Arch Gynecol Obstet
DOI 10.1007/s00404-015-4003-8
GENERAL GYNECOLOGY
Epidural anesthesia for cesarean section for pregnant women
with rheumatic heart disease and mitral stenosis
Wei Wu1 • Qiang Chen2 • Liangcheng Zhang1 • Wenhua Chen1
Received: 28 May 2015 / Accepted: 21 December 2015
Ó Springer-Verlag Berlin Heidelberg 2016
Abstract
Purpose Pregnancy increases stress on the circulation of
parturient with mitral stenosis secondary to rheumatic heart
disease and increases the risk of peripartum heart failure,
especially during delivery. This study investigated the
epidural anesthesia management for cesarean section in
pregnant women with rheumatic heart disease and mitral
stenosis.
Methods 48 parturients with rheumatic heart disease and
mitral stenosis that had cesarean section deliveries with
epidural anesthesia in the Union Hospital, Fujian Medical
University (Fuzhou, China) from Jan 2002 to Dec 2012
were retrospectively analyzed. Heart rate (HR), systolic
arterial pressure (SAP), diastolic arterial pressure (DAP),
mean arterial pressure (MAP), central venous pressure
(CVP), fluid intake volume and fluid output volume (blood
loss ? urine volume) were analyzed.
Results Medication included digitalis drugs for heart
failure or potential heart failure, digoxin and furosemide
for chronic congestive heart failure and beta blockers for
arrhythmia. Frequent premature ventricular contractions
were treated with lidocaine and propafenone. Dexametha-
sone was administered when heart failure occurred during
less than 37 weeks gestation. HR, SAP, DAP, MAP and
W. Wu and Q. Chen contributed equally to this study and share the
first authorship.
& Liangcheng Zhang
wuwei2196@163.com
1 when heart failure occurs. Timely cesarean section is cru-
Department of Anesthesia, Union Hospital, Fujian Medical
University, Fuzhou 350001, People’s Republic of China
2 born [4, 5]. However, the risk of anesthesia during cesarean
Department of Cardiovascular Surgery, Union Hospital,
Fujian Medical University, Fuzhou 350001,
People’s Republic of China
CVP were significantly increased at the time of delivery.
The fluid intake volume was more elevated in the NYHA
III–IV group of parturients than the NYHA I–II group,
while fluid output volume was less. All parturients
survived.
Conclusions Epidural anesthesia was applied success-
fully for cesarean sections for parturients with rheumatic
heart disease and mitral stenosis.
Keywords Pregnancy
Rheumatic heart disease

Epidural anesthesia
Cesarean section
Introduction
It is well known that changes in the cardiovascular system
during pregnancy may increase the burden upon the heart.
The circulating blood volume has increased by an average
of 50 % by late pregnancy and hemodilution, increased
tissue fluid and decreased systemic and uterine vascular
resistance result in an increase in cardiac output and heart
rate (HR) [1, 2]. Mitral stenosis (MS) is the most common
form of rheumatic heart disease (RHD). Pregnant women
with moderate/severe MS are more prone to heart failure
and pulmonary edema than normal pregnant women [3]. It
is vital to prevent a mother’s potential heart failure prior to
delivery. But the risk of MS in pregnancy may not be taken
seriously because of lack of medical knowledge and poor
economic or health conditions, and many women are
diagnosed with MS during mid to late pregnancy or even
cial to ensure the safety of both the mother and the new-
section for pregnant women with RHD and MS is partic-
ularly high. Obstetric anesthesia requires minimal pain,
123

