patients with a repaired or unrepaired atrial septal defect. Ventricular Septal Defect There are four types of ventricular septal defects; the most common type is a perimembranous ventricular septal defect. Pregnancy is well tolerated in women with a repaired ventricular septal defect or a small ventricular septal defect in the absence of pulmonary hypertension. An unrepaired ventricular septal defect with Eisenmenger syndrome is associated with a high risk for maternal cardiac complications (see later discussion). Pregnancy is not recommended in patients with a ventricular septal defect and Eisenmenger syndrome. If the dissection occurs in the third trimester and the fetus is deemed viable, an urgent cesarean delivery followed by aortic surgery may be performed. Both neuraxial63,64 and general anesthesia65 may be safely performed in these patients, with emphasis on meticulous blood pressure stability and control. Invasive blood pressure monitoring is recommended to facilitate tight hemodynamic control. Dural ectasia and scoliosis may complicate neuraxial anesthetic techniques in parturients with Marfan syndrome. Patent Ductus Arteriosus Pregnancy is well tolerated in patients with patent ductus arteriosus, and complications are rare. Pregnancy is not recommended in women with patent ductus arteriosus with Eisenmenger syndrome. Coarctation of the Aorta Women with repaired coarctation of the aorta tolerate pregnancy well. The coarctation may be associated with a bicuspid aortic valve in more than half the patients. Use of neuraxial anesthesia avoids the adverse effects of myocardial depression and positivepressure ventilation on the Fontan circulation, which lacks a functioning right ventricle (see Table 41. In both conditions, the aorta originates from the right ventricle and the pulmonary artery originates from the left ventricle. Pregnant women born with d-transposition of the great arteries have undergone surgical correction-traditionally an atrial switch procedure (Senning or Mustard) or the more contemporary arterial switch procedure (Jatene or Rastelli). In the atrial switch procedure, the right ventricle functions as the systemic ventricle. Atrial arrhythmias, right ventricular (systemic ventricle) dysfunction, tricuspid regurgitation (systemic atrioventricular valve), atrial baffle obstruction or leaks, and pulmonary hypertension are some of the long-term complications of the traditional atrial switch surgical repair of d-transposition of the great arteries. It can be performed for valvular defects such as tricuspid or pulmonic atresia, or other anomalies with a single ventricle. Because there is no functional right ventricle, blood flow from the periphery to the lungs occurs at very low pressure gradients. Owing to the presence of surgical scar tissue in the atrium, patients with a Fontan repair are prone to supraventricular and, less commonly, ventricular arrhythmias. Women who have undergone the Mustard operation tolerate pregnancy well85,86; however, there is a risk for right ventricular dysfunction84,87 that may be irreversible. Successful cesarean delivery with general anesthesia has been reported in a parturient with d-transposition of the great arteries corrected with a Jatene procedure. It is commonly associated with an atrial septal defect and preexcitation syndromes. Accessory pathways result in arrhythmias in approximately 30% of patients; the most commonly observed arrhythmias include atrial tachycardia, atrial flutter, and atrial fibrillation. Unrepaired tetralogy of Fallot is rarely seen in developed countries; pregnancy is associated with significant risk in patients with unrepaired defects and is not recommended. The white lines with arrows represent the pathway of venous blood returning to the heart. After surgery, important considerations include residual pulmonic valve insufficiency and resulting right ventricular dilation and dysfunction. The preanesthesia evaluation of these patients should include detailed echocardiographic evaluation of cardiac structure and function. Patients with repaired tetralogy of Fallot are at risk for atrial and ventricular arrhythmias. In the presence of right ventricular compromise, high filling pressures are needed to enhance right ventricular performance and ensure adequate pulmonary blood flow. The 2013 updated classification lists pulmonary hypertension caused by congenital heart disease in Group 2. Older studies reported maternal mortality rates as high as 56%104; however, more contemporary studies have demonstrated some improvement in maternal mortality, with rates ranging from 16% to 33%. Congenital/acquired left heart inflow/outflow tract obstruction and congenital cardiomyopathies 3. Pulmonary hypertension with unclear multifactorial mechanisms Updated clinical classification of pulmonary hypertension. Of note, all deaths in both studies occurred in the postpartum period, most within the first postpartum week. Right ventricular hypertrophy progresses to dilation of the right-sided chambers, eventually leading to right ventricular failure and death. The second heart sound is widely split owing to delayed closure of the pulmonic valve resulting from high right-sided pressures (pulmonary valve closes after the aortic valve). A right-sided holosystolic murmur of tricuspid regurgitation is frequently appreciated. Echocardiographic assessment of right-sided pressures may be inaccurate; therefore, invasive right-sided-and frequently left-sided-heart catheterization is required for the definitive diagnosis of pulmonary arterial hypertension. Right-sided heart catheterization allows pressure measurements, thermodilution and Fick cardiac output determination, and vasoreactivity testing. Vasoreactivity testing is usually performed with inhaled nitric oxide or intravenous infusion of sodium nitroprusside, epoprostenol, or adenosine in the cardiac catheterization laboratory. Eisenmenger syndrome is associated with ventricular septal defect, atrial septal defect, patent ductus arteriosus, and atrioventricular septal defect (also referred to as endocardial cushion defect). Diuretics are frequently needed to manage volume overload in patients with pulmonary arterial hypertension. Diuretics may be particularly helpful in the immediate postpartum