ANAESTHETIC IMPLICATIONS AND MANAGEMENT OF PREGNANCY WITH RHD(MS, MR)

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ANAESTHETIC IMPLICATIONS AND MANAGEMENT
OFPREGNANCY WITH RHD(MS, MR)

• Presenter Dr. Vineeta venkateswar Moder
  ator Dr. Deepti

University College of Medical Sciences GTB
Hospital, Delhi
www.anaesthesia.co.in
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CARDIOVASCULAR CHANGES DURING NORMAL PREGNANCY

• CARDIAC OUTPUT
• ? from 5th wk, peak (40-50) at 30-34 wks
• ? further during labour (50) immediate
  postpartum (70)
• Pre-labour values 1 hr after delivery
  pre-pregnancy values by 4wks
• BLOOD PRESSURE
• SVR ? by 20
• ? in diastolic BP and MAP by 5-10 mmHg

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• HEART RATE
• ? by 20
• HAEMATOLOGICAL CHANGES
• Blood volume ? by 40-50. Maximum at 30-32 wks.
• Hemoglobin mass ? by 20-30
• Plasma volume ? 40-50. Overall effect
  hemodilution, fall in Hb.
• Hypercoagulable state- Increase in fibrinogen,
  clotting factors.

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• CLINICAL FINDINGS
• Apex beat 4th ICS, lateral to mid-clavicular
  line.
• Heart sounds S1 - loud, split. S3 may be heard
• Murmur systolic murmur in apical or pulmonary
  area,
• continuous mammary murmur.
• CHEST X RAY
• Avoided
• Heart displaced upwards rotated on its axis
• Straightening of upper left cardiac border

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• ECG
• Reflects the altered heart position
• LAD of 15 degree
• QRS complex - low voltage
• Atrial and ventricular extrasystoles

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MITRAL STENOSIS
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EPIDEMIOLOGY

• Heart disease in pregnancy 0.3 3.5
• Incidence of RHD ?, esp in developed countries
  and some urban areas
• Most common cardiac lesion in India - rheumatic
  origin, followed by congenital ones
• Maternal mortality in RHD - lt1 in asymptomatic
  patients to 17 in complicated cases
• RHEUMATIC HEART DISEASE - cardiac involvement of
  an auto immune reaction, myocardial protein
  laminin imunologically similar to cell membrane
  proteins of beta-hemolytic streptococci and
  becomes target of auto antibodies

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• MITRAL STENOSIS
• Decrease in Mitral valve orifice area leading to
  chronic fixed mechanical obstruction to LV
  filling
• RF first occurs at 6-15 yrs
• MS after about 5 yrs
• First symptoms after another about 15yrs
• Average age of onset of symptoms 31 yrs
• Pulmonary congestion, pulmonary hypertension, RVF
  after another 5-10 yrs

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• Over several decades MS evolves by
• Thickening of the leaflets
• Fusion of the commisures
• Fusion or shortening of the chordae (fish-mouth
  or button-hole valve)
• Calcification of valve
• Thrombus due to venous stasis in LA

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MITRAL STENOSISPATHOPHYSIOLOGY
Right Heart Failure Hepatic Congestion JVD TR RA Enlargement Atrial Fib LA Thrombi Pulmonary HTN Pulmonary Congestion LA Enlargement ? LA Pressure
RV Failure RVH RV Pressure Overload LV Filling
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• Mechanical obstruction to left ventricular
  diastolic filling
• Adaptative ? in LAP to maintain LV filling
• ------------------------------------------------
  -------------------------
• LA enlargement ? in pulmonary venous pressure
  ? ? in pulmonary arterial pressure
• Atrial fibrillation Transudation of fluid into
  pulmonary interstitial space
• Thrombus formation
• Systemic thrombo-embolism ?ed pulmonary
  compliance ?Work of breathing
• Progressive dyspnoea on exertion/rest
• Chest pain, palpitations, fainting
• Pregnancy, Pain, sepsis (? HR/CO)
  Acute ? in LAP Pulmonary edema
• ? in pulmonary arterial pressure
• Pulmonary arterial hypertrophy (Pulmonary HTN)