relaxed muscles and avoidance of maternal or fetal circu-
latory and respiratory inhibition. Considerable risks are
involved with general anesthesia including airway
obstruction and if anesthesia is not of adequate depth
severe adverse cardiac side effects can result for both the
mother and the fetus [6]. Epidural anesthesia is the rec-
ommended option because it can expand the peripheral
vasculature, reduce venous return, provide an optimal
analgesic effect, relieve the burden on the heart and prevent
aggravation of heart failure [7].
To confirm the effect of epidural anesthesia in puerperal
women with RHD and MS, this retrospective study ana-
lyzed the anesthetic management during cesarean section
and the clinical results of the pregnant women with RHD
and MS that were admitted to Union Hospital of Fujian
Medical University. Chinese population presents different
characteristics of the parturients from the perspective of
Western or developed countries. RHD is much less com-
mon in developed countries, than in developing countries
but still represents 22 % of valvular heart disease in Europe
[5]. However, in most situations women with MS would
have received surgical and medical management before
pregnancy and would have received advice about the risks
of becoming pregnant and then support throughout the
pregnancy [6]. This study presents a population of women
that had not received the optimal treatment or advice.
To confirm the effect of epidural anesthesia in puerperal
women with RHD and MS, this retrospective study ana-
lyzed the anesthetic management during cesarean section
and the clinical results of the pregnant women with RHD
and MS that were admitted to Union Hospital of Fujian
Medical University.
Methods
The retrospective study was approved by the Ethics
Committee of Union Hospital according to the principles of
the Declaration of Helsinki. The requirement for written
informed consents was waived by the Ethics Committee.
The digitally stored medical records of the included par-
turients were obtained by computer and retrospectively
analyzed.
Patients
Forty-eight pregnant women that underwent cesarean sec-
tion with RHD and MS from Jan 2002 to Dec 2012 were
analyzed. The inclusion criteria were pregnant women with
RHD and MS. RHD was diagnosed by a cardiologist based
on medical history, physical examination and ultrasound
echocardiography. The exclusion criteria were with other
pregnancy complications (for example, hypertensive
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Arch Gynecol Obstet
disorder complicating pregnancy) or other severe chronic
disease such as diabetes, hypertension, asthma or renal
dysfunction. Due to poor health and economic conditions,
most parturients lacked standardized antenatal examina-
tion. These factors resulted in most parturients being
admitted to Union Hospital at 33–36 weeks of gestation.
In order to classify the outcome of patients by cardiac
function the parturients were grouped into two according to
the New York Heart Association (NYHA) class: NYHA
class I–II and NYHA class III–IV.
Digitalis drugs were administered to parturients with
heart failure or potential heart failure (significantly
enlarged heart estimated by cardiothoracic ratio, ejection
fraction \50 %) to maintain a HR below 100 beats/min.
Digoxin (0.125 mg Bid) and furosemide (20 mg Bid) were
administered for parturients with chronic congestive heart
failure. Concurrently, electrolyte balance, particularly
potassium concentration, was monitored and adjusted to
within a normal range by the doctors-in charge. For par-
turients with arrhythmia, HR was controlled prior to sur-
gery with medication such as beta blockers. Parturients
with frequent premature ventricular contractions were
treated with lidocaine and propafenone. Atropine was not
administered to parturients with a ventricular rate over 70
beats/min. Delivery of the fetus and intensive medical
treatment [8] was used in cases where heart failure
occurred after 34 weeks of gestation. Dexamethasone was
administered when heart failure occurred during a gestation
period of less than 37 weeks, to promote fetal lung matu-
rity and improve neonatal survival [9].
Echocardiography was performed for all parturients
between 33 and 36 gestational weeks. Multidisciplinary
meetings were conducted to discuss parturients’ manage-
ment including cardiology, high-risk obstetrics and cardiac
surgery, as well as cardiac and obstetric anesthesiology.
Cesarean section was performed for all parturients after a
communication between the obstetricians and the pregnant
women or their spouse and agreement was given. Cesarean
section was performed in an operating room with cardiac
surgeons present.
Anesthetic management
An oxygen mask was provided to the pregnant women
upon entering the operating room. 1–2 L/min oxygen was
administered over 24 h. Transcutaneous oxygen saturation
(SpO2), HR and ECG were monitored. Cannulation was
performed in the radial artery and jugular vein (or sub-
clavian vein) after local anesthesia. Arterial and central
venous pressures were monitored and the rehydration
channel established. The epidural was applied with the
patient in the lateral position. Epidural puncture was at the
L1/L2 or L2/L3 junction of lumbar vertebrae in the right
