Investigación Científica y Tecnológica

 

Pregnant patient with cardiac diseases*

Risk based peripartum management. Case series 2005-2009

Germán A. Monsalve**, Catalina M. Martínez***, Tatiana Gallo***, María Virginia González***, Gonzalo Arango***, Alejandro Upegui***, Juan Manuel Castillo***, Juan Guillermo González***, Jorge Rubio****, Leonardo Mojica*****

* El resumen de este artículo fue aceptado y presentado como póster en el 42° Congreso de la Sociedad Americana de Anestesia Obstétrica y Perinatologia (SOAP), en San Antonio, Texas, Estados Unidos.12 de mayo de 2010.
** Médico Anestesiòlogo, Coordinador Unidad de Alta Dependencia Obstétrica Clinica del Prado. Medellín, Colombia. gerafomejia@yahoo.com.
*** Anestesiòlogos Unidad de Alta Dependencia Obstétrica Clinica del Prado. Medellín, Colombia.
**** Anestesiòlogo cardiovascular Unidad de Alta dependencia Obstétrica Clinica del Prado. Medellín, Colombia.
***** Anestesiòlogo intensivista Unidad de Alta dependencia Obstétrica Clinica del Prado. Medellín, Colombia.

Recibido: mayo 29 de 2010. Enviado para modificaciones: junio 30 de 2010. Aceptado: julio 14 de 2010.

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SUMMARY

Objetive. We report a series of obstetric patients with a wide range of cardiac diseases, using a risk based strategy to develop peripartum plans in which the anesthetic management is included.

Methodos. Case reports. Retrospective analysis of 37pregnant patients with a wide range of cardiac diseases admitted to the High Dependency Unit of Clínica del Prado, in Medellín, Colombia from 2005 to 2009.

Results. From a total of 37 patients, 15 had congenital heart disease, 13 valvular disease, 5 postpartum cardiomyopathy, and the other 4 included rhythm abnormalities and ischemic heart disease. CARPREG study criteria were used for risk stratification. Eight patients were identified in the high risk group, and the rest as intermediate and low risk. Most of the patients had regional anesthesia management (89.2 %). The decision for caesarean section was decided for obstetric indication was performed in 35 % of the cases. There were cardiac complications in 10.8 % of the cases and there were no maternal deaths.

Conclusions. The application of a morbidity and mortality cardiac risk stratification protocol in pregnant women allows the anesthesiologist to participate in a multispecialty treatment team, and so they are able to achieve the best possible maternal outcome in this group of patients.

Keywords: Heart diseases, pregnancy complications, risk, anesthesia (Source: MeSH, NLM)

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INTRODUCTION

Cardiac diseases complicate between 1 and 4% of all pregnancies in the USA, and are the main cause of maternal morbidity and mortality in the United Kingdom (1). Rheumatic heart disease has been the most common cardiac disease in developing countries, but with the improvement of neonatal care of newborns with congenital heart diseases (CHD) and the development of cardiac surgery, CHD is currently the most frequent cardiac disease in pregnancy (2,3).

Another factor that increases the incidence or pregnancy in cardiac patients, is that women postpone pregnancies to the fourth and even fifth decades of their lives (4,5) when comorbidities like hypertension, diabetes, hypercholesterolemia, increase the incidence of ischemic heart disease (IHD).

METHODS

A retrospective review of 37 consecutive pregnant patients with a cardiac disease diagnosis, including cardiac valvular disease (CVD), IHD and peripartum cardiomyopathy (PCM) admitted to the High Dependency Unit of Clínica del Prado, in Medellín (Colombia), from 2005 to 2009. The purpose of this study is to describe the demographics, parity, gestational age, cardiac functional class using New York Heart Association (NYHA) criteria, type of delivery, severity of disease using risk scales like Clark et al (6), CARPREG (7,8) and that of the American College of Cardiologists / American Heart Association (ACC/AHA) in 2006 and the European Society of Cardiology (ESC) in 2007 (9,10), obstetric outcome, type of anesthesia used in delivery, monitoring, postpartum care, and associated morbidity and mortality.

