Circulation

AHA SCIENTIFIC STATEMENT

Anesthetic Care of the Pregnant Patient With

Cardiovascular Disease: A Scientific Statement
From the American Heart Association
This statement is endorsed by the Society for Obstetric Anesthesia and Perinatology and the Society of Cardiovascular
Anesthesiologists.
The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational
tool, October 2022.

Marie-Louise Meng, MD, Chair; Katherine W. Arendt, MD; Jennifer M. Banayan, MD; Elisa A. Bradley, MD; Arthur J. Vaught, MD;
Afshan B. Hameed, MD; Jade Harris, MSN, RN, C-OB, C-EFM; Benjamin Bryner, MD; Laxmi S. Mehta, MD, FAHA, Vice Chair;
on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia; Council on Cardiopulmonary,
Critical Care, Perioperative and Resuscitation; and Council on Peripheral Vascular Disease

ABSTRACT: The pregnancy-related mortality rate in the United States is excessively high. The American Heart Association is
dedicated to fighting heart disease and recognizes that cardiovascular disease, preexisting or acquired during pregnancy, is the
leading cause of maternal mortality in the United States. Comprehensive scientific statements from cardiology and obstetrics
experts guide the treatment of cardio-obstetric patients before, during, and after pregnancy. This scientific statement aims
to highlight the role of specialized cardio-obstetric anesthesiology care, presenting a systematic approach to the care of
these patients from the anesthesiology perspective. The anesthesiologist is a critical part of the pregnancy heart team as
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the perioperative physician who is trained to prevent or promptly recognize and treat patients with peripartum cardiovascular
decompensation. Maternal morbidity is attenuated with expert anesthesiology peripartum care, which includes the management
of neuraxial anesthesia, inotrope and vasopressor support, transthoracic echocardiography, optimization of delivery location,
and consideration of advanced critical care and mechanical support when needed. Standardizing the anesthesiology approach
to patients with high peripartum cardiovascular risk and ensuring that cardio-obstetrics patients have access to the appropriate
care team, facilities, and advanced cardiovascular therapies will contribute to improving peripartum morbidity and mortality.

Key Words: AHA Scientific Statements ◼ anesthesiology ◼ cardiovascular disease ◼ maternal mortality ◼ obstetrics ◼ patient care team
◼ peripartum period

T
he pregnancy-related mortality rate is disconcert- cipline of cardio-obstetrics aims to improve maternal
ingly high in the United States compared with morbidity and mortality through the multidisciplinary
other high-income nations. In 2017, the preg- care of pregnant patients with congenital or acquired
nancy-related mortality ratio in the United States was heart disease. The discipline seeks to improve the rec-
17.3 per 100 000 pregnancies compared with <10 per ognition of CVD in pregnancy and to promote multidis-
100 000 in other high-income nations.1 Cardiovascular ciplinary care coordination to mitigate peripartum and
disease (CVD) is the leading cause of maternal mortal- postpartum complications. The role of the anesthesi-
ity in the United States, accounting for >25% of mater- ologist in a multidisciplinary pregnancy heart team is
nal deaths,2 with cardiovascular maternal morbidity and crucial to peripartum care.4 The goal of this scientific
mortality disproportionately affecting Black patients, statement is to provide a practical framework for coor-
who have a 3- to 4-fold higher rate of death than non- dinating the anesthetic care of cardio-obstetric patients
Hispanic White pregnant patients.3 The evolving dis- undergoing delivery (Figure).

© 2023 American Heart Association, Inc.

Circulation is available at www.ahajournals.org/journal/circ

Circulation. 2023;147:00–00. DOI: 10.1161/CIR.0000000000001121 TBD TBD, 2023 e1

 Meng et al Anesthetic Care of the Pregnant Patient With CVD
CLINICAL STATEMENTS
AND GUIDELINES

Figure. Planning for delivery framework.

CARPREG indicates Cardiac Disease in Pregnancy; SOAP, Society for Obstetric Anesthesia and Perinatology; and WHO, World Health Organization.

or without consideration of other stratification tools such

PLANNING FOR DELIVERY FRAMEWORK as the CARPREG (Cardiac Disease in Pregnancy) II risk
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score, which is composed of general, lesion-specific,

Who: The Patient and Pregnancy Heart Team and delivery-of-care variables.17,18 However, risk stratifi-
It is critical that the cardio-obstetrics patient undergo cation tools remain imperfect in determining absolute in-
an individualized assessment and have a care plan de- dividual risk because they are based on population-level,
veloped by an expert multidisciplinary pregnancy heart often retrospective studies.18–20 For example, although
team. The ROPAC cohort (Registry of Pregnancy and the mWHO system may be the most well-suited tool
Cardiac Disease) includes almost 6000 pregnant pa- for the anesthesiologist,15 it does not account for the
tients with heart disease (2007–2018) from >60 magnitude of CVD (eg, valvular gradients or functional
countries. Data from ROPAC have led to numerous pub- impact). Risk scoring systems are also less effective in
lications outlining specific cardiac disease processes distinguishing mild from life-threatening events that may
complicating pregnancy and, in turn, has helped clini- require hospitalization or early delivery.
cians better guide care for these patients.5–12 Data from The pregnancy heart team is typically made up of
ROPAC demonstrate that although rates of maternal specialists with expertise in cardiology, obstetrics, gyne-
mortality and heart failure were high among women with cology, maternal fetal medicine, primary care, nursing
particular types of CVD, 9% mortality with pulmonary (specifically, critical care obstetric nurses), pharmacy, and
arterial hypertension and 11% rate of heart failure in anesthesiology. This group works together to develop an
the entire study population overall, most patients with individualized antepartum, labor and delivery, and post-
CVD did well, suggesting that safe pregnancy can be partum care plan for patients with CVD4,16,21 (Table 2).
achieved with proper care.13 ROPAC also highlights the Obstetric anesthesiologists have expertise in the peri-
high rate of obstetric and fetal complications in pregnan- partum anesthetic care of pregnant patients and are
cies complicated by CVD, at 17% and 21%, respective- an integral part of this multidisciplinary team. The par-
ly.13 Expert cardio-obstetric care includes preconception ticipation of cardiothoracic anesthesiologists may be
counseling, risk stratification and education, multidisci- useful for patients who sustain or are at risk for acute
plinary coordination, and careful planning guided by a cardiovascular decompensation, potentially requiring
multidisciplinary team.4–11,14–16 It is reasonable for wom- peripartum cardiothoracic surgery or mechanical support
en with heart disease to be risk-stratified according to such as extracorporeal membrane oxygenation (ECMO;
the lesion-specific Modified World Health Organization Table 2). Critical care obstetric nurses are experienced
(mWHO) Pregnancy Risk Classification (Table 1), with obstetric nurses who have specialized critical care skills

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 Meng et al Anesthetic Care of the Pregnant Patient With CVD

Table 1. The Cardio-Obstetrics Patient

CLINICAL STATEMENTS
mWHO risk class Cardiovascular condition Risk (mortality and morbidity) Considerations

AND GUIDELINES
Class I Uncomplicated, small, or mild: No increased risk of maternal Care at local hospital
Pulmonary stenosis mortality Delivery at local hospital
Patient ductus arteriosus No or mild increase in morbidity
Mitral valve prolapse
Successfully repaired simple lesions (atrial or ventricular septal
defect, patent ductus arteriosus, anomalous pulmonary venous
drainage)
Atrial or ventricular ectopic beats, isolated
Class II Unoperated atrial or ventricular septal defect If otherwise well, then a small Care at local hospital
(if otherwise well Repaired tetralogy of Fallot increased risk of maternal Delivery at local hospital
and uncomplicated) mortality
Most arrhythmias Pregnancy heart team consultation
Moderate increase in morbidity
Turner syndrome without congenital cardiac disease
Class II or III Mild LV impairment (EF >45%) Pregnancy heart team consulta-
(depending on Hypertrophic cardiomyopathy tion
individual)
Native or tissue valvular heart disease not considered WHO I or
IV (mild mitral stenosis, moderate aortic stenosis)
Marfan syndrome or other HTAD without aortic dilation
Aorta <45 mm in aortic disease associated with bicuspid aortic
valve
Repaired coarctation without residua (non-Turner)
Atrioventricular septal defect
Class III Moderate LV impairment (LVEF, 30%–45%) Significantly increased risk of Care at appropriate level hospital
Previous pregnancy cardiomyopathy without any residual LV im- maternal mortality or severe with appropriate members of the
pairment morbidity pregnancy heart team available
Mechanical valve
Systemic RV with good or mildly decreased ventricular function
Fontan circulation (uncomplicated)
Cyanotic heart disease (unrepaired)
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Other complex congenital heart disease