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PREGNANCY WITH MS

• EFFECT OF PREGNANCY ON MS
• Worsening of NYHA functional status by 1-2
  grades. Presentation of anatomically moderate
  stenosis become functionally severe.
• ? incidence of pulmonary congestion (25),
  AF(7), paroxysmal atrial tachycardia(3), other
  complications like RVF, embolism, IE

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New York Heart Association(NYHA)Functional
Classification of Heart Failure

• NYHA 1 Known cardiac disease with no limitation
  of physical activity and no objective evidence of
  cardiovascular disease
• NYHA 2 Slight limitation of normal physical
  activity and objective evidence of minimal
  disease
• NYHA 3 Marked limitation of physical activity
  and objective evidence of moderate disease
• NYHA 4 Severe limitation of activity including
  symptoms at rest and objective evidence of severe
  disease

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• Women who were asymptomatic before pregnancy
  usually tolerate pregnancy well but not with
  severe MS
• Physiological basis
• ? HR of pregnancy limits time available for
  filling of left ventricle ? results in increased
  LA and PA pressures ? risk of pulm edema
• ? blood volume ? additional load
• fixed cardiac output state ? CO cannot ? to
  compensate for ? SVR

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• Risk of maternal death greatest after 30 wks ,
  esp during labour and immediate post partum
• Physiological basis
• CO and blood volume peak at this time
• Tachycardia during labour- along with further ?
  peripheral demand
• Sudden ? in preload immediately after delivery
  floods the central circulation? severe pulm edema

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• EFFECT OF MS ON PREGNANCY
• High-risk pregnancy
• Increased risk of complications, mortality
• Close monitoring, repeated visits required
• EFFECT OF MS IN PREGNANCY ON FETUS
• Cardiac output cannot be ?, fetal circulation
  compromised
• IUGR, LBW babies
• Preterm labour

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HISTORY AND EVALUATION

• 25 women with MS 1st symptoms during pregnancy
• H/o rheumatic fever in childhood
• Fatigue, progressive shortness of breath.
• Cough, hemoptysis
• Chest pain, palpitations
• Right sided failure (neck vein distension,
  peripheral edema)
• Left sided failure (orthopnea, PND)
• Worsening of sypmtoms in prior pregnancies
• If known case may be on digoxin/diuretics/
  betablockers/ IE prophylaxis

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• TREATMENT HISTORY
• DIGOXIN
• Narrow therapeutic range 0.5 to 2 ng/ml
• Life- threatening arrhythmias
• Hypokalemia,Hypercalcemia and hypomagnesemia
  precipitate
• Co-administration with beta blockers, or calcium
  channel blockers can cause serious bradycardia.
• BETA BLOCKERS
• Labetalol, propanolol , esmolol
• Co- administration with digoxin serious
  bradycardia
• DIURETICS
• Electrolyte disturbances
• Can precipitate digoxin toxicity

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EXAMINATION

• GENERAL FEATURES
• Depends on severity
• Low volume pulse
• Peripheral edema, JVP raised
• Mitral facies Pink purple patches on the cheeks,
  cyanotic skin changes from low cardiac output
• SYSTEMIC EXAMINATION
• Respiratory
• Basal crepts in pulmonary edema
• Abdomen
• Tender hepatomegaly
• Ascites (advanced)

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• CARDIAC SYSTEM
• S1 loud
• S2 closely split or fixed, P2 accentutated
• opening snap at base of heart along left sternal
  border (mitral area), absent in later stages,
  narrow OS-S2 gap indicates severity.
• Middiastolic rumbling murmur with presystolic
  accentuation best heard at the apex in lateral
  recumbent position, severity related to duration.