Ethical aspects: The study was approved by the internal review board of Clínica del Prado.

RESULTS

The average age of the patients was 26.9 years (18 through 42 years old), parity was 1.9 (1-8), gestational age was 36 weeks (9-40) and 97 % had prenatal care. In this series, 15 patients had CHD, 13 VHD, 5 PCM and the other 4 had other entities: tachycardiomyopathy, complete AV block, and IHD. All patients were admitted prepartum, and those with prenatal care had at least two prior visits and had cardiological assessment ordered in them.

The details of VHDs of the patients are listed in Table 1. There were severe aortic stenosis, mitral stenosis, and three patients with isolated pulmonary valve disease. In the group with CHD, we highlight two patients classified as high risk, one with a diagnosis of non achondroplastic dwarfism with an Eisenmenger syndrome associated with an atrial septal defect with severe suprasystemic pulmonary hypertension, severe right ventricular dysfunction and severe pulmonary regurgitation without previous prenatal care or echocardiographic evaluation during pregnancy. The other was a patient with an uncorrected Fallot's tetralogy with pulmonary stenosis and severe right ventricular dysfunction also without prenatal care. The most relevant information of the patients with CHD is listed in Table 2.

All five cases of PCM were admitted with a NYHA class III / IV and pulmonary edema. The echocardiographic assessment diagnosed severe left ventricular dysfunction with ejection fractions under 30 % and severely dilated left ventricle (a left ventricular end diastolic diameter > 5.5 cm). One of these patients had an episode of sudden death from an episode of ventricular tachycardia, torsade de pointes, that required an implantable cardiac defibrillator. The most relevant data of the group are listed in Table 3.

The delivery mode was decided jointly with the obstetricians. Thirty five percent had a caesarean section of which 23 % had general anesthesia (GA), 30 % had spinal anesthesia (SA), 39 % had combined spinal epidural anesthesia (CSE) and the remaining 8 % had epidural anesthesia (EA). Sixty percent of the patients had vaginal delivery all under epidural analgesia. The remaining 2 patients were early pregnancies that resulted in abortion that required dilation and curettage to extract the placental remnants under general anesthesia. During labor or caesarean section, 64 % of the patients required some type of invasive monitoring, mainly an arterial line. Four of the five patients with PCM required pulmonary artery catheterization for peripartum management.

Among the complications, in the group of PCM there were four pulmonary edemas of which two required prolonged mechanical ventilation for more than 72 hrs. The patient with the sudden death episode from a ventricular arrhythmia was included in a hypothermia-aftercardiac-arrest protocol, and when weaned from mechanical ventilation 72 hrs later, had no relevant neurological deficit. One of the PCM patients required management with cardiology with levosimendan because of refractory heart failure after dobutamine and amrinone infusions. One patient developed oliguric renal failure that did not require renal replacement therapy. All patients with PCM were anticoagulated and transferred to cardiac intensive care units (ICU) in the postpartum period for assessment from the transplantation group, because of refractory ventricular failure.

In the one year follow-up none has required cardiac transplantation. The patient with Eisenmenger syndrome was transferred to a cardiovascular center because of the high risk of her disease, and she had a successful delivery with postoperative care in the cardiovascular ICU.

There were no maternal deaths.

DISCUSSION

Cardiac disease during pregnancy increases risks so it should be addressed in an interdisciplinary approach to develop risk stratification protocols to avoid fatal outcomes that could occur because of unplanned management. This approach could lead to a reduction in cardiovascular complications in these patients. The most important aspects of this approach are described below:

Risk stratification

Several risk stratification systems have been conceived, the first was developed by Clark et al (6). It uses the anatomical severity of abnormalities as the only way to stratify, it established that patients with severe aortic stenosis, pulmonary hypertension of any cause, and aortic diseases as those with the highest mortality (50 %). The problem of this classification is that it ignores clinical data or previous cardiac events. The other risk index was published in a Canadian study known as CARPREG (7,8) which was intended to predict cardiac related complications in pregnancy, in which they not only assessed anatomical problems but also included clinical data.