period, when uterine contraction and autotransfusion cause an increase in ventricular preload. Case reports have described the successful use of nitric oxide for vaginal and cesarean deliveries in parturients with pulmonary arterial hypertension. Successful pregnancy has been described in patients with pulmonary arterial hypertension treated with epoprostenol. In a systematic review that included reports from 1978 to 1996,104 operative delivery was an independent risk factor for maternal mortality. In contrast, the mode of delivery was not identified as a risk factor for maternal death in a systematic review that included more recent cases. Cesarean delivery is associated with larger changes in intravascular volume, more bleeding complications and blood loss, and a greater risk for thromboembolism; therefore, it seems reasonable to reserve cesarean delivery for obstetric indications. The development of pulmonary hypertension results, at least in part, from endothelial dysfunction and vascular remodeling of the pulmonary vascular bed. The peripartum period, with its rapid fluid shifts and increased oxygen demand, is particularly challenging. In a systematic review of case reports of pulmonary hypertension associated with congenital heart disease published between 1997 and 2007 (n = 29),105 all eight maternal deaths occurred postpartum (range, 0 to 24 days after delivery). Women with Eisenmenger syndrome often cannot respond to the increased oxygen demands of pregnancy. These changes, together with the normal pregnancy-associated decrease in functional residual capacity, predispose women with Eisenmenger syndrome to hypoxemia. Maternal hypoxemia leads to a high incidence of fetal growth restriction and fetal demise. With contemporary drug therapy, cardiac imaging, and collaborative care, successful pregnancy has been described in patients with Eisenmenger syndrome. Current evidence on choice of anesthetic technique for patients with pulmonary arterial hypertension is based on case reports and series from high-volume referral centers. Slowly titrated epidural or combined spinalepidural anesthesia eliminates the undesirable effects of myocardial depression and positive-pressure ventilation (with its associated decrease in preload) associated with general anesthesia. Intravascular volume assessment in patients with pulmonary arterial hypertension is of utmost importance. It is likely best achieved with central venous pressure monitoring; pulmonary artery catheterization without the use of fluoroscopy is technically challenging owing to the frequent presence of tricuspid regurgitation and right-sided chamber enlargement in these patients. Both transthoracic and transesophageal echocardiography are very helpful, and invasive blood pressure monitoring is indispensable. Because patients with pulmonary arterial hypertension frequently require systemic anticoagulation, the choice of anesthesia in these patients is best determined by a multidisciplinary team. Because of its ease of administration, nitric oxide can be readily administered in the urgent setting. Nitric oxide has been administered during epidural anesthesia for emergency cesarean delivery using a noninvasive ventilation device. In patients with one of these highrisk conditions who have an established infection. It is important to note that the level of evidence for these recommendations is B (data from a single randomized trial or nonrandomized trials). In young women of childbearing age, there is no difference in the rate of prosthetic valve endocarditis with mechanical or bioprosthetic valves. Diagnosis and Treatment the diagnosis of endocarditis rests on a very high index of suspicion, physical examination, laboratory findings, and cardiac imaging. The modified Duke criteria are the most widely accepted criteria for the diagnosis of endocarditis (Box 41. Therefore, absence of bacterial growth in blood cultures does not automatically rule out endocarditis. In addition to systemic antibiotic therapy, valve replacement may be required in pregnant women with endocarditis. Alternatively, successful treatment with aggressive antibiotic therapy has been described. Neuraxial Anesthesia in Patients with Systemic Infection the safety of neuraxial anesthesia in patients with systemic infection has been debated for many years (see Chapter 36). Prevention of infective endocarditis: guidelines from the American Heart Association. It is most frequently associated with intravenous drug use or preexisting structural heart and valve abnormalities. Maternal and fetal mortality rates are both high (approximately 15% and 22% respectively). New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Patients who develop hemodynamic instability caused by bradycardia should receive a temporary venous pacemaker. Transcutaneous pacing is an attractive alternative, but it is uncomfortable for prolonged use. Because the majority of patients requiring temporary pacing have underlying congenital heart disease, it is critically important to understand the cardiac anatomy before placing the venous pacemaker to minimize complications such as perforation or valve injury. Rather, the severity of underlying structural heart disease determines the overall complication rate. Published data and clinical experience suggest that spinal anesthesia may be safely administered in patients who have received antibiotic treatment and are responding to treatment at the time of dural puncture. Similarly, it is likely that epidural anesthesia may be safely administered to patients with treated systemic infection. Therefore, it may be difficult to determine whether the neuraxial procedure contributed to the development of the infection if meningitis or epidural abscess should develop in a patient with endocarditis receiving neuraxial anesthesia. It is important to recognize that different devices may respond quite differently to magnet placement. Most pacemakers will pace in an asynchronous mode after application of an external magnet. The mechanisms have been attributed to atrial14 and ventricular stretch41 caused by increased intravascular volume as well as the increase in resting heart rate. Additionally, autonomic and hormonal changes of pregnancy have been proposed as putative mechanisms.