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INVESTIGATIONS

• Routine investigations
• complete hemogram
• serum electrolytes Serum K, Ca, Mg levels
• Serum digoxin levels
• Coagulation profile
• ECG
• 2D /Doppler ECHO

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ECG

• P mitrale (LAH) broad notched P wave, large,
  bifid appearance in II, III ,aVF
• RVH, RAD

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• Chest X-ray
• (usually not done in pregnant patients)
• normal to ?ed cardiac shadow
• straightening of the left heart border and
  elevation of left main bronchus (left atrial
  enlargement)
• mitral calcification
• evidence of pulmonary edema/ HTN

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• 2D /Doppler Echocardiography
• (non radiological investigation-preferred in
  pregnant patients)
• anatomy/size of mitral valve its appendages
• severity of MS (area of orifice)
• size function of ventricles
• thrombus
• transvalvular pressure gradient , PA pressure
  (Doppler)
• Cardiac catheterization invasive measurement
• almost never necessary
• reserved for situations ECHO sub-optimal/conflict
  with clinical presentation

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CLASSIFICATION
Mild Moderate Severe
Mean gradient (mm Hg) lt 5 5- 10 gt 10
Pulmonary artery systolic pressure (mm Hg) lt 30 30- 50 gt 50
Valve area (cm2) gt 1.5 1.0- 1.5 lt 1.0
ACC AHA Guidelines 2006
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• If severe, patient referred to a cardiac centre
  for mitral valve surgery to enable her to
  complete pregnancy
• Mitral Valvotomy (preferred) palliative , buys
  time for woman to complete pregnancy.
• Mitral Balloon Valvuloplasty safe effective
  if valve pliable, avoids open heart surgery
• Mitral Commissurotomy may be required at any
  stage of gestation.

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GOALS OF MANAGEMENT

• Maintain a slow heart rate, tachycardia to be
  strictly avoided
• Maintain sinus rhythm - AF to be aggressively
  treated
• Optimize venous return and PCWP to maximize
  LVEDV- avoid aortocaval compression blood loss
• Avoid ? SVR- maintain adequate SVR
• Avoid ? PVR- prevent pain , hypoxemia,
  hypercarbia and acidosis

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ROLE OF ANAESTHESIOLOGIST

• During pregnancy
• Sudden decompensation intensive care
• -AF
• -CHF
• Non-obstetric surgery
• Normal vaginal delivery
• Caesarean section

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ATRIAL FIBRILLATION
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• Digoxin 0.25 to 0.5 mg IV, then 0.25 mg IV 4 to 6
  hrly to maximum of 1 mg
• Propanolol 1 mg IV over 2 minutes, may repeat
  every 5 min to maximum of 5 mg, maintenance 1 to
  3 mg IV 4 hrly
• Calcium channel blocker
• Diltiazem 15 to 20 mg IV over 2 min, may repeat
  in 15 min, maintenance 5 to 15 mg per hr by
  continuous IV infusion
• Verapamil 5 to 10 mg IV over 2 min, may repeat
  in 30 min

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ANTI COAGULANTS

• Anticoagulation indicated if
• History of embolic phenomena or
• Chronic AF
• Heparin during first last trimester of
  pregnancy, Unfractionated heparin s.c. 10 000 to
  20000 units every 12 hr aPTT 1.5 x control
• LMW Heparin may be considered despite the limited
  data available
• Warfarin - considered during the second trimester
  for pregnant patients with AF at high
  thromboembolic risk.

