Obstetric Anesthesia

  • Masataka KameiEmail author


Despite advances in anesthetic and obstetric care, cardiovascular disease in pregnancy continues to cause significant rates of morbidity and mortality in obstetric surgery. As a growing population of adults with congenital heart disease reaches childbearing age, the incidence of cardiovascular disease in pregnancy has been dramatically increasing. As a result, anesthesiologists are also increasingly faced with managing cesarean sections in patients with pre-existing cardiovascular disease. Cesarean delivery is inherently one of the most challenging surgeries for such patients. This chapter focuses on perioperative anesthetic management for cesarean section in this population. The major anesthetic goal is to achieve a multidisciplinary-based optimization of maternal hemodynamics to improve outcomes for the two patients, mother and baby. There is unfortunately no definitive evidence to guide anesthesiologists on how to best manage cesarean patients with cardiovascular disease. Consequently, the author’s recommended approach described herein is primarily based on physiological principles, as well as on personal experience. Therefore, a thorough understanding of the pathophysiology, available options for anesthesia, and potential complications is crucial if today’s anesthesiologist is to optimize hemodynamics in mothers with cardiovascular disease who are undergoing cesarean section.


Anesthesia Cesarean section Cardiovascular disease 


  1. 1.
    European Society of Gynecology (ESG), Association for European Pediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM) et al (2011) ESC Guidelines on the management of cardiovascular diseases during pregnancy: the task force on the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). Eur Heart J 32:3147–3197CrossRefGoogle Scholar
  2. 2.
    Elkayam U, Goland S, Pieper PG et al (2016) High-risk cardiac disease in pregnancy: Part I. J Am Coll Cardiol 68:396–410PubMedCrossRefGoogle Scholar
  3. 3.
    Siu SC, Sermer M, Colman JM et al (2001) Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 104:515–521PubMedCrossRefGoogle Scholar
  4. 4.
    Khairy P, Ouyang DW, Fernandes SM et al (2006) Pregnancy outcomes in women with congenital heart disease. Circulation 113:517–524PubMedCrossRefGoogle Scholar
  5. 5.
    Hilfiker-Kleiner D, Haghikia A, Nonhoff J et al (2015) Peripartum cardiomyopathy: current management and future perspectives. Eur Heart J 36:1090–1097PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Meschia G (2011) Fetal oxygenation and maternal ventilation. Clin Chest Med 32:15–19PubMedCrossRefGoogle Scholar
  7. 7.
    Zeeman GG, Hatab M, Twickler DM (2003) Maternal cerebral blood flow changes in pregnancy. Am J Obstet Gynecol 189:968–972PubMedCrossRefGoogle Scholar
  8. 8.
    Nevo O, Soustiel JF, Thaler I (2010) Maternal cerebral blood flow during normal pregnancy: a cross-sectional study. Am J Obstet Gynecol 203:475.e1–475.e6CrossRefGoogle Scholar
  9. 9.
    Ikeda T, Ikenoue T, Mori N et al (1993) Effect of early pregnancy on maternal regional cerebral blood flow. Am J Obstet Gynecol 168:1303–1308PubMedCrossRefGoogle Scholar
  10. 10.
    Lapinsky SE, Kruczynski K, Slutsky AS (1995) Critical care in the pregnant patient. Am J Respir Crit Care Med 152:427–455PubMedCrossRefGoogle Scholar
  11. 11.
    Campbell LA, Klocke RA (2001) Implications for the pregnant patient. Am J Respir Crit Care Med 163:1051–1054PubMedCrossRefGoogle Scholar
  12. 12.
    Grindheim G, Toska K, Estensen ME et al (2012) Changes in pulmonary function during pregnancy: a longitudinal cohort study. BJOG 119:94–101PubMedCrossRefGoogle Scholar
  13. 13.
    McAuliffe F, Kametas N, Costello J et al (2002) Respiratory function in singleton and twin pregnancy. BJOG 109:765–769PubMedCrossRefGoogle Scholar
  14. 14.
    Hegewald MJ, Crapo RO (2011) Respiratory physiology in pregnancy. Clin Chest Med 32:1–13PubMedCrossRefGoogle Scholar
  15. 15.