Moderate mitral stenosis
Severe asymptomatic aortic stenosis
Moderate aortic dilation defined as:
40–45 mm in Marfan syndrome, bicuspid aortic valve
<50 mm in tetralogy of Fallot
ASI 20–25 mm/m2 in Turner syndrome
Ventricular tachycardia
Class IV Pulmonary arterial hypertension of any cause Extremely high risk of maternal Care at appropriate level hospital
Severe systemic ventricular dysfunction (LVEF <30%, NYHA FC mortality with appropriate members of the
class III or IV) Extremely high risk of maternal pregnancy heart team available
Previous peripartum cardiomyopathy with any residual impairment morbidity
of LV function Pregnancy contraindicated
Severe mitral stenosis
Severe symptomatic aortic stenosis
Systemic RV with moderate to severely decreased LV function
Severe aortic dilation defined as:
>45 mm associated with Marfan syndrome
>50 mm associated with bicuspid aortic valve
>50 mm associated with tetralogy of Fallot
ASI > 25 mm/m2 with Turner syndrome
Native severe coarctation
Vascular Ehler-Danlos
Fontan circulation with any complication

ASI indicates aortic size index; HTAD, heritable thoracic aortic diseases; LV, left ventricular; LVEF, left ventricular ejection fraction; mWHO, Modified World Health
Organization; NYHA FC, New York Heart Association functional class; RV, right ventricular; and WHO, World Health Organization.
Adapted with permission from Thorne et al,15 copyright © 2006 BMJ Publishing Group Ltd; and from Regitz-Zagrosek et al,16 copyright © 2018 the European
Society of Cardiology and the European Society of Hypertension.

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 Meng et al Anesthetic Care of the Pregnant Patient With CVD

Table 2. Members of the Pregnancy Heart Team and training in invasive hemodynamic monitoring and
CLINICAL STATEMENTS

Core pregnancy heart team 4,16 knowledge of advanced obstetric physiology and phar-
AND GUIDELINES

Cardiologist
macology.22,23 Coordinating care among members of the
pregnancy heart team is sometimes a delicate negotia-
Obstetrician
tion, and clear definition of roles and leadership is essen-
Maternal fetal medicine specialist
tial. Team leadership may vary over the course of the
Anesthesiologist pregnancy, and the anesthesiologist may provide leader-
 Nurse specialists (critical care obstetrics nurse, intensive care nurse, ob- ship during the peridelivery time.
stetric nurse, lactation specialist)
Additional experts to consider when creating a pregnancy heart team4,16,21
  Obstetric anesthesiologist
What: Mode of Delivery
  Cardiothoracic anesthesiologist Medical counseling focuses on the risk of morbidity and
   Cardiothoracic or ECMO surgeon
mortality, including maternal cardiovascular, fetal, and
obstetric risks, as well as management and mitigation
Other cardiovascular specialists
strategies. Individualized care plans developed by the
  Heart failure
pregnancy heart team should consider the patient’s un-
  Adult congenital derlying anatomy and physiology, access to care, deliv-
  Pulmonary hypertension ery facility capabilities, and availability of multidisciplinary
  Electrophysiologist expertise. Shared decision-making is essential for all pa-
  Imaging specialist tients but especially those with the highest risk for ma-
  Interventionalist
ternal morbidity or mortality, and the patient should be
engaged in discussions of all potential risks and thera-
Intensivist
peutic options.4 These patients include those with known
Geneticist
mWHO risk class IV lesions (Table 1).24 The decision to
Neonatologist continue a very high-risk pregnancy is personal to each
Hematologist patient and should be respected.
Pharmacist The pregnancy heart team should remain focused on
Pulmonologist
the most appropriate mode of delivery, weighing maternal
cardiovascular, fetal, and obstetric risk.4 For patients who
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Perfusionist
carry a pregnancy to near term or term, vaginal delivery is
Reasons to consult cardiothoracic anesthesiologist
the preferred mode of delivery for most patients because
Lesion triggers it decreases the risk of obstetric complications and allows
   Severe right- or left-sided heart failure more gradual hemodynamic changes at the time of deliv-
   Systemic RV with moderate or severely decreased ventricular function ery, which is favorable for women with high-risk CVD. The
   Fontan with complications Valsalva maneuver during vaginal delivery is reasonable
   Symptomatic heart failure (especially if complicated by preeclampsia)
for most patients with CVD. However, assistance in the
second stage to avoid prolonged or forceful Valsalva may
   Severe mitral stenosis
be considered in select patients with the highest risk for
   Severe aortic stenosis
maternal decompensation such as those with significant
  PASP >50 mm Hg, pulmonary hypertension with right heart failure, pul- ventricular dysfunction or failure, Fontan circulation, and
monary hypertension with significant cyanosis with or without RV failure
severe pulmonary hypertension.25 The 2 main maternal
   Any unstable cardio-obstetrics patient (ie, dissecting major vessel) risks with the Valsalva maneuver are (1) the significant
  Presence of major cardiovascular support device (LVAD, RVAD, ECMO) reduction in preload during Valsalva, which may not be
Anticipated monitor/procedure triggers tolerated by patients with left-sided obstructive lesions
   Titration of inotropes such as severe mitral stenosis, aortic stenosis, or hyper-
   Need for echocardiography in management
trophic obstructive cardiomyopathy, and (2) the aortic
shear stress that results from the large stroke volume
   Need for pulmonary pressure monitoring
ejection from the previously empty, now full left ventricle.
   Maternal decompensation requiring general anesthesia
This shear stress could pose a risk to patients with under-
   Cardiothoracic surgeon or ECMO on standby lying significant aortopathy. In general, cesarean delivery
   Need for combined cardiac procedure and delivery is reserved for obstetrical indications, for patients who
Obstetic trigger are at a very high risk of decompensation at the time of
   Heart failure with preeclampsia
delivery, including patients with high-risk aortopathy or
maternal decompensation, or for the coordination of care
ECMO indicates extracorporeal membrane oxygenation; LVAD, left ventricu-
lar assist device; PASP, pulmonary arterial systolic pressure; RV, right ventricu-
in select cases. Coordination of cesarean delivery and
lar; and RVAD, right ventricular assist device. cardiovascular procedures may be necessary in cases

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 Meng et al Anesthetic Care of the Pregnant Patient With CVD

in which expedited delivery allows optimal timing, hemo- Care Center, where services outside of the usual scope

CLINICAL STATEMENTS
dynamic control, and resource coordination such as the of labor and delivery suites can often be brought to the