Percutaneous coronary interventions for treatment of myocardial infarction include conventional "plain old balloon angioplasty" and stent placement treatment plant generic oxybutynin 2.5 mg fast delivery. An advantage of conventional balloon angioplasty is that it does not require dual antiplatelet therapy; however symptoms bladder infection oxybutynin 5 mg overnight delivery, placement of a stent is associated with a lower risk for abrupt vessel closure in the short term and a lower long-term risk for restenosis treatment writing generic oxybutynin 5 mg with mastercard. Dual antiplatelet therapy is mandatory after placement of a coronary artery stent to prevent stent thrombosis (Table 41 medicine number lookup generic 5 mg oxybutynin free shipping. However medications hyperthyroidism generic oxybutynin 2.5 mg buy on line, the safety and efficacy of these newer antiplatelet agents in pregnancy are unknown. Radial arterial access for the percutaneous coronary intervention procedure is preferable because it has fewer bleeding complications and a lower mortality rate than femoral arterial access. Systemic anticoagulation with unfractionated heparin appears most Stent Type Choice In patients with a nonacute coronary syndrome. When either bare-metal stents or drug-eluting stents are placed in a patient with any acute coronary syndrome. The advantage of drug-eluting stents is a decreased risk for in-stent restenosis than occurs with bare-metal stents. However, drug-eluting stent technology is advancing, and in the future, new generation drug-eluting stents may allow for shorter durations of dual antiplatelet therapy. Overall rates of death and myocardial infarction are similar with drug-eluting and bare-metal stents. The risk for stent thrombosis may be lower with contemporary drugeluting stents than with bare-metal stents. Polymer-free biolimus A9 drug-eluting stents allow for 1 month of dual antiplatelet therapy and will likely supplant the use bare-metal stents in patients with high bleeding risk. The resulting ischemia and arrhythmias have been associated with sudden cardiac death. The effect of the physiologic changes of pregnancy in women with coronary artery anomalies has not been well studied. The general management principles for pregnant women with valvular heart disease are directed toward specific hemodynamic goals and the need for anticoagulation in patients with a mechanical valve. Dual Antiplatelet Therapy Bare-metal and polymer-free drug-eluting stents174 allow for discontinuation of dual antiplatelet therapy 1 month after percutaneous coronary intervention, if necessary, even in the setting of acute coronary syndrome (see Table 41. This may be advantageous in pregnant women who are at risk for intrapartum and postpartum hemorrhage. Therefore, although prospective clinical trials are not available, most interventional cardiologists will implant a bare-metal stent or a contemporary polymer-free drug-eluting stent in a pregnant woman with acute coronary syndrome. Continuing research is being performed to determine the optimal duration of dual antiplatelet therapy after percutaneous coronary intervention in the nonpregnant population. It is not advisable to perform neuraxial anesthesia in patients receiving dual antiplatelet therapy. Both spinal and epidural anesthesia can be performed safely in patients receiving aspirin. Clopidogrel should be discontinued 7 days before performance of neuraxial anesthesia. A 2002 meta-analysis found no overall increase in the risk for congenital malformations when aspirin was administered in the first trimester; however, a twofold increase in the risk for gastroschisis was observed. Less common causes/types of aortic stenosis include rheumatic, supravalvular, and subvalvular aortic stenosis. The hemodynamic implications of the various causes of aortic stenosis are similar. Calcific aortic stenosis of an anatomically normal tricuspid aortic valve occurs much later in life and is unlikely to be encountered in women of childbearing age. It is heritable; therefore, first-degree relatives of patients with a bicuspid aortic valve should be screened. Symptoms of aortic stenosis (dyspnea on exertion, chest pain, syncope) generally present in the third and fourth decades of life. Importantly, patients with a bicuspid aortic valve have underlying aortic root pathology in the media that is associated with aortic root dilation, thus predisposing to ascending root dissection. There is no pressure gradient across a normal aortic valve with normal resting cardiac output. The updated valvular aortic stenosis classification takes into account valve anatomy, valve hemodynamic characteristics, structural heart consequences of stenotic valve hemodynamics, and patient symptoms (Table 41. Therefore, the traditional and new nomenclature are used interchangeably in this chapter. Coronary Artery Anomalies Coronary artery anomalies occur in approximately 1% of the general population. Coronary artery anomalies are frequently associated with congenital heart disease such as d-transposition of the great arteries