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If a patient on Anticoagulant requires surgery

• Warfarin
• Elective -discontinue at least 5 days before
  elective procedure, assess INR 1 to 2 days
  before surgery, if gt1.5, consider 1-2 mg of oral
  vitamin K
• Emergency- consider 2.5-5 mg of i.v. vitamin K,
  consider FFP
• Patients at high risk for thromboembolism bridge
  with therapeutic s.c. LMWH (preferred) or i.v.
  UFH
• Heparin
• LMWH last dose 24 hrs before surgery
• Heparin discontinued 4 hrs before surgery
• American Society of Regional Anesthesia (ASRA)
  Guidelines 2010

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ROLE OF ANAESTHESIOLOGIST

• During pregnancy
• Sudden decompensation
• -AF
• -CHF
• Non-obstetric surgery
• Normal vaginal delivery
• Caesarean section

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CHF

• Similar as in non-pregnant pts
• General
• Bed rest
• Salt fluid restriction
• Supplemental oxygen
• Diuretics
• Loop diuretics , eg. furosemide 20-80 mg 1-2
  times/day
• Thiazides K-sparing to be avoided
• Beta-blockers
• Metoprolol (6.25- 75 mg 12hrly), bisoprolol,
  carvedidol
• Digoxin (0.125- 0.5 mg/d)
• Consider termination of pregnancy

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IE PROPHYLAXIS

• Pregnancy carries no additional risk for
  bacterial endocarditis.
• Routine antibiotic prophylaxis in patients with
  valvular heart disease undergoing uncomplicated
  vaginal delivery or caesarean section no longer
  recommeded (unless infection suspected).
• Antibiotic prophylaxis as practiced for the
  prevention of wound sepsis is more than adequate.
• Indications for antibiotic prophylaxis
• Patients with prosthetic heart valves,
• Previous history of endocarditis,
• Complex congenital heart disease
• The Committee on Rheumatic Fever, Endocarditis
  and Kawasaki Disease (American Heart
  Association),
• Circulation.2008 118 2395-2451 ACC/AHA 2008
  Guidelines

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• Non penicillin allergic patient
• Intravenous Ampicillin 2 g plus gentamicin 1.5
  mg/kg IV or IM 30 min before procedure, followed
  by ampicillin 1 g IV or IM, or amoxicillin 1 g
  orally, 6 hours after initial dose.
• Penicillin allergic patient
• Vancomycin 1 g IV once plus gentamicin as above
  within 30 min of the start of the procedure

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ROLE OF ANAESTHESIOLOGIST

• During pregnancy
• Sudden decompensation
• -AF
• -CHF
• Non-obstetric surgery
• Normal vaginal delivery
• Caesarean section

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NORMAL VAGINAL DELIVERY

• Invasive hemodynamic monitoring ( CVP. IBP, PA
  catheters)
• Severe MS
• NYHA III or IV
• Sudden cardiovascular collapse
• Persistent oliguria despite adequate fluid
• PA catheter
• Trends signify changes in LA pressure
• Maintain around 15 mmHg

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• First stage of labour
• Restricted fluid intake- conc. solutions of
  drugs, diuretics
• Left uterine displacement oxygen fetal
  monitoring
• Adequte analgesia to prevent tachycardia-lumbar
  epidural catheterization recommended
• Epidural analgesia low dose bupivacaine(0.125-0.
  0625) fentanyl- 2 mcg/ml or sufentanil 0.2-0.3
  mcg/ml
• CSE use also recommended
• Intrathecal- fentanyl 15-25 mcg or sufentanil
  1.5-5 mcg
• Epidural- slow low-dose bupivacaine
  opioid
• Opioids infusions, PCIA

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• Epidural Test Dose
• Traditional Lignocaine with 15-20 mcg Adr
• Role is controversial
• Alternatives
• Adr replaced with fentanyl 50-200 mcg observe
  for dizziness, drowsiness after 5 min
• Air (1 ml) Doppler over precordium
• Guay et al The Epidural Test Dose A Review
  Anesth Analg 20061029219

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• Second stage of labour
• Maternal pushing efforts result in a Valsalva
  maneuver- sudden undesirable ? in venous return.
• Maintain adequate analgesia Perineal analgesia (
  paracervical / pudendal nerve block.) epidural
  extended
• Mother discouraged from bearing down or pushing
• Obstetrician cuts short second stage - vacuum
  extraction or outlet forceps