Arch Gynecol Obstet
lateral position. Aliquots of a minimal dose of 1 % lido-
caine plus 0.5 % ropivacaine (3–5 ml) were slowly injec-
ted into the epidural space. Anesthesia was limited to
below the thoracic spinal nerve 6–8 (T6–T8). The patient
was placed in the supine position for surgery.
For all parturients, arterial pressure, HR, central venous
pressure (CVP), pulse oximetry, ECG and fluid intake/
output were continuously monitored. The Apgar scores of
the neonates (at 0, 1, and 5 min), birth weight and prog-
nosis of the newborns were recorded. Apgar score B7
points at 5 min determined the transfer to NICU.
During surgery and after administration of anesthesia, if
the patient’s blood pressure decreased by more than 20 %
of the basal level, a small dose of phenylephrine
(50–100 lg) was administered to maintain stable circula-
tion. The operating table was tilted up at a 30° angle on the
head side when necessary to ensure controlled levels of
blood pressure. Central venous pressure and urine volume
were monitored throughout surgery, care was taken when
accelerating infusion rate and volume as an excessive
infusion amount within a short period of time may induce
or aggravate heart failure. Blood gas exchanges were
monitored during surgery. Small doses of digitalis (0.2 mg)
were administered to reduce the ventricular rate to below
100 beats/min for parturients with tachycardia, atrial fib-
rillation or rapid ventricular rate. Cardiac index (CI) was
measured by a noninvasive hemodynamic monitoring
system. For parturients with high central venous pressure
and a rapid HR, 0.2 mg digitalis and 20 mg furosemide, or
continuous infusion of nitroglycerin, was administered to
women in a dorsal elevated position following cesarean
section.
After delivery, oxytocin 10 l administered intravenously
and 10 l administered intramuscularly were used.
Statistical analysis
Data are presented as mean ± standard deviation (SD).
Comparisons between the two groups were analyzed with
independent-sample t test. A p value of \0.05 was con-
sidered statistically significant.
Results
The baseline data are shown in Table 1. All parturients
presented with RHD symptoms including palpitations,
exercise intolerance and mild-moderate lower-limb edema.
The age range was 21–37 years (mean 30.5 ± 2.1) and
gestation was 35.6 ± 6.2 weeks. In terms of concomitant
diseases 10 cases had anemia, 2 cases pregnancy hyper-
tension, 5 cases gestational diabetes mellitus and 2 cases
had RHD combined with pulmonary infection. Changes in
the vital signs of the mothers and information concerning
the newborns during anesthetic management are shown in
detail in Tables 2, 3. In all women, the parameters of HR,
systolic arterial pressure (SAP), diastolic arterial pressure
(DAP) and mean arterial pressure (MAP) and CVP sig-
nificantly increased at the time of delivery compared to the
time before administration of anesthesia, pre-operation and
at the end of the cesarean (Table 2). The duration of the
surgery was within the range 0.5–1.5 h (mean
1.1 ± 0.3 h). The cardiac function NYHA III–IV group
had a significantly lower fluid intake and a significantly
higher fluid output compared to the cardiac function
NYHA I–II group (Table 3). There were no perinatal
deaths in either group. In addition, there was no significant
difference between infants born to mothers in the cardiac
function NYHA I–II group and those born to mothers in the
cardiac function NYHA III–IV group in terms of Apgar
score, birth weight and admission to NICU.
Postoperative arrhythmia, including rapid atrial fibrilla-
tion occurred in 15 cases, with subsequent medication for
symptomatic treatment. There were two cases of heart
failure, and these were significantly improved after treat-
ment with cardiac agents and diuretics. No cases of mul-
tiple organ function failure and postpartum hemorrhage
occurred.
Discussion
Parturients with MS require careful preoperative, multi-
disciplinary assessment and anesthetic planning before
delivery in order to optimize cardiac function during the
peripartum period. They also need to make informed
decisions regarding the mode of delivery and anesthetic
technique. Pregnant women with mild heart disease with-
out severe pulmonary hypertension or an obstetric com-
plication can have a vaginal delivery, but for pregnant
women with level III–IV cardiac function or an obstetric
complication, cesarean section should be performed [1, 2].
Caesarean section shortens delivery time, reduces hemo-
dynamic changes caused by contraction of the uterus and
labor and alleviates the burden on the heart [10]. In this
study we present information from 48 pregnant women
with MS who underwent epidural anesthesia for delivery
by cesarean section in our unit over a period of 10 years to
evaluate the effectiveness and safety of the procedure. The
methods used ensured the procedure was successful with
no perinatal mortality.
In the current study, during parturition, changes in the
hemodynamics and fluid intake/output of parturients with
level III–IV cardiac function were more noticeable than
parturients with level I–II cardiac function, indicating that
anesthesiologists must be preoperatively aware of many
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 Arch Gynecol Obstet