    Douglas MJ (2001) Platelets, the parturient and regional anesthesia. Int J Obstet Anesth 10:113–120CrossRefGoogle Scholar
  16. 16.
    Lapinsky SE, Posadas-Calleja JG, McCullagh I (2009) Clinical review: Ventilatory strategies for obstetric, brain-injured and obese patients. Crit Care 13:206PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Fraser D, Jensen D, Wolfe LA (2008) Fetal heart rate response to maternal hypocapnia and hypercapnia in late gestation. J Obstet Gynaecol Can 30:312–316PubMedCrossRefGoogle Scholar
  18. 18.
    Reitman E, Flood P (2011) Anaesthetic considerations for non-obstetric surgery during pregnancy. Br J Anaesth 107(Suppl 1):i72–i78PubMedCrossRefGoogle Scholar
  19. 19.
    Ivankovic AD, Elam JO, Huffman J (1970) Effect of maternal hypercarbia on the newborn infant. Am J Obstet Gynecol 107:939–946PubMedCrossRefGoogle Scholar
  20. 20.
    Polvi HJ, Pirhonen JP, Erkkola RU (1995) The hemodynamic effects of maternal hypo- and hyperoxygenation in healthy term pregnancies. Obstet Gynecol 86:795–799PubMedCrossRefGoogle Scholar
  21. 21.
    Maxwell BG, El-Sayed YY, Riley ET et al (2013) Peripartum outcomes and anaesthetic management of parturients with moderate to complex congenital heart disease or pulmonary hypertension. Anaesthesia 68:52–59PubMedCrossRefGoogle Scholar
  22. 22.
    Langesaeter E, Dragsund M, Rosseland LA (2010) Regional anaesthesia for a caesarean section in women with cardiac disease: a prospective study. Acta Anaesthesiol Scand 54:46–54PubMedCrossRefGoogle Scholar
  23. 23.
    Ioscovich AM, Goldszmidt E, Fadeev AV et al (2009) Peripartum anesthetic management of patients with aortic valve stenosis: a retrospective study and literature review. Int J Obstet Anesth 18:379–386PubMedCrossRefGoogle Scholar
  24. 24.
    Weiss BM, Zemp L, Seifert B et al (1998) Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996. J Am Coll Cardiol 31:1650–1657PubMedCrossRefGoogle Scholar
  25. 25.
    Lewis NL, Dob DP, Yentis SM (2003) UK registry of high-risk obstetric anaesthesia: arrhythmias, cardiomyopathy, aortic stenosis, transposition of the great arteries and Marfan’s syndrome. Int J Obstet Anesth 12:28–34PubMedCrossRefGoogle Scholar
  26. 26.
    Ngan Kee WD (2010) Prevention of maternal hypotension after regional anaesthesia for caesarean section. Curr Opin Anaesthesiol 23:304–309PubMedCrossRefGoogle Scholar
  27. 27.
    Mercier FJ (2011) Fluid loading for cesarean delivery under spinal anesthesia: have we studied all the options? Anesth Analg 113:677–680PubMedCrossRefGoogle Scholar
  28. 28.
    Maayan-Metzger A, Schushan-Eisen I, Todris L et al (2010) Maternal hypotension during elective cesarean section and short-term neonatal outcome. Am J Obstet Gynecol 202:56.e1–56.e5CrossRefGoogle Scholar
  29. 29.
    Laudenbach V, Mercier FJ, Rozé JC et al (2009) Anaesthesia mode for caesarean section and mortality in very preterm infants: an epidemiologic study in the EPIPAGE cohort. Int J Obstet Anesth 18:142–149PubMedCrossRefGoogle Scholar
  30. 30.
    Moore SA, Dietl CA, Coleman DM (2016) Extracorporeal life support during pregnancy. J Thorac Cardiovasc Surg 151:1154–1160PubMedCrossRefGoogle Scholar
  31. 31.
    Ng K, Parsons J, Cyna AM et al (2004) Spinal versus epidural anaesthesia for caesarean section. Cochrane Database Syst Rev 2:CD003765Google Scholar
  32. 32.
    Kasaba T, Onizuka S, Takasaki M (2003) Procaine and mepivacaine have less toxicity in vitro than other clinically used local anesthetics. Anesth Analg 97:85–90PubMedCrossRefGoogle Scholar
  33. 33.
    Hamlyn EL, Douglass CA, Plaat F et al (2005) Low-dose sequential combined spinal-epidural: an anaesthetic technique for Caesarean section in patients with significant cardiac disease. Int J Obstet Anesth 14:355–361PubMedCrossRefGoogle Scholar
  34. 34.
    Roofthooft E, Van de Velde M (2008) Low-dose spinal anaesthesia for Caesarean section to prevent spinal-induced hypotension. Curr Opin Anaesthesiol 21:259–262PubMedCrossRefGoogle Scholar
  35. 35.