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• Hypotension prevented by judicious use of fluids
  and continuous left uterine displacement
• If hypotension occurs
• Vasopressor of choice-
• Phenylephrine 100-500 mcg increments IV bolus
  followed by 100-180 mcg/min constant infusion
• Metarminol also used i.v. infusion of 15-100 mg
  in 500 ml of 5 dextrose or NS)
• Prophylactic ephedrine and rapid overenthusiastic
  fluid therapy to be avoided
• Post partum careful monitoring

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ROLE OF ANAESTHESIOLOGIST

• During pregnancy
• Sudden decompensation
• -AF
• -CHF
• Non-obstetric surgery
• Normal vaginal delivery
• Cesarean section

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CAESAREAN SECTION

• REGIONAL ANAESTHESIA (preferred in mild to
  moderate stenosis)-
• Lumbar epidural anaesthesia preferred- produces
  slower, more controllable hemodynamic changes,
  anesthetic level established slowly by titrating
  drug with the degree of anaesthesia.
• Epidural catheter, if inserted during labour, can
  be extended
• CSE may be used -5mg hyperbaric .5 bupivacaine
  with 25mcg fentanyl, 3ml 2 lignocaine
• Update In Anesthesia Issue 19 (2005) Article 9
  Anaesthesia For The Pregnant Patient With
  Acquired Valvular Heart Disease Joubert IA, Dyer
  RA, 

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• Role of SAB
• Avoided due to precipitous fall in BP
• Small-dose spinal anaesthesia (e.g.1mL 0.25
  bupivacaine with 10-20mcg fentanyl or 0.1-0.2mg
  morphine) may be used as an alternative to
  epidural anaesthesia
• (may be inadequate for Cesaerean Section,
  adequate for short-duration labour analgesia)
• Update In Anesthesia Issue 19 (2005) Article 9
  Anaesthesia For The Pregnant Patient With
  Acquired Valvular Heart Disease Joubert IA, Dyer
  RA, 

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• General Anaesthesia
• Indications
• NYHA functional class III or IV
• obstetric indications
• Pt on anticoagulants
• Mild stenosis (NYHA grade I/II)
• intravenous thiopentone/ etomidate for induction
  
• Rocuronium/scholine for tracheal intubation
• quick and gentle laryngoscopy
• tachycardia following tracheal intubation or
  surgical incision avoided - ß blockers

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• Moderate or severe stenosis (NYHA III/IV)
• slow induction with inhalational agents like
  sevoflurane and IV fentanyl suggested
• Opioids- sufentanil, remi
• avoid nitrous oxide (in pulm HTN)
• avoid hypoxia, hypercarbia acidosis and pain to
  prevent ?PVR
• reversal- slow, with use of esmolol if required
• invasive monitoring

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• Uterotonic Drugs after delivery
• Oxytocin - vasodilation and hypotension
• Ergometrine- ? SVR and can cause pulmonary edema
• PG F2alpha (carboprost)- ? PA pressure and PCWP.
• PG E1 (misoprost) -under investigation as
  second-line drug
• When necessary , 3U of oxytocin diluted to 10 ml
  given slowly over 30sec is the agent of choice
• Second agent of choice is misoprostol, dosage
  regimens not yet established
• International Journal of Obstetric Anesthesia
  (2010) 19, 313319 The use of uterotonic drugs
  during caesarean section R.A. Dyer, D. van Dyk,
  A. Dresner

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• Postoperative care-
• Observation in a HDU or PACU recommended for 48
  hrs, as high risk of pulm edema and hemodynamic
  compromise during immediate post partum period.
• Elective post-op ventilation if required
• monitoring- ABG, Chest Xray

