General anesthesia for cesarean section in the presence of mitral stenosis associated with severe pulmonary hypertension

Usha V. Bansal, Varun V. Bansal, Bhavesh R. Patel


Rheumatic heart disease (RHD) is the most common cause of cardiac disease during pregnancy in India. A case of severe pulmonary hypertension (pulmonary arterial pressure- 98 mm Hg) secondary to mitral stenosis associated with RHD in a 28-year old woman, is described. She underwent a high risk elective cesarean section under general anesthesia at 36 weeks of gestation. The intraoperative and postoperative course was uneventful. The advantages of general anesthesia over neuraxial blockade during cesarean section are discussed in this report. The management of patients at a high risk of developing pulmonary edema and decompensated heart failure in the perioperative period has been stressed upon. A thorough understanding of the pathophysiology and complications of RHD during pregnancy and cesarean section is required for managing the disease successfully.


Rheumatic heart disease, Cesarean section, General anesthesia, Pulmonary hypertension

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French KA, Poppas A. Rheumatic Heart Disease in Pregnancy: Global Challenges and Clear Opportunities. Circulation. 2018;137(8):817-9.

Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, et al. ESC Scientific Document Group. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018;39(34):3165-241.

Weiner MM, Vahl TP, Kahn RA. Case scenario: Cesarean section complicated by rheumatic mitral stenosis. Anesthesiology. 2011;114(4):949-57.

Pan PH, D'Angelo R. Anesthetic and analgesic management of mitral stenosis during pregnancy. Reg Anesth Pain Med. 2004;29(6):610-5.

Gomar C, Errando CL. Neuroaxial anaesthesia in obstetrical patients with cardiac disease. Curr Opin Anaesthesiol 2005;18(5):507-12.

Choudhury M. Neuraxial anaesthesia in parturient with cardiac disease. Indian J Anaesth. 2018;62(9):682-90.

Kocum A, Sener M, Calıskan E, Izmirli H, Tarım E, Kocum T, et al. Epidural anesthesia for cesarean section in a patient with severe mitral stenosis and pulmonary hypertension. J Cardiothorac Vasc Anesth. 2010;24(6):1022-3.

Arendt KW, Lindley KJ. Obstetric anesthesia management of the patient with cardiac disease. Int J Obstet Anesth. 2019;37:73-85.

Rex S, Devroe S. Anesthesia for pregnant women with pulmonary hypertension. Curr Opin Anaesthesiol. 2016;29(3):273-81.

Kela M, Buddhi M. Combined mitral and aortic stenosis in parturient: Anesthesia management for labor and delivery. J Anaesthesiol Clin Pharmacol. 2017;33(1):114-6.