///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Severe Mitral Stenosis with Severe Pulmonary Hypertension - Anesthesia Management for Labor and Cesarean Delivery

Abstract Number: RF2AB-147
Abstract Type: Case Report Case Series

Laura Puertas Ocio Md, PhD1 ; Tery Gray MD2; Robert H Small MD3

Case: 21 year old G1P0 at 36w6d, PMH of AV canal defect s/p repair at 6 months of age and follow-up surgery at age 5, sub aortic membrane s/p repair and small residual VSD who was unknown to the anesthesia team, presented for induction of labor due to PPROM. Echocardiogram after admission showed severe pulmonary hypertension (PHTN) (RVSP 65-70 mm Hg), severe mitral stenosis (MS) (mean gradient 23 mm Hg), mild mitral regurgitation, and mild aortic valve insufficiency. Hydromorphone-only epidural infusion initially reduced the patient’s pain, but it was changed to bupivacaine with fentanyl due to increasing pain. To minimize abrupt changes in the patient’s SVR and preload, initiation of bupivacaine 0.625% with fentanyl 2 mcg/mL was completed by administering 20 mL over one hour, followed by an infusion rate of 14 mL/hour. She underwent cesarean delivery due to arrest of descent. General anesthesia was planned due to urgency, hemodynamic concerns, and patient preference. Midazolam was titrated during pre-induction a-line insertion to minimize hypercarbia and increasing PA pressure. Phenylephrine infusion was administered to avoid the decline in SVR and arterial blood pressure secondary to sevoflurane in a patient with preload dependence. Post-operatively, an epidural hydromorphone infusion was continued for pain management. The patient recovered in our cardiac ICU and discharge 3 days later. Discussion: The management of a parturient with severe mitral stenosis and severe pulmonary hypertension is challenging. Due to the large intrapartum and postpartum volume shifts expected, volume status must be carefully managed to avoid both sudden decreases in preload and volume overload leading to pulmonary edema or RV failure (1). In addition to avoiding hypoxia, hypercarbia, hypotension and acidosis in a patient with PHTN, it is important to decrease sympathetic stimulation from pain in order to avoid increasing PVR (2). This goal also improves hemodynamics in the setting of MS by preventing pain-related tachycardia, therefore optimizing LV filling (1). Pregnant women with PHTN have a significantly high risk of morbidity and mortality, particularly during the third trimester and the postpartum period (3). Consensus guidelines recommend pregnancy prevention and early termination due to the high risk of maternal mortality, and education regarding risks and benefits of birth control methods remains fundamental for women of childbearing age with PHTN (3).

1. Kannan and Vijayanand. Mitral stenosis and pregnancy: Current concepts in anaesthetic practice. Indian Journal of Anaesthesia Vol. 54, Issue 5, Sep-Oct 2010 2. Rex and Devroe. Anesthesia for pregnant women with pulmonary hypertension. Current Opinion in Anaesthesiology. 29(3):273–281, JUN 2016

3. Memon and Park. Pulmonary Arterial Hypertension in Women. Methodist Debakey Cardiovasc J. 2017 Oct-Dec; 13(4):224-23

SOAP 2019