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SUMMARY OF MS IN PREGNANCY

• MS a low fixed cardiac output condition
• Worsening of NYHA status by 1-2 grades
• ? risk of complications Pulmonary edema and AF
• Tachycardia has to be avoided at any cost
• Vaginal delivery- good analgesia, cut short
  second stage
• Caesarian section- NYHA I II - Epidural block
  or CSE
• NYHA III IV - GA preferred, inhalational
  opioids advised
• Immediate post partum /postoperative is high risk
  period- needs strict monitoring

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MITRAL REGURGITATION
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• MITRAL REGURGITATION Retrograde flow of blood
  from LV to LA through incompetent mitral valve
  during systolic phase

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PATHOPHYSIOLOGY OF MR

• Regurgitation of blood from LV to the LA through
  an incompetent mitral valve.
• Over time, LA adapts to the increased blood
  volume by dilating and increasing compliance.
• LA pressure does not rise till late stages, thus
  left atrium protects the pulm venous, arterial
  and capillary beds from pressure overload.
• When LA pressure rises, PA and PCWP also rises ,
  causing pulm congestion and edema
• LV dilatation also occurs because of increase in
  preload afforded by the hypervolemic left atrium
• Forward ejection of blood through aortic vavle
  impaired by as much as 50-60
• Thus reduction LV afterload can decrease the
  amount of regurgitant blood and increase forward
  cardiac output

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PATHOPHYSIOLOGY OF MR

• Mitral regurgitation
• Systolic (Retrograde) ejection into LA
• Acute Chronic
• Volume overload in LA LV ?ed LV afterload
  (into LA)
• ?ed LA, LV Pressure ?ed LA/LV size/ compliance
• Pulmonary edema ?ed Cardiac output LA
  dilatation ?ed contractility
• AF ? CO
• Pulmonary congestion

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DIAGNOSIS

• HISTORY
• H/o rheumatic fever in childhood
• fatigue, progressive shortness of breath.
• left sided failure (orthopnea, PND)
• right sided failure (neck vein distension,
  peripheral edema)
• cough, hemoptysis, chest pain, palpitations

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• Physical examination
• arterial pressure N/?
• pulse (Water Hammer pulse- ?DBP, ? SBP)
• signs of RVF like ? JVP
• systolic thrill at apex (hyperdynamic
  circulation)
• Cardiac auscultation
• S1 is absent, soft or buried in the systolic
  murmur
• S2 low pitched, wide split in later stage-
  premature closure of aortic valve
• Holosystolic murmur best heard at apex
  radiating to axilla

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MR
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• ECG
• Non-specific findings
• Atrial fibrillation
• LA enlargement/LV hypertrophy
• Chest X-ray
• Left heart chamber enlargement
• Pulmonary congestion
• Echocardiography
• Diagnosis/mechanism/severity of MR/MS
• Impact on cardiac chamber size, pressure
  function
• Pulmonary artery pressure
• Presence of thrombus
• Invasive measurement

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• SEVERITY OF MR

Mild Moderate Severe
MR jet area as percentage of LA area 20-30 30-40 gt40
RegurgitantFraction 20-30 30-40 gt55
MR jet area lt3 sq. cm 3-6 gt6
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ANAESTHETIC MANAGEMENT

• Goals of management
• During course of pregnancy
• Normal vaginal delivery
• Caesarian section

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GOALS OF MANAGEMENT

• Prevent ? in SVR
• Maintain normal to slightly ? HR
• Maintain sinus rhythm- aggressively treat AF
• Avoid aortocaval compression and maintain venous
  return but prevent ? in central vascular volume
• If G.A is given, avoid myocardial depressant
  drugs
• Prevent pain , hypoxemia, hypercarbia and
  acidosis which may ? PVR

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ANAESTHETIC MANAGEMENT

• Goals of management
• During course of pregnancy
• Normal vaginal delivery
• Caesarian section

