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| CASE REPORT |
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| Year : 2019 | Volume
: 14
| Issue : 2 | Page : 111-112 |
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Epidural analgesia for a 36-week parturient with severe mitral stenosis and pulmonary edema for spontaneous vaginal delivery
S John Paul, Srinivasan Parthasarathy
Department of Anesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Puducherry, India
| Date of Submission | 10-Mar-2019 |
| Date of Decision | 18-May-2019 |
| Date of Acceptance | 26-Aug-2019 |
| Date of Web Publication | 25-Nov-2019 |
Correspondence Address:
Dr. Srinivasan Parthasarathy
Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Pondicherry
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_54_19
A 26 year old near-term pregnant patient with severe mitral stenosis and pulmonary edema presented to us with labor pain. After starting her on oxygen, diuretics, we provided labor analgesia with a combination of low-dose epidural local anesthetics with fentanyl. The conduct of the delivery was uneventful. We recommend the use of labor analgesia to attenuate the response of pregnancy and labor on the cardiovascular system, especially in parturients with valvular disease like mitral stenosis. We also state that a multidisciplinary approach is necessary in handling such sick parturients.
Keywords: Analgesia, epidural, mitral stenosis, pregnancy
How to cite this article:
Paul S J, Parthasarathy S. Epidural analgesia for a 36-week parturient with severe mitral stenosis and pulmonary edema for spontaneous vaginal delivery. J Datta Meghe Inst Med Sci Univ 2019;14:111-2 |
| Introduction | |  |
A pregnant patient with heart disease represents a unique challenge to anesthesiologist. The management of valvular heart disease due to congenital or acquired etiology in a pregnant patient can be challenging. There is an increased incidence of adverse maternal and fetal outcomes in these patients. Determination of the appropriate analgesia and anesthetic modality requires a thorough understanding of the parturient's pathophysiology as well as pharmacological therapy and how these interact with anesthetic care. During the time of labor and delivery, there are several changes in the circulatory system that could result in hemodynamic decompensation.[1] Rheumatic mitral stenosis forms 88% of the heart diseases complicating pregnancy.[2] Patients with moderate or severe mitral stenosis can be managed successfully with medical therapy, which includes strict control of heart rate, volume status, and frequent monitoring.[3] The mortality and morbidity are considerably reduced by better perinatal care, where the anesthesiologist plays a major role in the multidisciplinary approach.[2] It is essential to administer some form of pain relief which effectively modulates the hemodynamic status.[4] Hence, understanding the normal hemodynamic changes in pregnancy with or without mitral diseases is required to effectively manage such cases.
| Case Report | | |
A 26-year-old female, married since 3 years, G3P1A1 L1 at 36 weeks of gestational age, who was a K/C/O rheumatic heart disease with mitral stenosis with mild regurgitation diagnosed at 2016 during her 5th month of first pregnancy. She was started on T. penicillin G 400 mg bd, T. torsemide 5 mg, and T. metoprolol 12.5 mg. She gave birth to a normal healthy child by forceps assisted vaginal delivery 3 years ago. However, she stopped the medication 1 year later. She was not a known case of diabetes mellitus, hypertension, asthma, epilepsy, or tuberculosis. Her second pregnancy was spontaneous abortion, for which dilation and curettage were done 1½ years ago. She was asymptomatic throughout this period. At present, she came for normal antenatal visit for her third pregnancy, her previous antenatal visits being uneventful. She was restarted on cardiac medications at 5th month of the present pregnancy. She had a sore throat and cough for which she took antiviral medications. She went into labor after 5 days. On examination, the patient was conscious with a regular pulse rate 106/min, and there was neither pallor nor pedal edema. On auscultation mid-diastolic murmur, bilateral diffuse crepitations, and wheeze were present with stable vitals. A cardiologist opinion was sought and was diagnosed to have mitral stenosis with acute onset pulmonary edema. She remained hemodynamically stable during this period. Injection furosemide was administered in titrated doses. Continuous cardiac monitoring was done. Her echocardiogram revealed severe mitral stenosis (mitral valve area = 0.7–0.8 cm 2) with a dilated left atrium, elevated pulmonary artery systolic pressure (64 mm/Hg), severe pulmonary hypertension, with mild mitral and tricuspid regurgitation. Other cardiac valves were normal with an ejection fraction was 61%, clots, effusion, and regional wall motion abnormalities were not seen. As labor progressed she had severe pain (visual analog scale [VAS] 8–9/10) with a cervical dilation of 4 cm, the cardiothoracic team was alerted. A lumbar epidural catheter was secured at L3–L4 segment; she received 0.1% ropivacaine 10 ml with 25 μg of fentanyl for three doses. Her vitals remained stable during this period with a blood pressure 100/60 mm/Hg; there was no hypotension. Continuous fetal heart rate monitoring was done. She had persistent tachycardia with a heart rate-110–120/min. The patient had adequate pain relief with a pain score VAS of 2/10 after every top-up dose. She perceived good uterine contraction; oxytocin was used to augment labor. The second stage was cut short using forceps assisted vaginal delivery. An alive healthy baby was delivered and injection furosemide 20 mg intravenous was administered. The vitals were stable with only minimal crepitations. Epidural catheter was removed, and the patient shifted to labor ward. The patient was discharged on the 7th postpartum day and was advised to continue cardiac medications.
| Discussion | | |
There are innumerable influencing factors of labor pain and thereby its hemodynamic disturbances.[5] Pregnant women with mitral stenosis coming with labor pain present a challenge to the managing physician. There is an added morbidity, especially is there is frank pulmonary edema. In our case, we inserted an epidural catheter and administered a dilute solution of local anesthetic with fentanyl. Concurrent administration of neuraxial opioid in our case decreased pain with stable hemodynamics.[6] At the time of delivery, the greatest risk associated with mitral stenosis is pulmonary edema due to the increase in cardiac output. We managed the same with titrated dose of diuretics. Rheumatic heart disease is the most common cause of mitral stenosis. It is one of the most common valvular lesions in parturients. Other valvular lesions associated with rheumatic fever-like mitral regurgitation, aortic stenosis, and aortic regurgitation are less frequent. Complications related to mitral stenosis include increased incidence of maternal cardiac failure and mortality, increased risk of premature delivery, low APGAR scores, and lower birth weight. In our case, we had premature delivery with pulmonary edema.[7] Operative delivery is only on obstetric indications but not for the sake of only mitral stenosis. Hence, the obstetrician opted for vaginal delivery with epidural analgesia which was successfully done. An urgent ECHO and a cardiology support for us made the management more comfortable. A controlled general anesthesia with invasive lines would be the next choice if cesarean section is contemplated in such sick parturients. Gupta et al.[8] have reported a similar case for cesarean section with 0.4% ropivacaine with fentanyl while we used 0.1% only as we needed analgesia only.
| Conclusion | | |
Successful normal spontaneous vaginal delivery is possible in parturients with severe mitral stenosis with pulmonary edema. Titrated diuretics, epidurally administered dilute ropivacaine with fentanyl, vigilant monitoring are necessary for this delivery. A multidisciplinary coercive action is the key for success in such cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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