Anesthetic Management of Emergency Cesarean Delivery in Severe Mitral Stenosis: A Case Report

An emergent cesarean delivery performed on a 28-year-old COVID-19 positive primigravida at 39 weeks gestation with rheumatic heart disease highlights the efficacy of low-dose spinal anesthesia. Managed by medical teams including Dr. Poonam Kumari and Dr. Amarjeet Kumar, the technique prevented dangerous aerosol generation while maintaining maternal hemodynamic stability.

Managing pregnant patients with concurrent viral respiratory infections and complex structural cardiac abnormalities presents profound clinical challenges. When fetal distress forces an immediate surgical delivery, the chosen anesthetic technique must balance maternal heart preservation against the immediate delivery needs of the neonate. Recent case documentation published in medical literature outlines how targeted regional blockade successfully navigates these compounding physiological risks.

In Plain English: The Clinical Takeaway

• Subarachnoid Blockade: A spinal injection that numbs the lower half of the body while keeping the patient fully awake, chosen here to avoid breathing tubes that spread viral particles.
• Hemodynamic Stability: Maintaining steady blood pressure and heart rate, which is critical when a patient has a narrowed heart valve (mitral stenosis).
• Aerosol Generation: The release of microscopic respiratory droplets into the air during procedures like placing breathing tubes, which poses infection risks to operating room staff.

Navigating Multi-Valvular Disease During Viral Infection

The patient at the center of this case presented at 39 weeks of gestation with a documented history of rheumatic heart disease (RHD) featuring multivalvular lesions. These included mild mitral stenosis, severe mitral regurgitation, and mild aortic regurgitation. Compounding this structural cardiac burden, a reverse transcription-polymerase chain reaction (RT-PCR) test confirmed a concurrent SARS-CoV-2 infection accompanied by a cough and sore throat. According to clinical evaluations reported by Dr. Poonam Kumari and colleagues, the patient’s baseline echocardiography demonstrated an ejection fraction of 60 percent, reflecting preserved left ventricular systolic function despite the valvular pathology.

Physiologically, pregnancy naturally increases plasma volume while lowering systemic vascular resistance, producing a higher cardiac output. While regurgitant valvular lesions are typically well-tolerated under these conditions, stenotic lesions like mitral stenosis restrict the heart’s ability to handle increased volume and heart rate. Adding a severe acute respiratory infection alters pulmonary gas exchange and escalates systemic stress. Because clinical outcomes for COVID-19 positive pregnant women are statistically worse than for their nonpregnant peers, immediate multidisciplinary planning is mandatory when fetal distress dictates an emergency lower segment cesarean section (LSCS).

Anesthetic Technique and Intraoperative Management

To mitigate infection transmission, clinical guidelines emphasize minimizing procedures that generate aerosols. Standard general anesthesia requires preoxygenation, face mask ventilation, endotracheal intubation, and airway suctioning—all high-risk vectors for viral dissemination among healthcare personnel. Consequently, the surgical team selected a central neuraxial blockade as the preferred primary technique.

In the operating room, standard American Society of Anesthesiologists monitors were applied, and two peripheral intravenous lines (20-gauge and 18-gauge) were secured alongside anti-aspiration prophylaxis. Positioning the patient in a sitting posture, clinicians administered a subarachnoid blockade in the L3-4 interspace using a targeted dose of 2 milliliters containing 10 milligrams of hyperbaric bupivacaine. Intraoperatively, oxygen supplementation was delivered via nasal prongs at 4 liters per minute. Following the delivery of the infant, a slow intravenous infusion of 20 milligrams of oxytocin was administered.

The surgery concluded within 75 minutes with an estimated blood loss of 500 milliliters, supported by a total fluid volume of 1,000 milliliters of balanced salt solution (BSS). The newborn achieved an APGAR score of 8 shortly after birth, though due to meconium-stained amniotic fluid, the infant was transferred to the neonatal intensive care unit. While the baby initially tested negative for COVID-19 via RT-PCR, mild dyspnea emerged on the second day of life, necessitating temporary mechanical ventilation. The mother experienced an unremarkable postoperative recovery.

Intraoperative and Perinatal Metrics Summary

Clinical Parameter	Documented Value / Intervention
Gestational Age & Presentation	39 weeks primigravida, emergent LSCS for fetal distress
Cardiac & Viral Status	Rheumatic Heart Disease (mild mitral stenosis, severe mitral regurgitation, mild aortic regurgitation) + COVID-19 positive
Anesthetic Approach	Subarachnoid blockade (10 mg hyperbaric bupivacaine at L3-4)
Surgical Duration & Blood Loss	75 minutes; estimated blood loss of 500 mL
Neonatal Outcome	APGAR score of 8; transient neonatal dyspnea requiring ventilation on Day 2

During the COVID-19 pandemic, routine practices were modified to ensure safety of the mother and the baby while judiciously using resources including personal protective equipment (PPE), manpower, and designated areas. The successful execution of low-dose spinal anesthesia in this case aligns with broader findings by investigators such as Bhakta et al., who documented the use of regional blocks in patients having severe peripartum cardiomyopathy.

Unlike general anesthesia, which introduces hemodynamic volatility during induction and extubation, a carefully titrated subarachnoid block minimizes abrupt shifts in systemic vascular resistance. This stability protects stenotic cardiac valves from sudden pressure gradients. Authors Dr. Chandni Sinha, Dr. Ajeet Kumar, Dr. V.P. Akhil, and Dr. Rajnish Kumar concurred that after adequate fluid preloading, low-dose spinal anesthesia represents a viable option for emergency obstetric interventions in patients with RHD infected with SARS-CoV-2.

Contraindications & When to Consult a Doctor

While central neuraxial blockade offers significant hemodynamic and respiratory advantages, it is not universally appropriate. Pregnant individuals experiencing symptoms such as unexplained shortness of breath, chest pain, palpitations, or persistent cough—particularly those with a known history of congenital or rheumatic heart disease—must seek immediate medical evaluation. Timely assessment by a cardiologist and obstetrician is essential to establish an individualized delivery plan before the onset of labor.

Future Outlook on High-Risk Obstetric Care

The successful management of this complex case underscores the vital importance of adaptability in modern obstetric anesthesiology. By prioritizing regional anesthesia over aerosol-generating general techniques, clinical teams can simultaneously protect operating room personnel and safeguard mothers with structural heart disease. As institutional protocols continue to refine emergency responses for multi-morbid patients, such documented case reports provide an evidence base for clinical decision-making worldwide.

References

• Anesthetic Management of Emergent Cesarean Delivery in a Patient With Severe Rheumatic Mitral Stenosis and Cardiopulmonary Complications: A Case Report.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Patients with cardiac conditions or active infections should consult qualified healthcare professionals for personalized clinical guidance.

Photo: ovid.com