AND GUIDELINES
potential need for peripartum valvuloplasty or mechanical labor floor to optimize care. Examples of such care include
circulatory support.24 continuous infusion to control an arrhythmia, the ability to
initiate mechanical circulatory support, and the adminis-
tration of inhaled or intravenous pulmonary vasodilators
When: Timing of Delivery for severe pulmonary hypertension. When the support of
In patients with CVD, procedures and anesthesia may a cardiothoracic surgeon or ECMO may be necessary,
pose significant risk that should be acknowledged. The a cardiothoracic operating room or hybrid setup may be
timing of delivery for complex maternal CVD is not es- the appropriate location for cesarean delivery. The ideal
tablished and often debated; however, to preserve opti- location for delivery is often institution specific. Depend-
mal newborn outcomes, the goal is to achieve 39 weeks’ ing on locally available experts, services, and monitoring,
gestation unless there is concern for maternal or fetal consideration of surgical or cardiac care beds may be
decompensation.4 Typically, delivery timing is highly indi- required for postpartum recovery in patients with high-
vidualized on the basis of the complexity and severity of risk and advanced cardiovascular needs.
the cardiovascular lesion, signs of clinical decompensa-
tion, New York Heart Association functional class, as-
sociated comorbidities, anticoagulation status, and the How: Peripartum Plan
need for interventions that could be safely performed Hemodynamic Goals
only in the postpartum period in the nonpregnant state. Clinicians may encounter various hemodynamic changes
in the postoperative and peripartum periods (Table 3). On
an individual patient basis, the anesthesiologist should
Where: Type of Hospital and Location Within the work with the pregnancy heart team to create a care
Hospital plan specific to the cardiovascular anatomy and physiol-
The American College of Obstetricians and Gynecologists ogy in the context of anesthesia care for labor and de-
and Society for Maternal-Fetal Medicine have established livery or cesarean delivery (Table 4).39 When it comes to
the Levels of Maternal Care to improve maternofetal out- the anesthetic management, for decisions for complex
comes and to reduce disparities in care by standardiz- critically ill patients, there is often little evidence (espe-
ing care across hospitals and enabling hospital transfers cially in cardio-obstetrics) to suggest that one choice is
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when escalation of care is necessary.26 Maternal Level IV superior to another; therefore, a clinician’s comfort and
Care Centers are tertiary care centers with the ability to expertise in specific practices and modalities cannot be
provide cardiac surgery, specialized critical care cardiol- overstated. The peripartum care plan should be created
ogy, and involvement of appropriate cardiac subspecialist early when possible, usually in pregnancy weeks 20 to
experts such as pulmonary hypertension, adult congenital 28, and made available in the patient’s medical record
disease, and aortopathy specialists. that is readily accessible to all members of the preg-
In general, patients with mWHO II classification CVD nancy heart team to view.
such as repaired tetralogy of Fallot and most arrhythmias
can be cotreated by maternal fetal medicine specialists Peripartum Risks
and a cardiology consultant and may be delivered at a Pregnancy is a prothrombotic state, and thrombotic
local hospital.4 However, patients with mWHO class III or events contribute to major morbidity and mortality, espe-
higher are recommended to deliver at a Maternal Level IV cially in pregnant patients with CVD.41 Anticoagulation

Table 3. Hemodynamic Changes Peripartum and Plans for Mitigation

Hemodynamic issue Possible consequences Plan

↑ Catecholamines (attributable to pain and anxiety) ↑ Tachycardia and arrhythmias Avoid sudden alterations in heart rate and rhythm with
neuraxial anesthesia for pain control

↓ Systemic vascular resistance (attributable to neuraxial ↓ Coronary perfusion from decreased Control sudden decreases in afterload (systemic vascu-
anesthesia, pregnancy hormones, and hemorrhage) aortic diastolic pressure and increased LV lar resistance) with appropriate use of vasopressors
end-diastolic pressure

↑ Cardiac output must increase through labor and ↑ Heart failure Support the myocardium with inotropic medications or
delivery to accommodate the expected autotransfusion VA ECMO
(preload changes) Diuresis as needed

↑ Pulmonary blood flow ↑ Pulmonary pressure if pulmonary vascular Provide pulmonary vasodilators
resistance cannot decrease Control sudden changes in blood volume with diuresis

↓ Oncotic pressure ↑ Pulmonary edema Diuresis as needed

LV indicates left ventricular; and VA ECMO, venoarterial extracorporeal membrane oxygenation.

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 Meng et al Anesthetic Care of the Pregnant Patient With CVD

Table 4. Unique Cardiovascular Considerations in Obstetric Anesthesia

CLINICAL STATEMENTS

CVD Cardiovascular impact/hemodynamic changes Anesthesiology considerations

AND GUIDELINES

HDP
Chronic hypertension (<20 wk) Increased afterload in the setting of uncontrolled Hemodynamic goals: reduce systemic vascular resis-
Gestational hypertension (≥20 wk) blood pressure in pregnancy contributes to increased tance
maternal myocardial workload and poor myocardial Anesthetic plan: neuraxial anesthesia
 Preeclampsia and preeclampsia with relaxation, along with the potential for poor placental
severe features (proteinuria, thrombocy- Hemodynamic medication plan: antihypertensive medi-
perfusion.
topenia, renal insufficiency, impaired liver cation
Preeclampsia and eclampsia remain part of the spec-
function, pulmonary edema, or cerebral or Access: usual large-bore peripheral intravenous line
trum of PPCM.27
visual symptoms) and eclampsia Monitoring: consider arterial line if severe hyperten-
Chronic and gestational hypertension may be treated
sion requires continuous intravenous medication, or if
expectantly with pregnancy-safe medical therapy.
noninvasive measurements are inaccurate, consider
Preeclampsia and eclampsia require a more urgent transthoracic echocardiography or point-of-care cardiac
approach that considers timing of delivery, fluid man- ultrasound
agement, seizure prevention, lowering of blood pres-
Postpartum hemorrhage prevention and management:
sure, and prevention of end-organ damage.
avoid methylergonovine
Special considerations: monitor for thrombocytope-
nia, liver dysfunction, coagulopathy, and myocardial
dysfunction
Recovery: usual care
Cardiomyopathy with severe LV systolic dysfunction
Increased-risk conditions*: Patients with severe systolic dysfunction or elevated Hemodynamic goals: maintain normal sinus rhythm, aug-
  Systemic RV NYHA FC are at highest risk for low cardiac output ment contractility to maintain cardiac output
and cardiogenic shock, and pregnancy is generally Anesthetic plan: carefully titrated neuraxial anesthesia
  Any systemic ventricular systolic dys-
contraindicated.
function Hemodynamic medication plan: inotropic medications
In those with prior PPCM, there is high risk for wors-
High-risk conditions†: Access: usual large-bore peripheral intravenous line; con-
ening LV dysfunction and ≈19% risk of death in SSP if
sider central venous access (peripheral or central insertion)
   Systemic ventricular EF <30% the recovered LVEF is <50%.28
Monitoring: consider arterial line; consider transthoracic
  Systemic ventricular dysfunction with Young patients with cardiomyopathy may appear clini-
echocardiography or point-of-care cardiac ultrasound
NYHA FC III–IV cally well until late in pregnancy because of robust
compensatory mechanisms. Postpartum hemorrhage prevention and management:
usual care
Medical heart failure therapies may include β-blockers
Special considerations: in patients with low cardiac
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and afterload reduction (excluding ACE inhibitors,

ARBs, ARNI). output, severe right-sided heart dysfunction, systemic
RV, or ensuing shock, inotropes, mechanical circulatory
support, or ECMO may be considered
Recovery: consider intensive care unit
Valvular heart disease
Stenotic valve disease Left-sided valvular obstruction limits the ability to Hemodynamic goals: maintain aortic diastolic blood
provide adequate cardiac output in the setting of the pressure at baseline, normal sinus rhythm
low-SVR state of pregnancy. Anesthetic plan: carefully titrated neuraxial anesthesia
Severe mitral stenosis and severe symptomatic aortic Hemodynamic medication plan: vasopressor medica-
stenosis remain high-risk lesions for which pregnancy tions
is contraindicated.
Access: usual large-bore peripheral intravenous line
Patients with severe left-sided heart obstruction are at
Monitoring: consider arterial line for severe stenotic le-
risk of poor cardiac output, congestion, heart failure,
sions; consider transthoracic echocardiography or point-
and arrhythmia; postdelivery autotransfusion may ex-
of-care cardiac ultrasound
acerbate this physiology.
Postpartum hemorrhage prevention and management:
usual care
Recovery: consider intensive care unit for high risk
Regurgitant valve disease Regurgitant valve disease is typically better tolerated Hemodynamic goals: avoid hypertension and brady-
than stenosis, but chamber dilatation may occur. cardia
Anesthetic plan: neuraxial anesthesia
Hemodynamic medication plan: consider vasopressor
medications with chronotropic properties, inotropic
medications
Access: usual large-bore peripheral intravenous line
Monitoring: usual care; consider transthoracic echocar-
diography or point-of-care cardiac ultrasound
Postpartum hemorrhage prevention and management:
usual care
Recovery: usual care
(Continued )

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 Meng et al Anesthetic Care of the Pregnant Patient With CVD

Table 4. Continued

CLINICAL STATEMENTS
CVD Cardiovascular impact/hemodynamic changes Anesthesiology considerations

