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

Critical rheumatic mitral stenosis complicated by pulmonary hypertension and right ventricular dysfunction during pregnancy represents one of the most challenging scenarios in obstetric anesthesia. These patients are classified as modified World Health Organization (mWHO) Class IV, which is the highest maternal risk category with high maternal mortality rates. The peripartum period is especially dangerous since even modest hemodynamic shifts can trigger cardiovascular collapse. We report a successful case of anesthetic management of a 40-year-old gravida 3, para 2 at 29 weeks and three days gestation with severe rheumatic mitral stenosis, moderate-to-severe pulmonary hypertension, moderate-to-severe tricuspid regurgitation, and severely reduced right ventricular function. She was classified as New York Heart Association (NYHA) Class III, mWHO Class IV, and American College of Cardiology/American Heart Association (ACC/AHA) Stage C heart failure. She presented with worsening dyspnea and fetal decelerations after admission for decompensated heart failure and then underwent emergent cesarean section delivery, classified as category 2, with bilateral salpingectomy for permanent sterilization at the patient’s request. The anesthetic plan centered on three major strategies: a dural puncture epidural (DPE) with incremental dosing to allow gradual sympathectomy, invasive hemodynamic monitoring with early vasopressor support to preserve systemic vascular resistance (SVR), and prophylactic femoral arterial and venous sheath placement to allow rapid escalation to venoarterial (VA) extracorporeal membrane oxygenation (ECMO) if needed. Fortunately, the patient was hemodynamically stable throughout the procedure, did not require mechanical circulatory support, and was discharged in stable condition on postoperative day 10. This case demonstrates that favorable maternal outcomes can be achieved in patients with mWHO Class IV cardiac disease with meticulous multidisciplinary planning and an anesthetic strategy that prioritizes hemodynamics.