Four predictors of cardiac complications as pulmonary edema, cerebrovascular disease, cardiologic cardiac arrest and death, were identified:

• Poor functional class (NYHA III or IV or cyanosis)

• Previous cardiac event or arrhythmia

• Left ventricular obstruction (mitral valvular area under 2 cm², aortic valvular area < 1.5 cm², and left ventricular outflow gradient higher than 30 mmHg)

• Systolic dysfunction of left ventricle (ejection fraction (EF) under 40 %)

The ACC / AHA in 2006, and the ESC in 2007, published guidelines for valvular heart disease, in which they consider that pregnant women are high risk with the following pathologies (9,10):

• Severe aortic stenosis with or without symptoms

• Symptomatic mitral stenosis (NYHA II to IV)

• Aortic or mitral regurgitation with NYHA III or IV

• Aortic or mitral disease with severe left ventricular dysfunction (defined as a EF below 40 %) or severe pulmonary hypertension (systolic pulmonary artery pressure above 75 mmHg)

• Marfan syndrome with or without aortic regurgitation (11)

• Mechanical valvular prosthesis that requires anticoagulation

In the isolated assessment of CHD, a finding of severe pulmonary regurgitation, severe right ventricular dysfunction and Eisenmenger syndrome were associated with sudden deaths because of heart failure and arrhythmias in 4.8 to 4.5 % respectively (8,12). PCM is diagnosed when heart failure ensues in the last month of pregnancy or in the first five months postpartum, in the absence of other causes of heart failure associated with these criteria: EF < 45 %, ventricular shortening fraction (VSF) <30 % and a left ventricular end diastolic diameter (LVEDD) > 2.7 cm (13,14). Patients who have an EF <25 % and an LVEDD > 5.0 cm have poor prognosis and are very likely to require a heart transplant in case of a new pregnancy (15).

In this report, the patients with CHD that were classified as high risk as stated earlier, were the patient with an Eisenmenger syndrome, and the patient with uncorrected Fallot's tetralogy. It is remarkable that they did not have any prenatal assessment which by itself is a risk factor or morbidity and mortality (16). The patient with severe aortic stenosis with an NYHA higher than II was also in this high risk category.

Our patients with PCM are in the group with the highest risk for fatal outcomes and transplant requirement (2) for which their management is a challenge with high risk of peripartum complications and difficulties in anesthetic management. These patients were given general anesthesia and were monitored with pulmonary artery catheters, and transferred in postpartum to cardiovascular centers with heart transplantation capabilities.

Mode of delivery

The decision is exclusively determined by obstetric criteria, but in general vaginal delivery is allowed. In our series 60 % had vaginal delivery all under regional analgesia. The only indications for caesarean section due to cardiac problems are: aortic dilation with a diameter >4 cm, or progressive dilation, aortic dissection or thoracic aortic aneurysm, and patients anticoagulated with mechanical prosthesis who have a risk of intraventricular cerebral hemorrhage in the fetus (6).

Large referral centers for obstetric patients with cardiac disease (17) are recommending the possibility of scheduled caesarean sections in patients with very high risk of death or of developing severe cardiac complications like those patients with severe pulmonary hypertension of any cause, because it allows the possibility of ending the pregnancy in a "controlled: environment. This can prevent complications related to a scenario where there are personnel not knowledgeable of the pathology or when there is shortness of resources in unplanned scenarios, basically weekends and night shifts.

Anesthetic technique

There are no reports addressing the issue of whether the anesthetic technique can modify the morbidity in this group of patients. Obstetric anesthetists groups have recently leaned toward the use of regional anesthesia (18). In our series, high risk patients like Fallot's tetralogy and patients with PCM with severe ventricular dysfunction were managed with general anesthesia, and the rest were managed with regional anesthesia using "hemodynamic goals". These are: maintenance of normovolemia and increases in vascular resistances in patients considered high risk.

The use of regional anesthesia that allows the titration or the anesthetic level desired, has been described in cases of severe left ventricular stenotic pathologies like severe aortic stenosis (19), or severe pulmonary hypertension (20) which has demonstrated its safety.