AND GUIDELINES
Aortopathy
Increased-risk conditions*: The hemodynamic and hormonal changes of pregnan- Hemodynamic goals: avoid increases in sheer stress with-
   Marfan syndrome with aorta 45–50 mm cy affect the integrity of the arterial vasculature and in the aorta and increased systemic vascular resistance
are an important risk factor for dissection, especially in Anesthetic plan: carefully titrated neuraxial anesthesia
  Bicuspid aortic valve with aorta 45–50
patients with connective tissue disease.29,30
mm Hemodynamic medication plan: vasodilator medications
Patients with vascular connective tissue disease are
High-risk conditions†: Access: usual large-bore peripheral intravenous line
also often at increased risk for obstetric and neonatal
   Marfan syndrome with aorta >45 mm events. Monitoring: consider arterial line if severe hypertension
   Bicuspid aortic valve with aorta >50 mm requires continuous intravenous medication; if noninva-
For some types of aortopathy, prophylactic aortic
sive measurements are inaccurate, consider transthorac-
Elevated risk, poorly defined magnitude: root replacement is advised to avoid spontaneous
ic echocardiography or point-of-care cardiac ultrasound
  Loeys-Dietz syndrome dissection; however, the impact during pregnancy is
less clear but likely includes consideration of absolute Postpartum hemorrhage prevention and management:
   Vascular Ehlers-Danlos syndrome avoid methylergonovine
diameter and cross section–to–height ratio.31
  Genetic-negative HTAAD/S Special considerations: may choose to perform cesarean
Pharmacological therapy with β-blockers is often used
in both pregnant and nonpregnant states. delivery in a cardiothoracic operating room for highest-risk
patients; specialized monitoring at the time of labor and de-
livery is often required and includes close watch over blood
pressure and heart rate, with a low threshold to use 3D
imaging if there is chest pain or other signs of dissection.
Recovery: consider intensive care unit if high risk
CHD
Increased-risk conditions*: The risk of pregnancy in CHD is determined by (1) the Hemodynamic goals: In Eisenmenger’s specifically, the in-
  Morphological RV in systemic position original congenital heart lesion and (2) intervention/ ability to lower high PVR leads to an increase in right-to-left
Fontan circulation surgical history. This risk can be affected by the devel- shunting. The increased shunt, combined with increased
opment of subsequent acquired CVD such as heart oxygen consumption in pregnancy, results in cardiopulmo-
   Unrepaired cyanotic heart disease
failure or arrhythmia. nary decompensation, typically starting in the second to third
   Other complex CHD trimester. In right-to-left shunts, cardiac output can be aug-
A few types of CHD involve a morphological RV
High-risk conditions†: placed in the systemic ventricular position (D-TGA mented by further increasing the right-to-left blood flow, and
   CHD with pulmonary hypertension after atrial switch and CCTGA). as a result, physiology that results in lowering SVR (ie, bleed-
ing, dehydration) may present initially as worsening hypoxia
  Eisenmenger syndrome (right-to-left Patients with unrepaired cyanotic CHD or Fontan cir-
that does not correct with peripheral oxygen administration.
shunt) culation are at increased risk for maternal cardiovas-
cular events, specifically heart failure and arrhythmia, Anesthetic plan: carefully titrated neuraxial anesthesia
   Native severe coarctation
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in addition to obstetric events such as postpartum Hemodynamic medication plan: will vary according to disease
hemorrhage.32 Access: usual large-bore peripheral intravenous line;
Patients with CHD-associated pulmonary hyperten- consider central venous access in severe, unrepaired, or
sion or Eisenmenger syndrome have extremely high decompensated conditions
mortality risk, estimated to be up to 40%.33 Monitoring: consider arterial line; consider transthoracic
echocardiography or point-of-care cardiac ultrasound
Postpartum hemorrhage prevention and management:
usual care, avoid methylergonovine and carboprost if
concurrent pulmonary hypertension is present
Special considerations: may choose to perform cesarean
delivery in a cardiothoracic operating room for highest-risk pa-
tients; in patients with low cardiac output, severe right-sided
heart dysfunction, systemic RV, or ensuing shock, inotropes,
mechanical circulatory support, or ECMO may be considered
Recovery: consider intensive care unit
Pulmonary hypertension
WHO group 1 disease† In patients with WHO group 1 PAH not on medical Anesthetic plan: carefully titrated neuraxial anesthesia
Non–WHO group 1 disease therapy, mortality is high (>50%).34 However, with Hemodynamic medication plan: pulmonary vasodilator
newer directed medical therapy, it is likely to be in the and inotropic medications
low double digits.13
Access: usual large-bore peripheral intravenous line;
Increased maternal morbidity and mortality occur consider central venous access (peripheral or central
most commonly as a result of RV failure and shock35 insertion); consider pulmonary artery catheter
precipitated by:
Monitoring: consider arterial line; consider transthoracic
Shifts in RV preload echocardiography or point-of-care cardiac ultrasound
 Inability to adequately lower PVR to increase car- Postpartum hemorrhage prevention and management:
diac output avoid methylergonovine and carboprost
 Changes in RV preload caused by blood loss and Special considerations: may choose to perform cesarean
autotransfusion during delivery delivery in a cardiothoracic operating room for highest-risk pa-
tients. In patients with severe pulmonary hypertension, Eisen-
menger syndrome, low cardiac output, severe right-sided
heart dysfunction, systemic RV, or ensuing shock, inotropes,
mechanical circulatory support, or ECMO may be considered.
Recovery: consider intensive care unit
(Continued )

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 Meng et al Anesthetic Care of the Pregnant Patient With CVD

Table 4. Continued
CLINICAL STATEMENTS

CVD Cardiovascular impact/hemodynamic changes Anesthesiology considerations

AND GUIDELINES

Ischemic heart disease

Coronary artery disease Patients with underlying atherosclerotic coronary dis- Hemodynamic goals: maintain normal sinus rhythm, aor-
SCAD ease are at increased risk for myocardial ischemia as- tic diastolic blood pressure, and cardiac output
sociated with the physiological changes in pregnancy. Anesthetic plan: carefully titrated neuraxial anesthesia
Depending on the degree of ischemia present, cardi- Hemodynamic medication plan: vasopressor medication,
ac arrest, ACS, arrhythmia, or heart failure may result inotrope medication, nitroglycerine
(≈10% of pregnancies) and should be monitored for
Access: usual large-bore peripheral intravenous line;
throughout pregnancy and postpartum.36
consider central venous access (peripheral or central
Preeclampsia and low birth weight have been shown insertion) if low cardiac output
to be more common in patients with atherosclerotic
Monitoring: consider arterial line; consider transthoracic
disease or diabetes.
echocardiography or point-of-care cardiac ultrasound
Neonatal events were also more frequent in patients
Postpartum hemorrhage prevention and management:
with underlying coronary disease (up to 30%).36
avoid methylergonovine
SCAD occurs in patients without nonatherosclerotic
Special considerations: may choose to perform ce-
coronary disease and remains the most common
sarean delivery in a cardiothoracic operating room for
cause of ACS in pregnant patients.37
highest-risk patients. In patients with low cardiac output,
SCAD was most common 18 wk after conception in a severe right-sided heart dysfunction, or ensuing shock,
large case-control study.38 inotropes, mechanical circulatory support, or ECMO
Potential risk factors for SCAD should be recognized: may be considered.
hypertension or vascular disease such as fibromuscu- Recovery: consider intensive care unit
lar dysplasia or connective tissue disease.
It is important to recognize that patients with SCAD,
like those with atherosclerotic coronary disease, are
at risk for heart failure, arrhythmia, and cardiac ar-
rest. However, most patients with SCAD tolerate the
remainder of pregnancy and lactation; it is important
to note that the risk for recurrent SCAD has not been
shown to be higher in SSPs for patients with SCAD.38

