Hysterotomy under general anesthesia in a patient with peripartum cardiomyopathy

Janani1, J Sivagurunathan2, K Senthil Kumar3

1Final year DNB Post Graduate, Department of Anesthesiology, Kauvery Hospital, Cantonment, Trichy

2Consultant – Department of Anesthesiology, Kauvery Hospital, Cantonment, Trichy

3HOD – Department of Anesthesiology, Kauvery Hospital, Cantonment, Trichy

Abstract

Peripartum cardiomyopathy (PPCM) is an idiopathic condition characterized by left ventricular systolic dysfunction with an ejection fraction of approximately 45% near the end of pregnancy or immediately after delivery. Anesthetic management in these patients is challenging due to their low physiological reserve. We report the case of a 30-year-old female with peripartum cardiomyopathy posted for hysterotomy, which was performed under general anesthesia using a laryngeal mask airway (LMA). These patients are at high risk; therefore, proper choice of anesthesia, intraoperative management, postoperative care, and a multidisciplinary approach are crucial.

Keywords: Hysterotomy; General anesthesia; Peripartum cardiomyopathy.

Introduction

Peripartum cardiomyopathy (PPCM) is an uncommon, potentially fatal clinical condition with no recognized cause. The diagnostic definition has four criteria:

(a) the onset of heart failure within the final month of pregnancy or within five months of delivery;

(b) absence of any other known cause of heart failure;

(c) no prior evidence of cardiac disease before the last month of pregnancy;

(d) echocardiographic evidence of left ventricular systolic dysfunction (ejection fraction ≤45% and reduced fractional shortening).

Thus, PPCM is a diagnosis of exclusion. For anesthesiologists, obtaining a complete history and ensuring preoperative optimization is essential, as intraoperative difficulties may be anticipated. The goals of anesthetic management are to prevent myocardial depression, maintain normovolemia, avoid drug overdose due to delayed circulation time, and prevent sudden hypotension if regional anesthesia is considered.

Case Presentation

A 30-year-old female, a known case of dilated cardiomyopathy, was admitted at 22 weeks of gestation and scheduled for hysterotomy. She was apparently normal three months prior, but later developed episodic fatigue and breathlessness (NYHA class II), which progressed to breathlessness on minimal exertion (NYHA class III).

On examination, she had a normal airway, heart rate of 84 bpm, and blood pressure of 100/70 mmHg. ECG showed a prolonged PR interval. Other laboratory investigations were within normal limits. 2D-ECHO revealed severe left ventricular dysfunction with ejection fraction 30%, global hypokinesia, dilated LV, grade II diastolic dysfunction, and moderate mitral regurgitation. She was advised to continue Tab. Bisoprolol 1.25 mg once daily.

After confirming nil per oral status and obtaining informed high-risk consent, the patient was shifted to the operating theatre (OT).

Intraoperative Course

Standard ASA monitors were attached—continuous ECG, non-invasive blood pressure, and SpO₂. Invasive arterial blood pressure (IABP) monitoring was established. The patient was pre-oxygenated with 100% oxygen for 3 min and premedicated with Inj. Glycopyrrolate 0.1 mg IV and Inj. Midazolam 2 mg IV. Induction was achieved with Inj. Fentanyl 140 µg IV, Inj. Etomidate 20 mg IV, and Inj. Cisatracurium 4 mg IV.

The airway was secured with size 3 I-gel, and controlled ventilation was initiated. Ventilator settings were adjusted to maintain normocapnia. Anesthesia was maintained with oxygen/air mixture (50:50), Sevoflurane (0.5% MAC), and Cisatracurium. Ventilator settings included tidal volume 400 ml, respiratory rate 16/min, and PEEP 5 cmH₂O.

After delivery of 22 weeks’ fetus through hysterotomy opening, an oxytocin infusion (10 units) was started to enhance uterine contraction. At the end of surgery, the patient was reversed with Inj. Neostigmine 2.5 mg IV and Inj. Glycopyrrolate 0.2 mg IV. She was extubated and shifted to the postoperative ward in a hemodynamically stable condition. Low molecular weight heparin was initiated 12 hours postoperatively.

Discussion

PPCM presents a significant challenge for anesthesiologists. The choice of anesthetic depends on the urgency of delivery and the patient’s physiological status.

The exact etiology of PPCM remains unclear, though possible causes include viral myocarditis, autoimmune phenomena, and genetic mutations affecting prolactin processing. Risk factors include multiparity, advanced maternal age, and Black ethnicity. Clinical features include tachycardia, tachypnea, pulmonary crepitation’s, cardiomegaly, and the presence of an S3 heart sound.

Management focuses on improving hemodynamics and contractility, controlling hypertension or hypotension, managing arrhythmias and pulmonary congestion, and preventing thromboembolic events. Beta-blockers (e.g., metoprolol, carvedilol) improve LV function, while class III antiarrhythmic (e.g., amiodarone) are preferred for ventricular arrhythmias.

For delivery, maintaining cardiac output and coronary perfusion is critical. Vaginal birth is preferred in compensated PPCM. In cesarean sections with severe decompensation—particularly in anticoagulated patients—general anesthesia is often preferred, as regional anesthesia may cause dangerous sympathetic blockade.

When general anesthesia is required, induction should be smooth to avoid sudden hypotension or hypertension. Opioids (e.g., fentanyl, remifentanil) may help attenuate the hemodynamic response to laryngoscopy and intubation. For stable patients undergoing non-emergent cesarean delivery, incremental epidural dosing is preferred. Early labor epidural analgesia reduces cardiovascular stress, decreases afterload, and provides an option for surgical anesthesia.

Conclusion

To avoid intraoperative complications, thorough preoperative evaluation is essential. The choice of anesthesia must be individualized according to the patient’s cardiac status. In this case, general anesthesia with an LMA was used, with care taken to maintain stable hemodynamics intraoperatively, leading to a favorable postoperative outcome.

References

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