Monitoring

In low risk patients we use basic Minimal Standards monitoring, and continuous fetal monitoring. In our center, moderate and high risk patients have invasive blood pressure monitoring for close control of blood pressure (64 % in this series), central venous catheter to assess the trend of filling pressures, more than any specific value, as it is known that in patients with cardiac diseases they are not a true indicator of volemia (21). Pulmonary catheters are used only in case of severe left ventricular dysfunction in patients with PCM, which in our series were five patients. In our patient with Eisenmenger syndrome we decided not to use it as there is much controversy, mainly because of the risk of arrythmias and pulmonary artery rupture (22).

Bacterial endocarditis prophylaxis

The American College of Obstetrics and Gynecology (ACOG) determined in 2007 regarding bacterial endocarditis, that no antibiotic prophylaxis be used in vaginal delivery in the absence of infection (23). Patients with high risk pathologies with established infections that could cause bacteremia, should have their infection treated, and the antibiotic regimen selected should protect against endocarditis producing germs.

The guidelines for the adult patient with congenital heart disease published in 2008 by the ACC / AHA, recommend administering prophylactic antibiotics before vaginal delivery when there is rupture of membranes in high risk patients, like those who have prosthetic cardiac valves or valves repaired with prosthetic material or in patients with cyanosing cardiac disease who either have palliative surgery or have not been corrected (24,25)

Albeit these guidelines, due to the simplicity and little adverse outcome of prophylaxis and the unpredictable complications of deliveries (as grade IV vaginal tears, urethral catheterizations in patients with asymptomatic bacteriuria, etc.), we provide antibiotic prophylaxis in patients with valvular disease, shunts from septal defects and in those patients with valvular prosthesis and artificial shunts (palliative surgeries in congenital diseases) (26).

CONCLUSIONS

The implementation of a universal protocol of cardiac risk assessment for death and major cardiac events in pregnant cardiac patients and the creation of multidisciplinary groups in which the anesthesiologist plays a fundamental role, could allow that the peripartum management be focused in minimizing the possibility of complications and improve the outcomes. In our case series there were no fatal outcomes, and a low incidence of cardiovascular complications was observed. The rational use of anesthetic techniques with which the anesthesiologist is more familiar, and based on "hemodynamic goals" can allow an optimal management that could be associated with a good maternal and prenatal outcome.

ACKNOWLEDGEMENTS

The authors thank all the nursing staff of the High Dependency unit of Clínica del Prado, in Medellín, Colombia.

REFERENCES

1.Lewis G. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers. Lives: reviewing maternal deaths to make motherhood safer-2003-2005. [internet] London: CEMACH; 2007 Dic. [citado 20/02 2010]. 12 p. Disponible en: http://www.cmace.org.uk/getattachment/05f68346-816b-4560-b1b9-af24fb633170/Saving-Mothers%E2%80%99-Lives-2003-2005_ExecSumm.aspx.

2.Van Mook WN, Peeters L. Severe cardiac disease in pregnancy, part II: impact of congenital and acquired cardiac diseases during pregnancy. Curr Opin Crit Care. 2005;11(5):435-48.

3.Perloff JK. Congenital heart disease and pregnancy. Clin Cardiol. 1994;17(11):579-87.

4.Fretts RC, Schmittdiel J, McLean FH, Usher RH, Goldman MB. Increased maternal age and the risk of fetal death. N Engl J Med. 1995;333(15):953-7.

5.Cunningham FG, Leveno KJ. Childbearing among older women--the message is cautiously optimistic. N Engl J Med. 1995;333(15):1002-4.

6.Dildy GA. Critical care obstetrics. 4th Ed. Malden: Blackwell; 2004.

7.Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation. 2001;104(5):515-21.

8.Khairy P, Ouyang DW, Fernandes SM, Lee-Parritz A, Economy KE, Landzberg MJ. Pregnancy outcomes in women with congenital heart disease. Circulation. 2006;113(4):517-24.

9.Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008;118(15):e523-661.

10.Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J. 2007;28(2):230-68.

11.Elkayam U, Ostrzega E, Shotan A, Mehra A. Cardiovascular problems in pregnant women with the Marfan syndrome. Ann Intern Med. 1995;123(2):117-22.