ACE indicates angiotensin-converting enzyme; ACS, acute coronary syndrome; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor;
CCTGA, congenitally corrected transposition of the great arteries; CHD, congenital heart disease; CVD, cardiovascular disease; D-TGA, dextro-transposition of the
great arteries; ECMO, extracorporeal membrane oxygenation; EF, ejection fraction; HDP, hypertensive disorders of pregnancy; HTAAD/S, heritable thoracic aortic
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aneurysm disease/syndrome; LV, left ventricular; LVEF, left ventricular ejection fraction; NYHA FC, New York Heart Association functional class; PAH, pulmonary arte-
rial hypertension; PPCM, peripartum cardiomyopathy; PVR, pulmonary vascular resistance; RV, right ventricle; SCAD, spontaneous coronary artery dissection; SSP,
subsequent pregnancy; SVR, systemic vascular resistance; 3D, 3-dimensional; and WHO, World Health Organization.
*Increased-risk conditions indicate WHO risk class III lesions.
†High-risk conditions indicate WHO risk class IV lesions.15,16

can affect the timing and safety of neuraxial anesthesia. fewer wound infections, and fewer thromboembolic
Therefore, the pregnancy heart team should be involved events.44–46 Neuraxial labor analgesia decreases ma-
in decisions on peripartum anticoagulation. To avoid spi- ternal plasma epinephrine and norepinephrine during
nal-epidural hematoma, neuraxial techniques should be labor.47 Therefore, it is reasonable to place the epidural
timed according to the anticoagulation medication and catheter at the onset of labor discomfort. An added
dose as recommended by the American Society of Re- benefit of an epidural catheter is that it provides a
gional Anesthesia and Pain Medicine guidelines and the conduit for conversion to surgical anesthesia should
Society for Obstetric Anesthesia and Perinatology con- emergency cesarean be necessary. It is recommended
sensus statement (Table 5).42,43 The anesthesiologist can that an epidural catheter be promptly replaced if it no
help coordinate the timing of stopping anticoagulation longer provides sufficient labor analgesia.39
with the obstetrician and cardiologist if neuraxial anes- Neuraxial catheters for labor analgesia may be placed
thesia is planned or advise in the setting of full antico- by an epidural, dural puncture epidural, or combined spinal-
agulation (mechanical heart valves) if general anesthesia epidural (CSE) technique. When an epidural catheter is
will be necessary. The anticoagulation strategy should placed with the loss-of-resistance technique, the use of
also include a plan for any event that may lead to early or saline rather than air may decrease the risk of venous air
unplanned delivery. embolism in the event of intravascular needle placement.
This is especially important in patients with intracardiac
shunt lesions in whom the risk of paradoxical embolism
ANESTHESIA FOR VAGINAL DELIVERY exists.48,49 In patients with CVD, consideration should be
A vaginal delivery with effective neuraxial analge- given to the risks and benefits of a traditional epidural test
sia is the preferred mode of delivery for most pa- dose. In patients who could decompensate from intravas-
tients with CVD.4 Compared with cesarean deliveries, cular epinephrine or the rapid onset of a spinal anesthetic,
vaginal deliveries are associated with less blood loss, the test dose could be divided into 2 separate intravascular

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 Meng et al Anesthetic Care of the Pregnant Patient With CVD

Table 5. Summary of American Society of Regional Anesthesia and Pain Medicine Guidelines and the Society for Obstetric
Anesthesia and Perinatology Consensus Statement

CLINICAL STATEMENTS
AND GUIDELINES
Heparin Dose Timing Recommendations39,42,43
Subcutaneous Low dose: ≥4–6 h from last dose Likely low risk to proceed with neuraxial
unfractionated 5000 U 2–3 times daily
heparin
Low dose: <4–6 h from last dose If activated partial thromboplastin time within normal range
5000 U 2–3 times daily or anti–factor Xa level undetectable, then likely low risk to
proceed with neuraxial
Intermediate dose: (7500 or 10 000 U twice daily) ≥12 h from last dose If activated partial thromboplastin time within normal range
or anti–factor Xa level undetectable, then likely low risk to
proceed with neuraxial
Intermediate dose: (7500 or 10 000 U twice daily) <12 h from last dose Wait 12 h from last dose and then proceed as above
High dose: any individual dose >10 000 U or total ≥24 h from last dose If activated partial thromboplastin time within normal range
daily dose >20 000 U or anti–factor Xa level undetectable, then likely low risk to
proceed with neuraxial
High dose: any individual dose >10 000 U or total <24 h Minimal data to guide risk assessment; therefore, wait 24 h
daily dose >20 000 U from last dose and then proceed as above
Subcutaneous Low dose: enoxaparin ≤40 mg once daily or 30 mg Wait 12 h after dose
low-molecular- twice daily
weight heparin
Intermediate (eg, enoxaparin >40 mg once daily Wait 24 h after dose
and <1 mg/kg) or high dose (enoxaparin 1 mg/kg
twice daily or 1.5 mg/kg once daily)

and intrathecal tests. This can involve (1) administering fen- tion of neuraxial labor analgesia. At the onset of neuraxial
tanyl 50 µg through the epidural catheter while asking the analgesia, maternal hypotension should be treated with
patient to report symptoms of intravascular opioid admin- vasopressor support to maintain maternal blood pressure
istration and (2) administering a low-dose local anesthetic at baseline. Small amounts of crystalloid supplementa-
solution (eg, bupivacaine 0.0625%–0.125%) through the tion (eg, 200 mL) may be used to treat mild hypotension,
epidural catheter while asking the patient to report with but vasopressor support should be the mainstay for aug-
motor and sensory assessments. If a CSE technique is used mentation of systemic vascular resistance and maternal
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for labor analgesia, lower doses of intrathecal medications blood pressure should it decrease as a result of neuraxial
such as bupivacaine 2 mg combined with fentanyl 10 µg anesthesia. It is routine for patients to require small doses
can be used. Regardless of the technique used to place the of intravenous phenylephrine (eg, 50–100 µg) or intra-
epidural catheter, slow aspiration with a low-volume syringe venous ephedrine (eg, 5–10 mg) to augment systemic
(1–3 mL) can be useful for detecting an inadvertent intra- vascular resistance. A continuous phenylephrine infusion
thecal or intravascular catheter. In cardiac patients, the initial can be used as necessary in laboring patients to main-
labor analgesia epidural medication should be titrated slowly, tain maternal blood pressure at baseline. Other vasopres-
over 10 to 20 minutes, with careful monitoring of vital signs sors such as norepinephrine or vasopressin and inotropic
and sensory and motor block to detect a misplaced catheter medications such as dobutamine, dopamine, milrinone, or
and to provide time to prevent and treat hypotension. Labor epinephrine may be administered less routinely during
analgesia may be maintained with standard local anesthetic vaginal delivery as determined by the patient’s clinical
and opioid infusions (eg, bupivacaine 0.0625%–0.125% status. For patients with an intracardiac shunt, in whom
with 1–2 µg/mL fentanyl), through either patient-controlled low afterload may lead to hypoxemia, it is critical for the
continuous epidural medication infusions or programmed anesthesiologist to rapidly correct decreases in afterload
intermittent boluses. Either mode may be accompanied by with vasopressor support.
patient-controlled epidural boluses.
Regardless of the technique used to initiate neur-
axial anesthesia, maintaining hemodynamic afterload at ANESTHESIA FOR CESAREAN DELIVERY
baseline is essential for maintaining coronary perfusion, Neuraxial anesthesia is typically preferred for cesarean
particularly in patients with left ventricular hypertrophy, delivery, including for patients with mWHO class III or
left ventricular outflow tract obstruction, stenotic valvular IV lesions, although the choice of anesthetic technique
lesions, or pulmonary hypertension. Intra-arterial pres- should be individualized to the patient with the anesthe-
sure monitoring may be useful to monitor and promptly siologist.50,51 Potential indications for proceeding with
treat maternal blood pressure deviations from baseline. general anesthesia include cardiopulmonary decom-
For patients with CVD who are at risk for pulmonary pensation necessitating intubation or a contraindication
edema, it may be reasonable for the anesthesiologist to to neuraxial anesthesia such as current anticoagulation,
avoid a prophylactic routine fluid bolus before the initia- severe thrombocytopenia, or maternal refusal of neuraxial

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 Meng et al Anesthetic Care of the Pregnant Patient With CVD