and tetralogy of Fallot. The two most common clinically significant anomalies are (1) a left main coronary artery that originates from the right coronary cusp and (2) a right coronary artery that originates from the left coronary cusp. Classically, the aortic valve area is estimated invasively in the cardiac catheterization laboratory using the Gorlin equation. Forward cardiac output is determined by thermodilution and/or Fick methods, and left ventricular and aortic pressures are simultaneously recorded. Doppler velocity measurements during echocardiography allow noninvasive estimation of aortic valve area using the continuity equation. Using both methods, the estimated transvalvular gradient increases during pregnancy because of the physiologic increase in cardiac output. The calculated valve area remains unchanged, however, because both the Gorlin equation and the continuity equation take cardiac output into account. The echocardiographic dimensionless valve index is useful in pregnant women as well as other patients; it takes into account both left ventricular outflow velocity and the aortic velocity. Because both velocities are increased during pregnancy, the dimensionless index and estimated valve area remain unchanged during pregnancy. Mild and moderate aortic stenosis (corresponding to stages A and B) are associated with favorable pregnancy outcomes. Additionally, women with severe disease are more likely to require a cardiac intervention (balloon valvuloplasty, valve replacement) during pregnancy or immediately postpartum. Percutaneous balloon valvuloplasty of the aortic valve is a palliative procedure that allows completion of pregnancy before definitive repair. Obstetric and Anesthetic Management Labor and assisted vaginal delivery are preferred. Whether general or neuraxial anesthesia is more appropriate for parturients with aortic stenosis has been a matter of debate. The choice between neuraxial and general anesthesia should not be made based on the aortic valve gradient or aortic valve area alone. The preanesthetic assessment should include physical examination, symptom evaluation, and comprehensive assessment of the right and left ventricular structure and function, as well as the structure and function of other cardiac valves. Serial assessment of the aortic valve area before and during pregnancy is very helpful in managing these patients. Patients with normal right and left ventricular function are more likely to tolerate fluid shifts and the depressant effects of general anesthetic agents. If left ventricular dysfunction develops in the presence of aortic stenosis, a condition referred to as lowoutput, low-gradient aortic stenosis may be present. The presence of pulmonary hypertension, right ventricular dysfunction, or mitral regurgitation is associated with greater dependence on preload and may unfavorably affect the hemodynamic response to neuraxial anesthesia. Patients with a dilated aortic root will likely benefit from gradual blood pressure changes, because aortic root dilation has been associated with aortic dissection. Left ventricular hypertrophy, frequently present with aortic stenosis, is associated with significant diastolic dysfunction and may impede left ventricular filling. The presence of left ventricular hypertrophy will render these patients more sensitive to the adverse effects of decreased preload, tachycardia, and the development of congestive heart failure, especially in the setting of acuteonset atrial fibrillation. The ventricles are exposed to both pressure and volume overload, further complicating hemodynamic management and response to anesthesia. The goals of anesthetic management are (1) maintenance of a normal heart rate, sinus rhythm, and adequate systemic vascular resistance; (2) maintenance of intravascular volume and venous return; (3) avoidance of aortocaval compression; and (4) avoidance of myocardial depression during general anesthesia (see Table 41. In the absence of prospective randomized trials in this patient population, current clinical evidence suggests that either neuraxial analgesia/anesthesia or general anesthesia is safe for patients with mild or moderate aortic stenosis with normal right and left ventricular ejection fraction and the absence of other significant valvular lesions or pulmonary hypertension. Neuraxial anesthetic techniques that allow gradual titration of anesthesia seem advantageous in these patients. In patients with severe aortic stenosis, general anesthesia remains the gold standard. Although published reports have described successful administration of neuraxial anesthesia for labor and vaginal and cesarean delivery in women with severe aortic stenosis, the influence of publication bias in these reports cannot be excluded. In contemporary obstetric anesthesiology practice, an opioid-based neuraxial labor analgesia technique, along with alternative forms of analgesia. General anesthesia may be the best choice for cesarean delivery in patients with severe aortic stenosis and other significant valvular lesions, pulmonary hypertension, and/or left