Table 1 Baseline data of 48 pregnant women with mitral stenosis similar to other women during pregnancy, the uterus
(MS) compresses the inferior vena cava, causing spinal vein
Patients (n = 48) dilation so that the extravascular volume of the epidural
space decreases and is more conducive to diffusion of the
Age (years) (mean ± SD) 30.5 ± 2.1
anesthetic [11]. HR, blood pressure and central venous
Height (cm) [mean ± SD(range)] 161.5 ± 2.3 (155–168) pressure did not significantly change before or after anes-
Weight (kg) 68.5 ± 4.5 (58–75) thesia. Epidural anesthesia provided sufficient analgesia,
Gravidity history (no.) 1.3 ± 0.8 (1–4) muscle relaxation and avoided aggravation of heart failure.
Parity history 1.1 ± 0.3 (1–2) For parturients whose lesions were primarily MS, frac-
Gestation (weeks) (mean ± SD) 35.6 ± 6.2 tionated injections of small doses of anesthetic were
Echocardiography exam administered and the level of anesthetic strictly controlled
[mean ± SD(range)]
below T6 to prevent a drop in blood pressure and
Maximum gradients across the mitral 21.1 ± 4.3 (15–30)
hypoventilation. As left atrial blood flow into the left
valve (mmHg)
ventricle was impeded in the diastole phase, it is recom-
Average gradients across the mitral 13 ± 4.1 (10–20)
valve (mmHg) mended that an i.v injection of 50–100 ml phenylephrine
Actual valve areas of the mitral 1.1 ± 0.3 (0.8–1.5) be administered to increase blood pressure when
valves (cm2) hypotension occurs. Furthermore, the operating table can
Left ventricular ejection fraction (%) 54.4 ± 10.5 (45–75) be tilted upward to the left at a 30° angle when the patient’s
Left atrial diameter (mm) 52.6 ± 5.7 (45–65) blood pressure drops allowing blood pressure to return to a
Estimated pulmonary artery pressure 60.2 ± 12.3 (45–75) normal range. For parturients with tachycardia, atrial fib-
(mmHg) rillation and rapid ventricular rate, digitalis may be
Cardiac function classification administered to maintain a ventricular rate below 100
I 2 beats/min. Epidural anesthesia can be performed in con-
II 8 junction with the administration of lidocaine which may
III 27 prevent arrhythmia. As the patient may be prone to circu-
IV 11 latory fluctuations, continuous monitoring of blood pres-
sure, HR, fluid intake and output, changes in ECG, arterial
pressure and central venous pressure may immediately
points; these include the primary lesion, any secondary reflect cardiac function and thus effectively guide transfu-
changes in vital organs and if the patient has a history of sion or the application of other treatment.
heart failure, atrial fibrillation, embolism or angina to Perioperative use of pulmonary artery catheters remains
determine the anesthesia tolerance. It is clear that for par- controversial. According to Leibowitz and Oropello [12],
turients with level III–IV cardiac function, cardiologists pulmonary artery catheterization should be reserved for
should be involved to perform cardiotonic, diuretic and cases where there is a high risk of hemodynamic distur-
vasodilation treatments, to regulate electrolyte and acid/ bances or in practice settings where there are experienced
base balance so as to best improve the cardiac function of practitioners to insert the catheter and interpret the data.
parturients prior to surgery. As most parturients in this study suffered from moderate
Parturients in the current study required lower than pulmonary hypertension, intensive perioperative oxygen
normal doses of anesthesia this is because in these patients supply improved blood pressure and arterial SpO2,