­anesthesia.42,43 In patients at risk for decompensated heart should be monitored throughout labor and delivery with
CLINICAL STATEMENTS

failure, there is a theoretical concern for hemodynamic de- a special focus during induction of neuraxial or general
AND GUIDELINES

compensation immediately after delivery because of the anesthesia, second and third stages of labor, cesarean
sudden autotransfusion that occurs with aortocaval de- delivery, or a postpartum hemorrhage. Intra-arterial blood
compression and uterine involution at the time of deliv- pressure monitoring is often used in patients with specif-
ery. If a patient with CVD is dyspneic or hypoxemic and ic cardiac lesions, most of which are classified as mWHO
cannot lie supine before cesarean delivery, then general class III or IV. Pulse oximetry and continuous electrocar-
anesthesia with intubation may be indicated to prepare diographic monitoring should be considered in all patients
for potential cardiopulmonary decompensation immedi- with CVD. Central venous and pulmonary artery pressure
ately after delivery. In such cases, continuous venous and monitoring is reserved for patients with cardiopulmonary
arterial monitoring is used to identify and manage rap- decompensation or right ventricular failure requiring titra-
idly changing hemodynamic status attributable to volume tion of vasopressors and pulmonary vasodilators, as well
shifts. The hemodynamic changes from the onset of a spi- as those who may be subject to large volume shifts. Pe-
nal anesthetic for cesarean delivery are more rapid and ripherally inserted central venous catheters can be useful
pronounced than for a slowly dosed (over 15–20 minutes) in patients in whom prolonged central access may be
epidural anesthetic.52 Patients with mWHO class I or II car- necessary or in whom access may be difficult. Pulmonary
diac disease typically tolerate a traditional intrathecal dose artery catheters are not commonly used as cardiac out-
of local anesthesia (eg, hyperbaric bupivacaine 10–15 put monitors in pregnant patients and may lead to com-
mg) for cesarean delivery. Depending on the cardiovas- plications such as arrhythmias and, rarely, bleeding and
cular lesion, patients with mWHO class III or IV lesions thromboembolic events.60 Therefore, pulmonary artery
may benefit from a more gradual-onset sympathectomy. catheters are generally deferred unless there is a need
Options include an epidural technique, a CSE technique for cardiopulmonary bypass or for continuous pulmonary
with intrathecal opioids and epidural local anesthetic, or pressure or cardiac output monitoring of patients with
a sequential CSE technique in which intrathecal opioids moderate or severe pulmonary hypertension or patients
and low-dose bupivacaine (2.5–5 mg) are administered, with severely reduced ventricular function in the inten-
followed by a slow epidural medication titration of local an- sive care unit postpartum.60,61 When needed and when
esthetic, typically 2% lidocaine to a T4 to T6 surgical lev- resources are available, less invasive monitoring such as
el.53 The sequential CSE technique theoretically combines bedside transthoracic echocardiography can be used for
the greater block reliability, symmetry, and consistency of cardiac function and output assessment.
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intrathecal local anesthesia with the more gradual-onset Focused cardiac ultrasound can be performed at the
sympathectomy of epidural local anesthesia. bedside to assist in treatment of the cardio-obstetric
At the time of the surgical block placement, it is rea- patient. It is a safe modality that can provide expe-
sonable to minimize the crystalloid fluid coload in patients dited answers to many clinical questions.62 The use of
at risk for pulmonary edema. It may also be beneficial focused cardiac ultrasound is associated with a sig-
to initiate the titration of a prophylactic vasopressor to nificant reduction in time to diagnosis and treatment.63
maintain systemic vascular resistance and blood pres- In the obstetric patient, cardiac ultrasound can assess
sure at maternal baseline so as to maintain coronary (1) volume status to help guide fluid administration or
perfusion regardless of the neuraxial technique used to diuresis, (2) left and right ventricular global function, (3)
achieve adequate anesthesia.54–56 For example, phenyl- regional wall abnormalities, (4) pericardial effusions,
ephrine (eg, starting titration at 0.5–0.75 µg∙kg−1∙min−1) (5) valvular status (regurgitation or stenosis), and (6)
or norepinephrine (eg, starting titration at 0.05–0.075 changes in the proximal ascending aorta. In the obstet-
µg∙kg−1∙min−1) infusion can be initiated through a periph- ric patient, the gravid uterus displaces the heart later-
eral intravenous line on completion of the neuraxial block ally and upward in the chest such that the parasternal
and titrated to maintain a heart rate >60 bpm and a views are relatively easy to obtain. The apical views can
mean arterial pressure near baseline.57,58 also generally be obtained easily in pregnant patients,
whereas the subcostal views may be more challeng-
ing. Transesophageal echocardiography may be useful
ACCESS, MONITORING, AND in the care of the patient under general endotracheal
ECHOCARDIOGRAPHY anesthesia if transthoracic imaging is not adequate.
Monitoring during a cesarean delivery includes standard
American Society of Anesthesiology monitors and often EXTRACORPOREAL MEMBRANE
intra-arterial blood pressure monitoring.59 The beat-to-
beat blood pressure measurements assist in titration of OXYGENATION
vasopressors (phenylephrine, norepinephrine, or ephed- ECMO is an important last line of support for acute
rine) during induction of a neuraxial or general anesthet- respiratory failure, ventricular failure, or cardiovascular
ic. Maternal heart rate and systemic arterial pressures decompensation. ECMO circuits consist of a venous

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 Meng et al Anesthetic Care of the Pregnant Patient With CVD

drainage cannula, usually inserted peripherally, a cen- cardio-obstetrics team must consider the side effects

CLINICAL STATEMENTS
trifugal pump, a gas exchanger, and a reinfusion can- of second-line uterotonic agents (eg, carboprost and

AND GUIDELINES
nula inserted either into the jugular or femoral vein for methylergonovine) in the setting of CVD.
venovenous ECMO or into the femoral artery for ve- Carboprost increases pulmonary vascular resistance
noarterial ECMO. Venovenous ECMO may be neces- and pulmonary artery pressures significantly. Carboprost
sary to treat refractory hypoxia, especially in the case has been described as precipitating bronchospasm,
of respiratory failure attributable to viral infections or abnormal ventilation perfusion ratios, increased intrapul-
increased shunting. Venoarterial ECMO effectively monary shunt fraction, hypoxemia, and death.71–74 Methy-
offloads the right ventricle and is ideal for supporting lergonovine causes vascular smooth muscle contraction
patients with acutely worsened pulmonary hypertension and increases systemic vascular resistance.75 In a large
or patients with severely reduced ventricular function retrospective cohort of all women (not specifically those
refractory to medical management. If the use of ECMO with CVD), methylergonovine did not appear to cause
is anticipated, a perfusionist and surgeon should be myocardial ischemia and was associated with reduced risk
notified so that they can be available. The insertion of of hemorrhage-related morbidity.75,76 Therefore, some may
small placeholder sheaths (5F) in the femoral vein and argue that in the setting of hemorrhage, especially with
artery before any procedures can facilitate rapid can- limited resources, contraindications to uterotonic drugs
nulation for ECMO. may be considered relative. Misoprostol is generally con-
Previously reported cases of successful resuscita- sidered to have few cardiovascular side effects, although it
tion with ECMO after peripartum cardiac arrest indicate is considered less therapeutically effective compared with
that deployment of an ECMO team, if available, early in oxytocin, methylergonovine, and carboprost.77
a maternal cardiac arrest can be lifesaving.64 In reported Because of the systemic side effects of uterotonics,
cases of maternal arrest when ECMO was used, 87.7% there should be early consideration of obstetric maneu-
of resuscitations were successful compared with vers in addition to medical uterotonics such as uterine
only 58.9% resuscitation success across all maternal massage, prompt surgical management, uterine compres-
arrests when ECMO may not have been used.64,65 In a sion sutures, and Bakri balloon placement. Rectal miso-
systematic review of ECMO use in pregnancy, the most prostol may be placed prophylactically after delivery. In the
common antepartum indications for ECMO were adult setting of massive hemorrhage, large-volume transfusion
respiratory distress syndrome (65.4%), cardiac fail- may be required, and point-of-care cardiac ultrasound
ure (9.9%), and pulmonary hypertension (8.6%). The may be particularly useful in these cases for volume and
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immediate postpartum indications (within 24 hours of myocardial function assessment. Early evaluation for and
delivery) were cardiac arrest (56.6%), cardiac failure use of venoarterial ECMO may be lifesaving in cases of
(23.2%), and amniotic fluid embolism (21.7%). Indica- massive hemorrhage in patients with severe or decom-
tions for ECMO >24 hours after delivery but within 42 pensated cardiac disease or can be used if myocardial
days of delivery included adult respiratory distress syn- failure results from hypovolemic arrest while the team is
drome (39.7%), peripartum cardiomyopathy (25.4%), providing fluid and appropriate transfusion resuscitation.
and cardiac failure (19%).64 According to the World Health Organization, in addi-
tion to standard care, tranexamic acid (TXA), an antifibri-
nolytic agent, may be considered in the early treatment
(within 3 hours of birth) of postpartum hemorrhage
POSTPARTUM HEMORRHAGE
after delivery by either vaginal birth or cesarean deliv-
PREVENTION AND MANAGEMENT ery when initial medical therapy fails. TXA should be
Patients with heart disease are at increased risk for avoided in patients with a known contraindication to
postpartum hemorrhage.66,67 Hemorrhagic shock in the antifibrinolytic therapy such as thromboembolic disease
setting of CVD may initiate rapid hemodynamic dete- during pregnancy.78 The WOMAN trial (World Maternal
rioration. Therefore, early active management of the Antifibrinolytic), an international, randomized, double-
third stage of labor and prevention of uterine atony blind, placebo-controlled trial of 20 060 women with
and hemorrhage are essential. In patients with CVD postpartum hemorrhage, showed a reduction in death
undergoing cesarean delivery, prophylactic oxytocin attributable to bleeding in women treated with TXA and
should be titrated with an infusion pump immediately demonstrated no significant increase in thromboembolic
after delivery. Bolus dosing or overdosing can rapidly events (pulmonary embolism, deep vein thrombosis,
decrease systemic vascular resistance.68 Doses of myocardial infarction, and stroke) compared with pla-
oxytocin greater than the ED95 (16.2 IU/h in nonla- cebo.79 Randomized trial data on the use of TXA in those
boring patients undergoing cesarean section and 44.2 with coronary stents or after cardiac arrest are lacking;
IU/h in laboring patients undergoing cesarean deliv- however, there are case reports in nonobstetric patients
ery) generally do not provide improved uterine tone of stent thrombosis with TXA use.80 TXA should be used
and increase the incidence of side effects.69,70 The with caution in the presence of coronary stents.

