Perioperative management of a caesarean section in a patient with isolated pulmonic stenosis and severe pre-eclampsia


The anaesthetic management of a parturient with isolated pulmonic stenosis and severe pre-eclampsia is particularly challenging. Each of this needs to be evaluated as a separate entity and managed in unison. The challenges that we faced were compounded by the urgent nature of Caesarean section in view of equivocal NST with meconium stained liquor. This provided us with little opportunity to evaluate the present cardiac status and the spectrum of manifestations of pre-eclampsia.

Central venous and arterial access was promptly established to enable monitoring of fluid and hemodynamic status peri-operatively. Management of preeclampsia was initiated by the use of intra-venous antihypertensive and magnesium sulphate. General anaesthesia with modified rapid sequence intubation was expeditiously administered and this facilitated early delivery of a healthy neonate. The mother was extubated uneventfully following assessment and optimisation of the cardiac status in the ICU.

A 25 year old primigravida, at 36 weeks of gestation presented to the labour room with severe abdominal pain, leak per vaginum and history of breathlessness. There was a marked limitation in physical activity due to breathlessness, even during less than ordinary activity, corresponding to New York Heart Association (NYHA) class three. She was a known case of isolated moderate pulmonic stenosis diagnosed during the first ante-natal check (ANC).

Physical examination revealed pallor and bilateral pitting pedal oedema. A heart rate of 110/min, blood pressure of 240/146 mm of Hg, respiratory rate of 25/min and room air saturation of 96% was recorded. On inspection, precordial pulsations were present; on auscultation, normal first heart sound, a widely split second heart sound and a systolic ejection murmur in the left upper sternal border was appreciated. There was no evidence of right heart failure and the rest of the systems were unremarkable. She was posted for an urgent LSCS in view of equivocal NST with meconium stained liquor.

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