A case of severe pulmonary stenosis in a 40-year-old female undergoing planned Caesarean section with epidural anaesthesia

Abstract

BACKGROUND: Pulmonary stenosis (PS) is a congenital heart defect that can present in a variety of clinical settings, depending on the severity. To ensure both maternal and fetal well-being, the management of PS in pregnant patients requires careful multidisciplinary coordination and consideration of both normal changes in maternal physiology and abnormal changes related to comorbidities.

CASE PRESENTATION: We present a 40-year-old female with a history of severe congenital pulmonary stenosis, hypertension, and diabetes mellitus, who underwent an elective caesarean section with tubal ligation under regional anaesthesia. She was diagnosed with PS in early childhood but was later lost to cardiology follow up. During antenatal assessment, trans-thoracic echocardiography revealed severe pulmonary stenosis with a gradient of 100mmHg, with severe right ventricular dilation. The patient maintained good exercise tolerance and had no symptoms suggestive of heart failure.

INTERVENTION AND OUTCOME: The caesarean section was conducted under lumbar epidural anaesthesia with careful monitoring of her cardiovascular status, including radial artery invasive blood pressure monitoring and CVP through a central venous catheter. Mild sedation was provided with boluses of midazolam. Postoperative recovery was uneventful, with stable blood pressure and mild improvement in the pulmonary gradient.

CONCLUSION: Epidural anaesthesia is a safe option for patients with severe PS undergoing Caesarean section provided that the block is achieved slowly to avoid rapid changes in blood pressure.