12.Drenthen W, Pieper PG, Roos-Hesselink JW, van Lottum WA, Voors AA, Mulder BJ, et al. Outcome of pregnancy in women with congenital heart disease: a literature review. J Am Coll Cardiol. 2007;49(24):2303-11.

13.Pearson GD, Veille JC, Rahimtoola S, Hsia J, Oakley CM, Hosenpud JD, et al. Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review. JAMA. 2000;283(9):1183-8.

14.Hibbard JU, Lindheimer M, Lang RM. A modified definition for peripartum cardiomyopathy and prognosis based on echocardiography. Obstet Gynecol. 1999;94(2):311-6.

15.Habli M, O'Brien T, Nowack E, Khoury S, Barton JR, Sibai B. Peripartum cardiomyopathy: prognostic factors for long-term maternal outcome. Am J Obstet Gynecol. 2008;199(4):415.e1-5.

16.Karnad DR, Lapsia V, Krishnan A, Salvi VS. Prognostic factors in obstetric patients admitted to an Indian intensive care unit. Crit Care Med. 2004;32(6):1294-9.

17.Kiely DG, Condliffe R, Webster V, Mills GH, Wrench I, Gandhi SV, et al. Improved survival in pregnancy and pulmonary hypertension using a multiprofessional approach. BJOG. 2010;117(5):565-74.

18.Langesaeter E, Dragsund M, Rosseland LA. Regional anaesthesia for a Caesarean section in women with cardiac disease: a prospective study. Acta Anaesthesiol Scand. 2010;54(1):46-54.

19.Ioscovich AM, Goldszmidt E, Fadeev AV, Grisaru-Granovsky S, Halpern SH. Peripartum anesthetic management of patients with aortic valve stenosis: a retrospective study and literature review. Int J Obstet Anesth. 2009;18(4):379-86.

20.Bonnin M, Mercier FJ, Sitbon O, Roger-Christoph S, Jais X, Humbert M, et al. Severe pulmonary hypertension during pregnancy: mode of delivery and anesthetic management of 15 consecutive cases. Anesthesiology. 2005;102(6):1133-7;discussion 5A-6A.

21.Mittnacht AJ, Fanshawe M, Konstadt S. Anesthetic considerations in the patient with valvular heart disease undergoing noncardiac surgery. Semin Cardiothorac Vasc Anesth. 2008;12(1):33-59.

22.Amgad N. Makaryus AF, Johnson M. Pregnancy in the patient with Eisenmenger's Syndrome. Mt Sinai J Med. 2006;73(7):1033-6.

23.ACOG Committee Opinion No. 421, November 2008: antibiotic prophylaxis for infective endocarditis. Obstet Gynecol. 2008 Nov;112(5):1193-4.

24.Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation. 2008;118(23):e714-833.

25.Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-54.

26.Pijuan Domenech A, Gatzoulis MA. Pregnancy and heart disease. Rev Esp Cardiol. 2006;59(9):971-84.

Conflicto de intereses: ninguno declarado. Este estudio fue financiado por los autores. No se recibió financiación externa.

1.Lewis G. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers. Lives: reviewing maternal deaths to make motherhood safer-2003-2005. (internet) London: CEMACH; 2007 Dic. (citado 20/02 2010). 12 p. Disponible en: http://www.cmace.org.uk/getattachment/05f68346-816b-4560-b1b9-af24fb633170/Saving-Mothers%E2%80%99-Lives-2003-2005_ExecSumm.aspx.        [ Links ]

2.Van Mook WN, Peeters L. Severe cardiac disease in pregnancy, part II: impact of congenital and acquired cardiac diseases during pregnancy. Curr Opin Crit Care. 2005;11(5):435-48.        [ Links ]

3.Perloff JK. Congenital heart disease and pregnancy. Clin Cardiol. 1994;17(11):579-87.        [ Links ]

4.Fretts RC, Schmittdiel J, McLean FH, Usher RH, Goldman MB. Increased maternal age and the risk of fetal death. N Engl J Med. 1995;333(15):953-7.        [ Links ]