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COURSE OF PREGNANCY

• MR is typically well tolerated
• Afterload reduction promotes forward flow low
  dose sodium nitroprusside (0.1 to 0.5 mcg
  /kg/min) or phentolamine (0.1 to 1 mcg/kg/min)
  along with dopamine for left ventricular
  inotropic support
• Myocardial depresssion not tolerated- left
  ventricular impairment usually accompanies MR,
  even minimal myocardial depression ? significant
  compromise
• ? blood volume intolerable to chronically
  compensated left ventricle ? pulm congestion
• ? risk of AF and systemic embolization- occurs in
  20 of pregnant MR patients.

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ANAESTHETIC MANAGEMENT

• Goals of management
• During course of pregnancy
• Normal vaginal delivery
• Caesarian section

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NORMAL VAGINAL DELIVERY

• Invasive hemodynamic monitoring if moderate or
  severe sympotomatic disease
• Pain, anxiety and maternal bearing down efforts
  during labour ? SVR ? forwards flow and
  ?regurgitation.
• Allay by regional anaesthesia techniques-
• Lumbar epidural catheterization or
• CSE with low dose intrathecal local anaesthetic
  opioid

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• Rationale behind regional anaesthesia
  techniques
• Pain relief prevents the ? SVR associated with
  labour
• In addition, sympathetic blockade causes
  peripheral vasodilation and further ?in SVR.
• Two edged sword
• Also causes ? venous return and hypotension-not
  tolerated well.
• -Careful administration of i.v. fluids
• -Left uterine displacement
• -10 degree Trendelenburg position- may help
• -Ephedrine helpful- ? HR

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ANAESTHETIC MANAGEMENT

• Goals of management
• During course of pregnancy
• Normal vaginal delivery
• Caesarian section

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CAESARIAN SECTION

• Regional anaesthesia
• Lumbar epidural or CSE - avoid hypotension
• General Anaesthesia
• Maintain adequate HR and decreased afterload.
• i.v. induction - ketamine for ? HR /- sodium
  nitroprusside to prevent peripheral
  vasoconstriction.
• Rapid gentle intubation with rocuronium,
  pancuronium
• Pressor response to intubation avoided
• Inhalational agents for maintenance- vasodilation
• Avoid hypoxia, hypercarbia acidosis, pain -
  prevent ?PVR

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MS with MR

• Both pressure and volume overload condition
• Less well tolerated than either isolated MS or
  MR- increased morbidity
• risk of complications pulm edema, AF , CHF
• Managed according to the goals of the dominant
  lesion

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REFERENCES

• Chestnut's Obstetric Anesthesia Principles and
  Practice, 4th Edition Cardiovascular Disease pg
  881-13
• Shnider and Levinson's Anesthesia for Obstetrics
  4th edition Cardiac Disease pg 252-283
• Textbook of Obstetric Anaesthesia Rachel Collis
  Obstetric Patient with Cardiac Disease, pg
  173-203
• Harrisons Principles of Internal Medicine, 18th
  edition Valvular Disease pg 1393- 1402
• Stoelting's Anesthesia and Co-Existing
  Disease 5th edition Valvular Heart Disease pg
  27-42
• Medical Care of the Pregnant Patient By Karen
  Rosene-Montella The Cardiac Patient pg 151-153
• ACC AHA Guidelines 2006 Classification of
  Severity of Valvular Diasease
• ASRA Guidelines 2010 The Patient on
  Anticoagulants, Antiplatelet Drugs,
  Thrombolytics, Fibrinolytics
• Update In Anesthesia Issue 19 (2005) Article 9
  Anaesthesia For The Pregnant Patient With
  Acquired Valvular Heart Disease Joubert IA, Dyer
  
• Circulation.2008 118 2395-2451 ACC/AHA 2008
  GuidelinesThe Committee on Rheumatic Fever,
  Endocarditis and Kawasaki Disease (American Heart
  Association)

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