ventricular dysfunction. Induction of anesthesia with a combination of etomidate and a moderate dose of a lipid-soluble opioid may be preferable to agents that cause myocardial depression and vasodilation (propofol, thiopental) and tachycardia (ketamine). Anesthesia can be maintained with an opioid and a low-dose volatile anesthetic technique. Peripartum invasive arterial blood pressure monitoring is recommended for parturients with moderate and severe aortic stenosis. Pulmonary artery catheterization is unlikely to provide much clinical benefit in this patient population. Development of atrial fibrillation with rapid ventricular response is deleterious in these patients because it decreases diastolic filling time and eliminates the atrial component of left ventricular filling. If new-onset atrial fibrillation results in hypotension or pulmonary edema, sinus rhythm should be promptly restored. Aortic Regurgitation the most common etiology of chronic aortic regurgitation in pregnant women is a degenerated bicuspid aortic valve; rheumatic aortic regurgitation occurs less frequently. Dilation of the ascending aorta and the resulting aortic leaflet separation may also result in aortic regurgitation. Most commonly, aortic root dilation results from cystic medial necrosis associated with Marfan syndrome, or it occurs in association with a bicuspid aortic valve. Chronic aortic regurgitation is generally well tolerated during pregnancy, especially in patients with preserved left ventricular ejection fraction. Although patients with chronic aortic regurgitation can compensate for the hemodynamic stress over time, patients with acute aortic regurgitation are frequently very ill and may require surgery. Endocarditis is the most common etiology of acute aortic regurgitation during pregnancy. Antepartum echocardiography may guide decisions regarding the choice of anesthesia and monitoring. Traditionally, a pulmonary artery catheter has been used for this purpose; in the future, transthoracic echocardiography will likely be used. The degree of aortic insufficiency, concomitant involvement of the mitral valve, and the size of the aortic root help define hemodynamic goals. Patients with a bicuspid aortic valve may have simultaneous aortic stenosis and aortic regurgitation. Both neuraxial analgesia/anesthesia and general anesthesia can be safely performed in patients with aortic regurgitation and preserved left ventricular ejection fraction. Severe aortic insufficiency with left ventricular dysfunction is not a contraindication for neuraxial anesthesia. Intra-aortic balloon pump placement is contraindicated in patients with aortic regurgitation because its use increases regurgitant flow. Increased blood volume with decreased diastolic filling time can result in pulmonary edema. Additionally, mitral stenosis predisposes patients to development of atrial tachyarrhythmias (atrial fibrillation, atrial flutter) as well as thromboembolic complications, with or without atrial arrhythmias. The underlying hypercoagulable state of pregnancy also increases the risk for thromboembolic complications in patients with mitral stenosis. Therefore, systemic anticoagulation is recommended for the duration of pregnancy and postpartum. In addition to valve area, diastolic pressure half-time, presence of pulmonary hypertension, and symptoms define severe mitral stenosis stages. Similarly, diastolic pressure half-time is affected by the physiologic changes of pregnancy, and its use and interpretation can present a diagnostic challenge. Suitability for percutaneous balloon valvuloplasty is determined by an echocardiography-based scoring system, which takes into account valve calcification and mobility as well as valvular and subvalvular thickening. Mitral Regurgitation Mitral regurgitation is generally well tolerated during pregnancy. Nonetheless, some evidence suggests that the volume overload associated with pregnancy may induce unfavorable structural alterations in women with mitral regurgitation. Chronic mitral regurgitation may be associated with left ventricular dysfunction; thus, echocardiographic assessment of left ventricular function helps guide anesthetic and fluid management. Obstetric and Anesthetic Management Cesarean delivery is typically reserved for obstetric indications. Vaginal delivery is usually assisted, because the Valsalva maneuver during the second stage of labor may result in a sudden increase in central venous pressure. Regardless of the method of delivery, patients are at risk for both intrapartum and postpartum hemodynamic compromise and pulmonary edema; therefore, these patients usually require postpartum intensive care. Intrapartum and postpartum invasive hemodynamic monitoring is often helpful, and close peripartum monitoring of filling pressures is important. Echocardiographic assessment of right-sided pressures appears to somewhat overestimate true pressures; therefore, in selected patients with severe mitral stenosis, a pulmonary artery catheter may help guide fluid management.

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