    Arzola C, Wieczorek PM (2011) Efficacy of low-dose bupivacaine in spinal anaesthesia for Caesarean delivery: systematic review and meta-analysis. Br J Anaesth 107:308–318PubMedCrossRefGoogle Scholar
  36. 36.
    Baghirzada L, Krings T, Carvalho JC (2012) Regional anesthesia in Marfan syndrome, not all dural ectasias are the same: a report of two cases. Can J Anaesth 59:1052–1057PubMedCrossRefGoogle Scholar
  37. 37.
    Henke VG, Bateman BT, Leffert LR (2013) Spinal anesthesia in severe preeclampsia. Anesth Analg 117:686–693PubMedCrossRefGoogle Scholar
  38. 38.
    Estcourt LJ, Ingram C, Doree C et al (2016) Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia. Cochrane Database Syst Rev 24:CD011980Google Scholar
  39. 39.
    Norfolk DR, Ancliffe PJ, Contreras M et al (1998) Consensus Conference on Platelet Transfusion, Royal College of Physicians of Edinburgh, 27-28 November 1997. Synopsis of background papers. Br J Haematol 101:609–617PubMedCrossRefGoogle Scholar
  40. 40.
    Stainsby D, MacLennan S, Hamilton PJ (2000) Management of massive blood loss: a template guideline. Br J Anaesth 85:487–491PubMedCrossRefGoogle Scholar
  41. 41.
    Samama CM, Djoudi R, Lecompte T et al (2005) Perioperative platelet transfusion: recommendations of the Agence Française de Sécurité Sanitaire des Produits de Santé (AFSSaPS) 2003. Can J Anaesth 52:30–37PubMedCrossRefGoogle Scholar
  42. 42.
    Horlocker TT, Wedel DJ, Rowlingson JC et al (2010) Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 35:64–101PubMedCrossRefGoogle Scholar
  43. 43.
    Kinsella SM (2008) A prospective audit of regional anaesthesia failure in 5080 Caesarean sections. Anaesthesia 63:822–832PubMedCrossRefGoogle Scholar
  44. 44.
    Bloom SL, Spong CY, Weiner SJ et al (2005) Complications of anesthesia for cesarean delivery. Obstet Gynecol 106:281–287PubMedCrossRefGoogle Scholar
  45. 45.
    Sun L (2010) Early childhood general anaesthesia exposure and neurocognitive development. Br J Anaesth 105(Suppl 1):i61–i68PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Sun LS, Li G, Miller TL et al (2016) Association between a single general anesthesia exposure before age 36 months and neurocognitive outcomes in later childhood. JAMA 315:2312–2320PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Afolabi BB, Lesi FE (2012) Regional versus general anaesthesia for Caesarean section. Cochrane Database Syst Rev 10:CD004350PubMedGoogle Scholar
  48. 48.
    Kan RE, Hughes SC, Rosen MA et al (1998) Intravenous remifentanil: placental transfer, maternal and neonatal effects. Anesthesiology 88:1467–1474PubMedCrossRefGoogle Scholar
  49. 49.
    Neilipovitz DT, Crosby ET (2007) No evidence for decreased incidence of aspiration after rapid sequence induction. Can J Anaesth 54:748–764PubMedCrossRefGoogle Scholar
  50. 50.
    Algie CM, Mahar RK, Tan HB et al (2015) Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. Cochrane Database Syst Rev 11:CD011656Google Scholar
  51. 51.
    Dean G, Jacobs AR, Goldstein RC et al (2011) The safety of deep sedation without intubation for abortion in the outpatient setting. J Clin Anesth 23:437–442PubMedCrossRefGoogle Scholar
  52. 52.
    Wagner CE, Bick JS, Johnson D et al (2014) Etomidate use and postoperative outcomes among cardiac surgery patients. Anesthesiology 120:579–589PubMedPubMedCentralCrossRefGoogle Scholar
  53. 53.
    Suehiro K, Okutani R (2011) Landiolol attenuates cardiovascular response at induction of general anesthesia for cesarean delivery. J Anesth 26:200–205PubMedCrossRefGoogle Scholar
  54. 54.
    Sugiura S, Seki S, Hidaka K et al (2007) The hemodynamic effects of landiolol, an ultra-short-acting beta1-selective blocker, on endotracheal intubation in patients with and without hypertension. Anesth Analg 104:124–129PubMedCrossRefGoogle Scholar
  55. 55.
    McKeen DM, George RB, O’Connell CM et al (2011) Difficult and failed intubation: incident rates and maternal, obstetrical, and anesthetic predictors. Can J Anaesth 58:514–524PubMedCrossRefGoogle Scholar
  56. 56.
    Shiga T, Wajima Z, Inoue T et al (2005) Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology 103:429–437PubMedCrossRefGoogle Scholar
