Maternal Comorbidities

Cardiac Conditions - Heartfelt Hurdles

• Pregnancy: ↑CO, ↑HR, ↑BV; ↓SVR. Goals: Hemodynamic stability, avoid pain/stress.
• Key Lesions & Goals:
  • MS: Slow HR, maintain preload/SVR. Avoid ↑PVR. Epidural preferred.
  • AS (Critical): Maintain NSR, preload, SVR. Avoid ↓SVR (spinal dangerous!). Slow epidural/CSE.
  • PHTN: Maintain SVR, RV function. Avoid ↑PVR (hypoxia, acidosis, pain).
  • PPCM: LV dysfunction (EF <45%) late pregnancy/postpartum. Avoid myocardial depressants.
• Anesthesia: Regional (epidural) often preferred for slow, controlled onset.

⭐ Eisenmenger syndrome carries the highest maternal mortality risk (30-50%) among cardiac conditions.

Respiratory & Hypertensive - Breathless & Pressured

• Respiratory (Pregnancy):
  • ↑MV (50%), ↑O₂ use; ↓FRC (20%) → rapid desat.
  • Airway: Edema, friable, ↑Mallampati. 📌 Difficult intubation risk.
  • Resp. alkalosis ($P_{aCO_2}$ 28-32 mmHg).
• Hypertension (Preeclampsia/Eclampsia):
  • Preeclampsia: BP ≥140/90 mmHg (post 20wks) + proteinuria/end-organ damage.
  • Severe: BP ≥160/110 mmHg, HELLP, pulm. edema, CNS.
  • MgSO₄ for seizures (Load: 4-6g IV; Maint: 1-2g/hr).
    • ⚠️ Toxicity: ↓DTRs, resp. depression. Antidote: Ca gluconate.
  • Definitive: Delivery.
• Anesthesia: Neuraxial preferred (platelets >75,000/μL). GA: RSI, small ETT.

⭐ MgSO₄ is key for eclampsia seizure prophylaxis/treatment. Therapeutic range 4-7 mEq/L. Monitor DTRs, RR. Antidote: Ca gluconate.

Endocrine & Hematological - Metabolic Mayhem

• Diabetes Mellitus (DM)

  • Pre-gestational / Gestational (GDM).
  • Target: Euglycemia (<140/80-110mg/dL intrapartum).
  • Neonate: Hypoglycemia risk.
  • Anes: Neuraxial pref. GA: DKA/asp. risk. Insulin.
  • 

  ⭐ Hyperglycemia teratogenic; tight glycemic control vital preconception/early pregnancy.

• Thyroid Disorders

  • Hyperthyroidism:
    • Risk: Thyroid storm (surgery/infection trigger).
    • Rx: PTU, methimazole, β-blockers. Avoid ketamine.
    • Neuraxial preferred.
  • Hypothyroidism:
    • Risk: Myxedema coma (rare).
    • Rx: Levo. ↑Sedative/opioid sensitivity.

• Hematological Issues

  • Anemia:
    • Common: Iron deficiency.
    • Thresholds: Hb <11(T1/3), <10.5(T2) g/dL.
    • Optimize. Transfuse Hb <7-8/symptomatic.
  • Thrombocytopenia:
    • Gestational: Mild, PLT >70k/µL.
    • Others: ITP, HELLP.
    • Neuraxial: PLT >80k (trend/cause). ⚠️ No NSAIDs.
  • Coagulopathy & Anticoagulation:
    • VWD: DDAVP/Factor VIII.
    • Anticoagulants: Neuraxial timing critical (LMWH: 12h off proph, 24h off therap).

Obesity & Neurological - Weighty Nerves

• Obesity (BMI ≥30 kg/m²):
  • Challenges: Difficult airway (OSA), ↓FRC, positioning, co-morbidities (HTN, GDM).
  • Anesthesia: RSI for GA. Regional (epidural/CSE) preferred; USG for placement. Adjust LA dose.
  • Risks: ↑Aspiration, VTE, infection. 📌 RAMP positioning for intubation.
• Neurological Disorders:
  • Epilepsy: Continue AEDs. Regional preferred. Avoid pro-convulsants (e.g., meperidine).
  • Multiple Sclerosis: Avoid hyperthermia. Epidural preferred over spinal.
  • Myasthenia Gravis: ↑Sensitivity to NDMRs. Regional ideal.

⭐ For obese parturients, reduce epidural local anesthetic dose by 20-25% due to decreased epidural space volume from engorged veins.

High‑Yield Points - ⚡ Biggest Takeaways

• Cardiac Disease: Epidural preferred for minimal hemodynamic change; avoid aortocaval compression.
• Preeclampsia: Magnesium sulfate for seizures. Neuraxial for C-section if no coagulopathy/severe thrombocytopenia.
• Obesity: High risk: difficult airway, aspiration. Early epidural placement is key.
• Asthma: Continue therapy. Regional anesthesia preferred; avoid histamine-releasing drugs.
• Thrombocytopenia: Neuraxial safe if platelets >80,000/µL; <50,000/µL relative contraindication.
• Gestational Diabetes: Maintain euglycemia to prevent macrosomia, neonatal hypoglycemia.