Table 2 Changes in vital signs of 48 pregnant women with MS during anesthetic management (x ± s)
Item Before anesthesia Pre-delivery At delivery At the end of the cesarean

HR (beats/min) 95.21 ± 10.28 90.63 ± 8.61 104.19 ± 10.87* 90.31 ± 9.01

SAP (mmHg) 134.54 ± 10.42 130.56 ± 7.46 144.40 ± 7.38* 135.06 ± 10.61
DAP (mmHg) 57.52 ± 6.99 56.77 ± 4.60 64.19 ± 5.78* 58.33 ± 6.95
Mean arterial pressure (mmHg) 108.87 ± 7.73 108.62 ± 7.26 117.66 ± 5.16* 109.49 ± 7.55
Central venous pressure (cmH2O) 14.58 ± 2.19 14.79 ± 2.21 16.85 ± 1.84* 14.56 ± 2.18
Pulse oximetry (SpO2) 98.98 ± 1.14 99.10 ± 1.04 99.04 ± 1.03 99.06 ± 1.06
CI [L/(min m2)] 3.84 ± 0.84 3.73 ± 0.75 4.19 ± 0.87 4.31 ± 0.61
MS mitral stenosis, HR heart rate, SAP systolic arterial pressure, DAP diastolic arterial pressure, CI cardiac index
* p \ 0.05 compare with the other three periods

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Arch Gynecol Obstet

Table 3 Characteristics of the

NYHA I–II NYHA III–IV
48 pregnant women and infants
during anesthetic management Input (ml) 793 ± 127.98 593.4 ± 81.52*
Output (ml) 225 ± 71.69 327.6 ± 54.15*
MAP (mmHg)
Before anesthesia 114.23 ± 3.86 107.46 ± 7.91
Pre-operation 111.8 ± 4.53 107.78 ± 7.64
At delivery 115.9 ± 3.10 118.12 ± 5.52*
End of cesarean 108.27 ± 6.83 109.81 ± 7.78
Central venous pressure (CVP) (mmHg)
Before anesthesia 15.9 ± 2.28 14.23 ± 2.06
Pre-delivery 15.9 ± 2.08 14.5 ± 2.18
At fetal childbirth 17.1 ± 2.02 16.79 ± 1.82*
End of cesarean 14.7 ± 2.21 14.53 ± 2.2
Apgar score [7/B7 points 9/1 33/5
Perinatal death (n) 0 0
Birth weight (n) C2500 g/\2500 g 9/1 10/28
Transfer to NICU (n) 1 5
Apgar score B7 points at 5 min determined the transfer to NICU
MAP mean arterial pressure, NICU neonatal intensive care unit
* p \ 0.05

increased oxygen transport capacity, alleviated hypoxia of
peripheral tissue and prevented pulmonary hypertension
[13]. Necessary pregnancy pulmonary function should be
maintained, and uterotonics such as oxytocin and ergot
should be avoided, while prostaglandins may be considered
to promote uterine contractions and reduce pulmonary
artery pressure.
Following birth, caution must be taken regarding chan-
ges in heart condition resulting from a surge in venous
return. If changes occur, the dorsal-elevated position and
abdominal compression is suggested and cardiac-drug
support should be provided when required. When parturi-
ents presented with elevated central venous pressure,
decreased arterial pressure and increased HR, the rate of
anesthetic infusion must be controlled and carefully mon-
itored and the appropriate cardiotonic and diuretic admin-
istered to reduce cardiac stress [10]. In other conditions,
when parturients present with decreased arterial blood
pressure, elevated HR and elevated, rather than decreased,
central venous pressure indicating dilation of the abdomi-
nal blood vessels, it is suggested that rapid infusion be
applied to restore the patient’s central venous pressure [14].
Arterial pressure and HR should gradually return to nor-
mal. In both situations, whilst the clinical manifestations
are similar, the measures to treat each manifestation dif-
fered and anesthetic management must always be individ-
ualized to optimize the patient outcome.
This study has some limitations. The study was retro-
spective, so there were no control group patients to com-
pare outcomes, nor was there blinding of the clinicians to
the clinical diagnosis, and all parturients received the most
appropriate treatment as judged by the clinical team.
Therefore, we cannot say that the methods used were in
any way superior to alternative methods and this will bias
the results. Some of the data was also not completely
available so we cannot provide exact details of the fluid
intake and dose of phenylephrine for comparison between
groups. Blood loss was estimated in a subjective manner by
the attending nurses, therefore, we also did not include this
data in the comparison. The number of women included in
the study was quite small; much larger numbers in multiple
centers would provide more evidence for the efficacy of the
treatment and anesthetic methods they received.
In conclusion, epidural anesthesia was successfully
applied for the pregnant women with RHD and MS that
underwent cesarean section in this study, with an experi-
enced multidiscipline team. It is important that women
with RHD and MS receive treatment and delivery in spe-
cialist centers.
Compliance with ethical standards
Conflict of interest None declared.
References
1. Bowater SE, Thorne SA (2010) Management of pregnancy in
women with acquired and congenital heart disease. Postgrad Med
J 86(1012):100–105. doi:10.1136/pgmj.2008.078030
2. Reisner L, Kuczkowski K (2003) Anesthetic considerations for
complicated pregnancies. Maternal-fetal medicine, 5th edn.
Elsevier, Philadelphia, pp 1243–1260

