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Obstetric Anaesthesia Annual Scientific Meeting 2026
14-15 May 2026 | Liverpool Convention Centre
7156420
Anaesthetic management of emergency caesarean section in a patient with undiagnosed severe rheumatic mitral stenosis
Poster Presenter
Authors
Affiliations
Part of Topic
Case report
Anaesthetic management of emergency caesarean section in a patient with undiagnosed severe rheumatic mitral stenosis
Dr Radharetnasivan Meiarasu ¹ Anaesthetics CT3 , Dr Vimla Victor ¹ Anaesthetics Consultant, Aneurin Bevan University Health Board
Introduction
-A leading cause of mortality during pregnancy is cardiac disease, of which mitral stenosis is the highest risk valvulopathy, with the greatest number of deaths occurring at 2-9 days post partum
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-The increase in cardiac output associated with pregnancy, labour and post-delivery auto-transfusion from uterine contraction; combined with a fixed cardiac output heightens the risk of pulmonary oedema.
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-This case details the anaesthetic management of caesarean section in a patient with undiagnosed mitral stenosis. [1]
Case Report
-A young white British woman presented at 41 weeks and 6 days gestation with abdominal pain, vomiting, one contraction per 10 minutes and loss of mucus plug. She had a history of well controlled epilepsy, penicillin allergy and was gravida 1 with no issues during pregnancy.
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-After admission overnight to labour ward for induction, an artificial rupture of membranes was completed. A Syntocinon infusion was started and effective epidural analgesia administered at request. Due to multiple unprovoked cardiotocography decelerations, she consented to a category 2 emergency caesarean section under epidural top up.
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-A total of 20mls 0.75% ropivacaine and 100mcg of fentanyl given in gradual 5ml aliquots provided adequate anaesthesia for surgery. Intraoperatively she experienced nausea, vomiting and abnormal hypotension.
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-A phenylephrine infusion of 100 mls/hr (20mcg/ml) and multiple boluses of metaraminol were used to maintain her blood pressure.
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-She had no features suggestive of a high block and remained conscious.
-Syntocinon boluses and infusions were used as uterotonics to prevent post partum haemorrhage (PPH) without issue.
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-After delivery, the vasopressor requirement improved and recovery was uneventful.
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-After discharge with routine care, she represented with positional dyspnoea, increased cough and a new oxygen requirement.
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-Chest radiographs revealed widespread haziness with blunting of costophrenic angles. [Figure 1]
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-Computed tomography showed widespread pulmonary oedema and large bilateral effusions. [Figure 2]
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-Echocardiography revealed severe rheumatic mitral stenosis with the classical “hockey stick” appearance of the anterior mitral valve (MV) leaflet and a dilated left atrium LA. The pressure and half-time measurements were also in keeping with severe mitral stenosis [Figures 3, 4, 5] [2]
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-The patient received medical management with diuretics, beta blockers and anticoagulation.
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-They later underwent balloon valvuloplasty at a tertiary centre and have since recovered well.
Discussion
-This was an unexpected and rare pathology given the patient demographic.
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-Our patient, being undiagnosed, was fortunate to have a good outcome out of hours without thorough perioperative planning.
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-Early epidural analgesia, progressive titration of local anaesthetic during top up and the use of alpha agonist vasopressors without chronotropic action; all worked to reduce symptoms of mitral stenosis by maintaining systemic vascular resistance (SVR) and avoiding tachycardia.
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-It is possible that use of Syntocinon for induction contributed to symptoms.
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-The use of Syntocinon post delivery as a uterotonic can cause tachycardia increasing cardiac output, worsening symptoms. However, it is preferable to managing PPH as fluid boluses are poorly tolerated in mitral stenosis.
Conclusion
-Good anaesthetic management of mitral stenosis in pregnancy involves limiting factors that increase cardiac output and maintaining systemic vascular resistance for coronary perfusion.
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-Regional anaesthesia is proven to be safe in this cohort of patients with epidurals being preferred to spinals. [1]
-Early detection, referral to tertiary centres and planning with multidisciplinary team involvement is essential to coordinate medical and surgical interventions and minimise risk in this population. [1]
Figure 1. Chest radiograph taken on readmission demonstrating pulmonary oedema
Figure 2. Bilateral pleural effusions revealed on CTPA
Figure 3. Echocardiography reveals dilated LA and rheumatic MV
Figure 4. Raised MV pressure half time of 288 ms and calculated MV Area of 0.76 cm2
Figure 5. Raised mean MV pressure gradient of 29.23 mmHg
References:
1. Burt, Christiana C.Durbridge, Jacqueline et al. Management of cardiac disease in pregnancy Continuing Education in Anaesthesia, Critical Care and Pain, April 2009, Volume 9, Issue 2, 44 - 47
2. Robinson, S., Ring, L., Augustine, D.X. et al. The assessment of mitral valve disease: a guideline from the British Society of Echocardiography. Echo Res Pract 8, G87–G136 (2021).