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 Meng et al Anesthetic Care of the Pregnant Patient With CVD

SPECIAL MEDICATION CONSIDERATIONS but can be achieved through proper evaluation

CLINICAL STATEMENTS

(Table 6). The American College of Obstetricians and

Many obstetric medications have cardiovascular con-
AND GUIDELINES

Gynecologists and the California Maternal Quality

sequences. Magnesium sulfate can lead to hypotension.
Care Collaborative recommend prompt evaluation for
Terbutaline causes tachycardia and increases myocar-
any pregnant patient with a heart rate ≥120 bpm, oxy-
dial contractility. Oxytocin decreases systemic vascular
gen saturation ≤95%, respiratory rate ≥25 breaths/
­resistance.68
min, systolic blood pressure ≥160 mm Hg, and short-
ness of breath at rest or with minimal exertion.4
RECOVERY CARE 2. Arrhythmia: Arrhythmia may be the initial presenta-
tion of cardiac disease in pregnancy or a complica-
The postpartum period, specifically the first 24 to 48
tion that develops as a result of atrial stretch from
hours after delivery, is associated with significant hemo-
the increased circulating blood volume of pregnancy.
dynamic changes and fluid shifts, which may precipitate
Most arrhythmias in pregnancy are asymptomatic or
heart failure and arrhythmias.18 However, in women at
benign, do not lead to hemodynamic instability, and
high risk of maternal cardiovascular decompensation,
do not require treatment. The most common arrhyth-
no formal guidelines suggest the appropriate duration
mias in pregnancy are premature atrial beats, prema-
of intensive care unit stay or monitored observation after
ture ventricular beats, sinus tachycardia, and sinus
delivery. Therefore, the level of postpartum care should
arrhythmia.82 Rarely, arrhythmias lead to hemody-
be individualized to the patient’s current clinical status, in-
namic compromise, requiring either pharmacological
corporating the unique monitoring and therapeutic needs
or electric urgent intervention.82 Because of terato-
and the ability to provide these resources in the current
genic effects during the first trimester, many antiar-
setting. Staffing models, physical design of the unit, ex-
rhythmic medications are not recommended during
perience, and access should be considered in the cre-
pregnancy. Metoprolol, propranolol, sotalol, verapamil,
ation of care and recovery plans. The unit location and
procainamide, flecainide, propafenone, and digoxin
nursing staff (obstetric, critical care obstetric, or intensive
are generally safe and well tolerated in pregnant
care nurses) for postpartum patients with cardiac disease
patients.82 If hemodynamically stable supraventricu-
should be selected according to the type and severity of
lar tachycardia cannot be treated conservatively
CVD, the obstetric and cardiopulmonary clinical acuity, and
with vagal maneuvers (carotid sinus massage and
the advanced cardiac monitoring requirements unique to
Valsalva maneuver), intravenous adenosine is safe in
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each patient. The immediate postpartum recovery period

pregnancy,82 as is electric cardioversion.16,82,83 Fetal
should include frequent assessment of the breasts for
monitoring is suggested before and after cardiover-
symmetry, redness, engorgement, and pain; the uterus for
sion because there is a small risk of fetal arrhythmia.
placement and tone; the bladder for distention; the bowel
Unstable sustained ventricular tachycardia should be
for sounds of intestinal motility; lochia for amount, clots,
immediately treated with electric cardioversion.16,82
color, and odor; lacerations or episiotomy for signs of in-
3. Maternal cardiac arrest: Maternal cardiac arrest
flammation or infection; the lower extremities for signs
occurs in 1 in 12 000 delivery hospitalizations or
of thrombophlebitis, including swelling, redness, and pain;
8.5 per 100 000 deliveries.65 Maternal CVD is the
and emotions or signs of postpartum mood disorders.
second leading cause of maternal arrest in the
Continuous bedside nursing care with ready access
United States. The top 4 causes include hemor-
to obstetric anesthesia, maternal fetal medicine, and car-
rhage (38.1%), heart failure or myocardial infarc-
diac teams should be available. Intensive care units can
tion (15.2%), amniotic fluid embolism (13.3%), and
be used for skill of nursing and frequency of monitor-
sepsis (11.2%).65 In the event of a maternal car-
ing in patients who are at the highest risk of postpartum
diac arrest, the anesthesiologist has multiple roles
complications such as arrhythmias and heart failure.18
as code team leader and is a critical resource for
Patients who recover off the labor and delivery unit must
performing code tasks.65,84 Hence, it is essential to
have the usual frequency of examinations by obstetri-
highlight here the cautionary statement from the
cians and obstetric nurses to ensure adequate uterine
“Society for Obstetric Anesthesia and Perinatology
tone and minimal postpartum bleeding.
Consensus Statement on the Management of
Cardiac Arrest in Pregnancy”: “The code leader
should not be task saturated, and should be able
SPECIAL SITUATIONS to direct interventions, communicate effectively,
1. Urgent evaluation: Several initiatives exist to help cli- and periodically reassess management goals and
nicians identify early warning signs of undiagnosed outcomes.”84 A comprehensive review of the care
or new-onset CVD in pregnancy.4 Distinguishing required during a maternal arrest is beyond the
between signs and symptoms of normal pregnancy scope of this scientific statement. Updated algo-
and those of heart disease can be challenging rithms are available and should be used at the time

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 Meng et al Anesthetic Care of the Pregnant Patient With CVD

Table 6. How to Differentiate Common Signs and Symptoms of Normal Pregnancy From Those That Are Abnormal and
Indicative of Underlying Cardiac Disease

CLINICAL STATEMENTS
AND GUIDELINES
Routine care Caution*† Stop†‡

Reassurance Nonemergency evaluation Prompt evaluation by pregnancy heart team

History of CVD None None Yes
Self-reported symptoms None or mild Yes Yes
Shortness of breath No interference with activates of With moderate exertion, new- At rest; paroxysmal nocturnal dyspnea or
daily living; with heavy exertion only onset asthma, persistent cough, orthopnea; bilateral chest infiltrates on CXR
or moderate or severe OSA§ or refractory pneumonia
Chest pain Reflux related that resolves with Atypical At rest of with minimal exertion
treatment
Palpitations Few seconds, self-limited Brief, self-limited episodes; no Associated with near syncope
light-headedness or syncope
Syncope Dizziness only with prolonged Vasovagal Exertional or unprovoked
standing or dehydration
Vital signs Normal
HR, bpm <90 90–119 ≥120
Systolic BP, mm Hg 120–139 140–159 ≥160 (or symptomatic low BP)
RR, breaths per min 12–15 16–25 ≥25
Oxygen saturation, % >97 95–97 <95 (unless chronic)
Physical examination Normal
JVP Not visible Not visible Visible >2 cm above clavicle
Heart S3, barely audible soft systolic murmur S3, systolic murmur Loud systolic murmur, diastolic murmur, S4
Lungs Clear Clear Wheezing, crackles, effusion
Edema Mild Moderate Marked