123

3. Pessel C, Bonanno C (2014) Valve disease in pregnancy. Semin
Perinatol 38(5):273–284. doi:10.1053/j.semperi.2014.04.016
4. Avila WS, Rossi EG, Ramires JA, Grinberg M, Bortolotto MR,
Zugaib M, da Luz PL (2003) Pregnancy in patients with heart
disease: experience with 1,000 cases. Clin Cardiol 26(3):135–142
5. Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA,
Morton BC, Kells CM, Bergin ML, Kiess MC, Marcotte F,
Taylor DA, Gordon EP, Spears JC, Tam JW, Amankwah KS,
Smallhorn JF, Farine D, Sorensen S, Cardiac Disease in Preg-
nancy I (2001) Prospective multicenter study of pregnancy out-
comes in women with heart disease. Circulation 104(5):515–521
6. Suresh M, Preston RL, Fernando R, C LaToya Mason MD (2002)
Anesthesia for the pregnant cardiac patient. In: Hughes SC,
Levinson G, Rosen MA (eds) Shnider and Levinson’s anesthesia
for obstetrics. Lippincott Williams & Wilkins, Philadelphia,
pp 345–381
7. Pan PH, D’Angelo R (2004) Anesthetic and analgesic manage-
ment of mitral stenosis during pregnancy. Reg Anesth Pain Med
29(6):610–615
8. Grewal J, Silversides CK, Colman JM (2014) Pregnancy in
women with heart disease: risk assessment and management of
heart failure. Heart Fail Clin 10(1):117–129. doi:10.1016/j.hfc.
2013.09.014
123
Arch Gynecol Obstet
9. Garbrecht MR, Klein JM, Schmidt TJ, Snyder JM (2006) Glu-
cocorticoid metabolism in the human fetal lung: implications for
lung development and the pulmonary surfactant system. Biol
Neonate 89(2):109–119. doi:10.1159/000088653
10. Gomar C, Errando CL (2005) Neuroaxial anaesthesia in obstet-
rical patients with cardiac disease. Curr Opin Anaesthesiol
18(5):507–512. doi:10.1097/01.aco.0000183108.27297.3c
11. Timofeev J, Reddy UM, Huang CC, Driggers RW, Landy HJ,
Laughon SK (2013) Obstetric complications, neonatal morbidity,
and indications for cesarean delivery by maternal age. Obstet
Gynecol 122(6):1184–1195. doi:10.1097/AOG.0000000000000
017
12. Leibowitz AB, Oropello JM (2007) The pulmonary artery
catheter in anesthesia practice in 2007: an historical overview
with emphasis on the past 6 years. Semin Cardiothorac Vasc
Anesth 11(3):162–176. doi:10.1177/1089253207306102
13. Vasu S, Stergiopoulos K (2009) Valvular heart disease in preg-
nancy. Hellenic J Cardiol 50(6):498–510
14. Orme RM, Grange CS, Ainsworth QP, Grebenik CR (2004)
General anaesthesia using remifentanil for caesarean section in
parturients with critical aortic stenosis: a series of four cases. Int J
Obstet Anesth 13(3):183–187. doi:10.1016/j.ijoa.2003.12.008