  57. 57.
    Djabatey EA, Barclay PM (2009) Difficult and failed intubation in 3430 obstetric general anaesthetics. Aaesthesia 64:1168–1171CrossRefGoogle Scholar
  58. 58.
    Kinsella SM, Winton AL, Mushambi MC et al (2015) Failed tracheal intubation during obstetric general anaesthesia: a literature review. Int J Obstet Anesth 24:356–374PubMedCrossRefGoogle Scholar
  59. 59.
    Enriquez AD, Economy KE, Tedrow UB (2014) Contemporary management of arrhythmias during pregnancy. Circ Arrhythm Electrophysiol 7:961–967PubMedCrossRefGoogle Scholar
  60. 60.
    Jeejeebhoy FM, Zelop CM, Lipman S et al (2015) Cardiac arrest in pregnancy: a scientific statement from the American Heart Association. Circulation 132:1747–1773PubMedCrossRefGoogle Scholar
  61. 61.
    McLaughlin VV, Shah SJ, Souza R et al (2015) Management of pulmonary arterial hypertension. J Am Coll Cardiol 65:1976–1997PubMedCrossRefGoogle Scholar
  62. 62.
    Bédard E, Dimopoulos K, Gatzoulis MA (2009) Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension? Eur Heart J 30:256–265PubMedCrossRefGoogle Scholar
  63. 63.
    Jaïs X, Olsson KM, Barbera JA (2012) Pregnancy outcomes in pulmonary arterial hypertension in the modern management era. Eur Respir J 40:881–885PubMedCrossRefGoogle Scholar
  64. 64.
    Naeije R, Manes A (2014) The right ventricle in pulmonary arterial hypertension. Eur Respir Rev 23:476–448PubMedCrossRefGoogle Scholar
  65. 65.
    Swedberg K, Young JB, Anand IS et al (2013) Treatment of anemia with darbepoetin alfa in systolic heart failure. N Engl J Med 368:1210–1219PubMedCrossRefGoogle Scholar
  66. 66.
    Rex S, Missant C, Segers P et al (2007) Thoracic epidural anesthesia impairs the hemodynamic response to acute pulmonary hypertension by deteriorating right ventricular-pulmonary arterial coupling. Crit Care Med 35:222–229PubMedCrossRefGoogle Scholar
  67. 67.
    Brickner ME (2014) Cardiovascular management in pregnancy: congenital heart disease. Circulation 130:273–282PubMedCrossRefGoogle Scholar
  68. 68.
    d’Udekem Y, Iyengar AJ, Galati JC et al (2014) Redefining expectations of long-term survival after the Fontan procedure: twenty-five years of follow-up from the entire population of Australia and New Zealand. Circulation 130:S32–S38PubMedCrossRefGoogle Scholar
  69. 69.
    Emani SM, del Nido PJ (2013) Strategies to maintain biventricular circulation in patients with high-risk anatomy. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 16:37–42PubMedCrossRefGoogle Scholar
  70. 70.
    Rajagopalan S, Nwazota N, Chandrasekhar S (2014) Outcomes in pregnant women with acute aortic dissections: a review of the literature from 2003 to 2013. Int J Obstet Anesth 23:348–356PubMedCrossRefGoogle Scholar
  71. 71.
    John AS, Gurley F, Schaff HV et al (2011) Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 91:1191–1196PubMedCrossRefGoogle Scholar
  72. 72.
    Chandrasekhar S, Cook CR, Collard CD (2009) Cardiac surgery in the parturient. Anesth Analg 108:777–785PubMedCrossRefGoogle Scholar
  73. 73.
    Mhyre JM, Tsen LC, Einav S et al (2014) Cardiac arrest during hospitalization for delivery in the United States. Anesthesiology 120:810–818PubMedPubMedCentralCrossRefGoogle Scholar
  74. 74.
    Mullens W, Abrahams Z, Francis GS et al (2009) Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol 53:589–596PubMedPubMedCentralCrossRefGoogle Scholar
  75. 75.
    Hanberg JS, Sury K, Wilson FP et al (2016) Reduced cardiac index is not the dominant driver of renal dysfunction in heart failure. J Am Coll Cardiol 67:2199–2208PubMedPubMedCentralCrossRefGoogle Scholar
  76. 76.
    Mishriky BM, George RB, Habib AS (2012) Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth 59:766–778PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Singapore 2019

Authors and Affiliations

  1. 1.Department of Clinical AnesthesiologyMie University Graduate School of MedicineTsu CityJapan

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