BP indicates blood pressure; CVD, cardiovascular disease; CXR, chest x-ray; HR, heart rate; JVP, jugular venous pressure; OSA, obstructive sleep apnea; and
RR, respiratory rate.
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*If unclear, any combination of factors in the Caution column that add up to ≥4 should prompt further evaluation.
†Data in this column are from Hameed et al.81
‡History of CVD or signs and symptoms in the Stop column should lead to urgent evaluation by the pregnancy heart team.
§Should raise concern about heart failure and should promptly be evaluated.
Reprinted with permission from ACOG Practice Bulletin No. 212,4 copyright © 2019 by the American College of Obstetricians and Gynecologists, published by
Wolters Kluwer Health, Inc; adapted from Thorne et al,15 copyright © 2006 BMJ Publishing Group Ltd.

of arrest to ensure that all steps are performed greater).84,85,87 If available, we encourage the early
rapidly with consideration given to the changes in use of venoarterial ECMO and transesophageal
cardiopulmonary resuscitation and differential diag- echocardiography when indicated in the setting of
nosis of arrest cause in the obstetric patient.84–86 maternal arrest.64
Briefly, cardiopulmonary resuscitation should be
performed as usual with similar compression ven-
tilation ratios, application of backboard, airway SPECIFIC DISEASE CONSIDERATIONS
support, medications, dosages, and defibrillation CVDs that affect pregnancy encompass a diverse group
as necessary.84,85 Key differences in the pregnant of unique diagnoses that result in distinct maternal he-
patient include preparations for fetal delivery par- modynamic changes superimposed on the dynamic
allel to the maternal resuscitative efforts, applica- variations expected throughout pregnancy and labor
tion of left lateral uterine displacement, avoidance and delivery. In short, no 2 cardiac disease states look
of nasal airways, placement of intravenous access the same in a pregnant woman. Common CVD states
above the diaphragm, and need for neonatology and the hemodynamic impact on the pregnant patient
team for fetal resuscitation and surgical or obstet- should be considered in the creation of the anesthesiol-
ric team to perform perimortem cesarean deliv- ogy plan. Table 4 highlights many of the unique maternal
ery.84,85 A perimortem cesarean delivery (also called CVD states. However, the heterogeneity contained within
a resuscitative hysterotomy) should be performed should underscore the importance of an individualized
at the site of maternal cardiac arrest within 4 to approach that relies on the assessment of each patient’s
5 minutes should there be no return of spontane- underlying CVD and current hemodynamic status when
ous circulation in which the uterus extends to or plans are made for pregnancy, labor, delivery, and post-
above the umbilicus (≈20 weeks of gestation or partum.

Circulation. 2023;147:00–00. DOI: 10.1161/CIR.0000000000001121 TBD TBD, 2023 e13

 Meng et al Anesthetic Care of the Pregnant Patient With CVD

FUTURE DIRECTIONS pregnancy heart team because they not only provide im-
CLINICAL STATEMENTS

proved recognition of patients at high cardiovascular risk

Many questions remain unanswered about the optimal
AND GUIDELINES

but also contribute to the formulation and delivery of safe

care of the cardio-obstetric patient. Research from mul-
peripartum care. Standardization of the anesthetic care
ticenter registries from pregnancy heart teams or na-
for pregnant women with high-risk CVD is essential as
tional and international data sets may be able to address
we aim to reduce and respond effectively to adverse ma-
specific intrapartum management by disease type such
ternal cardiovascular, fetal, and obstetric events.
as timing of delivery, prophylactic inotrope use, optimal
anesthesia technique, which patients benefit from the
resource of ECMO on standby, and improved risk pre- ARTICLE INFORMATION
diction for acute decompensation postpartum. The as- The American Heart Association makes every effort to avoid any actual or poten-
sessment of New York Heart Association functional tial conflicts of interest that may arise as a result of an outside relationship or a
class in pregnancy is challenging because the signs and personal, professional, or business interest of a member of the writing panel. Spe-
cifically, all members of the writing group are required to complete and submit a
symptoms of heart failure overlap with normal pregnancy Disclosure Questionnaire showing all such relationships that might be perceived
symptoms. Research to optimize the New York Heart As- as real or potential conflicts of interest.
sociation classification for pregnant patients could help This statement was approved by the American Heart Association Science
Advisory and Coordinating Committee on August 4, 2022, and the American
in appropriate triage and treatment. Training of current Heart Association Executive Committee on October 10, 2022. A copy of the
and future anesthesiologists in the treatment of cardio- document is available at https://professional.heart.org/statements by using
obstetric patients can be incorporated into residency and either “Search for Guidelines & Statements” or the “Browse by Topic” area. To
purchase additional reprints, call 215-356-2721 or email Meredith.Edelman@
fellowship training, and a new cardio-obstetric fellowship wolterskluwer.com.
pathway could be created that combines a 1-year fel- The American Heart Association requests that this document be cited as
lowship in obstetric anesthesia and a 1-year fellowship follows: Meng ML, Arendt KW, Banayan JM, Bradley EA, Vaught AJ, Hameed
AB, Harris J, Bryner B, Mehta LS; on behalf of the American Heart Association
in cardiothoracic anesthesia. Point-of-care cardiac ultra- Council on Cardiovascular Surgery and Anesthesia; Council on Cardiopulmo-
sound is now recognized as an anesthesiology residency nary, Critical Care, Perioperative and Resuscitation; and Council on Peripheral
core competency, so faculty training residents and all fu- Vascular Disease. Anesthetic care of the pregnant patient with cardiovascular
disease: a scientific statement from the American Heart Association. Circulation.
ture graduating anesthesiologists will soon have this skill 2023;147:e•••–e•••. doi: 10.1161/CIR.0000000000001121
for periobstetric care. The expert peer review of AHA-commissioned documents (eg, scientific
statements, clinical practice guidelines, systematic reviews) is conducted by the
AHA Office of Science Operations. For more on AHA statements and guidelines
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development, visit https://professional.heart.org/statements. Select the “Guide-

CONCLUSIONS lines & Statements” drop-down menu, then click “Publication Development.”
Permissions: Permissions: Multiple copies, modification, alteration, enhance-
The American Heart Association is committed to im- ment, and distribution of this document are not permitted without the express
proving maternal care before, during, and after delivery. permission of the American Heart Association. Instructions for obtaining permis-
sion are located at https://www.heart.org/permissions. A link to the “Copyright
The leading cause of maternal morbidity and mortality Permissions Request Form” appears in the second paragraph (https://www.heart.
is CVD.1,88 Anesthesiologists are an integral part of the org/en/about-us/statements-and-policies/copyright-request-form).

Disclosures
Writing Group Disclosures

Other Speakers’ Consultant/

Writing group Research research bureau/ Expert Ownership advisory
member Employment grant support honoraria witness interest board Other
Marie-Louise Meng Duke University Medical Center None None None None None None None
Laxmi S. Mehta The Ohio State University None None None None None None None
Katherine W. Arendt Self-employed, Mayo Clinic None None None None None None None
Jennifer M. Banayan Northwestern University None None None None None None None
Elisa A. Bradley Pennsylvania State University None None None None None None None
Benjamin Bryner Duke University Medical Center None None None None None None None
Afshan B. Hameed Self-employed, University of California, None None None None None None None
Irvine Medical Center
Jade Harris Morgan Stanley Children’s Hospital of New None None None None None None None
York Presbyterian, Columbia University
Arthur J. Vaught Johns Hopkins University None None None None None None None

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclo-
sure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives
$5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or
owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.

e14 TBD TBD, 2023 Circulation. 2023;147:00–00. DOI: 10.1161/CIR.0000000000001121

 Meng et al Anesthetic Care of the Pregnant Patient With CVD

Reviewer Disclosures

CLINICAL STATEMENTS
Other Speakers’ Consultant/

AND GUIDELINES
Research research bureau/ Expert Ownership advisory
Reviewer Employment grant support honoraria witness interest board Other
Joan Briller University of Illinois at Chicago None none None None None None None
Yunwei Chen Washington University in St. Louis None None None None None None None
Carlos Delgado University of Washington None None None None None None None
Audrey Merriam Yale University None None None None None None None
Sajid Shahul University of Chicago None None None None None None None

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more dur-
ing any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000
or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.

ease) of the European Society of Cardiology EURObservational Research

Programme. J Am Heart Assoc. 2021;10:e018176. doi: 10.1161/JAHA.
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