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Obstetric anesthesia in high-risk cardiac patients is a challenging and rewarding anesthesia subspecialty. Anesthesiologists must be well-versed in the physiological changes of pregnancy and the pathophysiology of cardiac disease to understand the best way to administer an anesthetic without exacerbating a cardiac condition. This activity reviews common cardiac conditions the anesthesiologist may encounter and highlights the anesthetic management of this fascinating subset of patients, emphasizing the interprofessional teamwork between the anesthesiologist, obstetrician, and cardiologist to deliver both the child and anesthetic safely. Objectives: Evaluate the physiologic changes of pregnancy. Assess the goals of anesthetic management of patients with coronary artery disease, valvular disease, pulmonary hypertension, and tachyarrhythmias. Identify tools that can be used to help assess anesthetic risk for obstetric patients. Access free multiple choice questions on this topic.

Cardiovascular disease is consistently cited as a major cause of maternal morbidity and mortality worldwide. Maternal heart disease is a comorbidity in 0.2 to 3% of all pregnancies. As this subset of patients is increasingly encountered, institutions are choosing to develop management pathways to minimize morbidity and mortality through highly coordinated multidisciplinary teams. In addition to an increasing magnitude of mothers with co-existing cardiovascular disease (ie, pulmonary hypertension, mitral regurgitation, aortic aneurysm, etc), patients with congenital heart disease who underwent corrective surgery are surviving longer and choosing to become pregnant. This creates an interesting subset of the patient population that requires an intentional and frequent multispeciality approach to their anesthetic management during labor, delivery, and cesarean section.[1][2][3] Risk Stratification Ideally, developing an anesthetic plan for a high-risk cardiac patient should begin preconception or early in pregnancy so the patient can better comprehend the risks involved with pregnancy and the anesthetic plan that may be best for the expectant mother. Risk stratification and discussion amongst an interprofessional team of physicians are especially important for patients with congenital heart disease.[3][4] A wide array of risk stratification tools are available to help the physician direct the intensity of an anesthetic plan and the patient toward hospitals of varying resources. Examples of these risk stratification tools include Cardiac Disease in Pregnancy (CARPEG) I & II, Zwangerschap bij Aangeboren Hartafwijking (ZAHARA), and World Health Organization (WHO) risk stratification calculators. CARPREG I & II and ZAHARA determine the likelihood of a significant cardiac event based on individual maternal risk factors. In contrast, the WHO risk stratification system divides individuals into 4 risk categories.[1]

Obstetric anesthesia for high-risk cardiac patients is a challenging endeavor that poses a risk to both the mother and fetus. The physiologic changes during pregnancy are not ideal for many cardiac conditions. For example, patients with moderate to severe mitral stenosis are sensitive to volume prenatally, so when pregnancy increases intravascular volume by 50%, it only exacerbates the condition. Decreases in systemic vascular resistance lower diastolic pressures and decrease coronary perfusion pressures as well—many of the typical anesthetics lower systemic vascular resistance, which can further challenge tenuous patients. Due to the complex nature of this patient population, it is important to pursue an interprofessional approach to the care of these patients. Multiple specialties of physicians should be involved when warranted as a multifaceted viewpoint is less likely to miss the potential for improvement in care. A cardiac anesthesiologist and cardiologist can work in conjunction with the obstetric team to help guide the successful delivery of a child to a mother with pulmonary hypertension or a significant right-to-left shunt. Without teamwork behind the scenes, the care of such complex patients could be compromised. Pregnancy is a stressful experience for the mother, only compounded by potentially life-threatening heart disease. Clear communication between the healthcare team is important to optimize outcomes for these high-risk patients.