5.Cunningham FG, Leveno KJ. Childbearing among older women--the message is cautiously optimistic. N Engl J Med. 1995;333(15):1002-4.        [ Links ]

6.Dildy GA. Critical care obstetrics. 4th Ed. Malden: Blackwell; 2004.        [ Links ]

7.Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation. 2001;104(5):515-21.        [ Links ]

8.Khairy P, Ouyang DW, Fernandes SM, Lee-Parritz A, Economy KE, Landzberg MJ. Pregnancy outcomes in women with congenital heart disease. Circulation. 2006;113(4):517-24.        [ Links ]

9.Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008;118(15):e523-661.        [ Links ]

10.Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J. 2007;28(2):230-68.        [ Links ]

11.Elkayam U, Ostrzega E, Shotan A, Mehra A. Cardiovascular problems in pregnant women with the Marfan syndrome. Ann Intern Med. 1995;123(2):117-22.        [ Links ]

12.Drenthen W, Pieper PG, Roos-Hesselink JW, van Lottum WA, Voors AA, Mulder BJ, et al. Outcome of pregnancy in women with congenital heart disease: a literature review. J Am Coll Cardiol. 2007;49(24):2303-11.        [ Links ]

13.Pearson GD, Veille JC, Rahimtoola S, Hsia J, Oakley CM, Hosenpud JD, et al. Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review. JAMA. 2000;283(9):1183-8.        [ Links ]

14.Hibbard JU, Lindheimer M, Lang RM. A modified definition for peripartum cardiomyopathy and prognosis based on echocardiography. Obstet Gynecol. 1999;94(2):311-6.        [ Links ]

15.Habli M, O'Brien T, Nowack E, Khoury S, Barton JR, Sibai B. Peripartum cardiomyopathy: prognostic factors for long-term maternal outcome. Am J Obstet Gynecol. 2008;199(4):415.e1-5.        [ Links ]

16.Karnad DR, Lapsia V, Krishnan A, Salvi VS. Prognostic factors in obstetric patients admitted to an Indian intensive care unit. Crit Care Med. 2004;32(6):1294-9.        [ Links ]

17.Kiely DG, Condliffe R, Webster V, Mills GH, Wrench I, Gandhi SV, et al. Improved survival in pregnancy and pulmonary hypertension using a multiprofessional approach. BJOG. 2010;117(5):565-74.        [ Links ]

18.Langesaeter E, Dragsund M, Rosseland LA. Regional anaesthesia for a Caesarean section in women with cardiac disease: a prospective study. Acta Anaesthesiol Scand. 2010;54(1):46-54.        [ Links ]

19.Ioscovich AM, Goldszmidt E, Fadeev AV, Grisaru-Granovsky S, Halpern SH. Peripartum anesthetic management of patients with aortic valve stenosis: a retrospective study and literature review. Int J Obstet Anesth. 2009;18(4):379-86.        [ Links ]

20.Bonnin M, Mercier FJ, Sitbon O, Roger-Christoph S, Jais X, Humbert M, et al. Severe pulmonary hypertension during pregnancy: mode of delivery and anesthetic management of 15 consecutive cases. Anesthesiology. 2005;102(6):1133-7;discussion 5A-6A.        [ Links ]

21.Mittnacht AJ, Fanshawe M, Konstadt S. Anesthetic considerations in the patient with valvular heart disease undergoing noncardiac surgery. Semin Cardiothorac Vasc Anesth. 2008;12(1):33-59.        [ Links ]

22.Amgad N. Makaryus AF, Johnson M. Pregnancy in the patient with Eisenmenger's Syndrome. Mt Sinai J Med. 2006;73(7):1033-6.        [ Links ]

23.ACOG Committee Opinion No. 421, November 2008: antibiotic prophylaxis for infective endocarditis. Obstet Gynecol. 2008 Nov;112(5):1193-4.        [ Links ]

24.Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation. 2008;118(23):e714-833.        [ Links ]

25.Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-54.        [ Links ]

26.Pijuan Domenech A, Gatzoulis MA. Pregnancy and heart disease. Rev Esp Cardiol. 2006;59(9):971-84.        [ Links ]