Individualised Anaesthetic Strategies for High-risk Cardiac Parturient: A Case Series

Cardiac disease in pregnancy is a significant contributor to maternal morbidity and mortality worldwide. Physiological changes of pregnancy including increased cardiac output, expanded blood volume, tachycardia, and decreased Systemic Vascular Resistance (SVR) place additional stress on the cardiovascular system. These changes may unmask previously asymptomatic cardiac abnormalities or worsen pre-existing disease. The management of pregnant women with underlying cardiac conditions poses a unique perioperative and obstetric challenge, requiring multidisciplinary coordination to maintain maternal and foetal stability. Here, the authors, present a series of four clinically distinct and rare cardiac conditions encountered during pregnancy, each demonstrating different mechanisms of haemodynamic compromise. The first case involved rheumatic mitral stenosis of a 26-year-old gravida, where increased circulatory demand precipitated pulmonary congestion and heightened risk of decompensated heart failure. The second case in a 32-yearold gravida, featured Partial Anomalous Pulmonary Venous Connection (PAPVC) with sinus venosus defect, a congenital anomaly infrequently detected during pregnancy due to its subtle symptom profile. The third case in 36-year-old primigravida was unique due to the coexistence of Coronavirus Disease 2019 (COVID-19) infection and acute myocardial infarction during the second trimester - a rare combination associated with a three to four-fold increased risk of infarction in pregnancy. The fourth case in a 38-year-old gravida 2, involved an Atrial Septal Defect (ASD) complicated by anaemia and beta-thalassaemia trait, where the additive effects of hypervolaemia and reduced oxygen-carrying capacity intensified right-sided volume overload. Each case required individualised management emphasising pharmacological optimisation, vigilant haemodynamic monitoring, and careful peripartum planning. The present case series highlights the importance of early recognition, risk stratification, and multidisciplinary care for achieving favourable maternal and foetal outcomes in pregnant patients with complex cardiac disease.