Successful Anesthetic and Perioperative Management of Severe Rheumatic Mitral Stenosis with Pulmonary Hypertension in a Pregnant Woman: A Case Report

Successful Anesthetic and Perioperative Management of Severe Rheumatic Mitral Stenosis with Pulmonary Hypertension in a Pregnant Woman: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Successful Anesthetic and Perioperative Management of Severe Rheumatic Mitral Stenosis with Pulmonary Hypertension in a Pregnant Woman: A Case Report Maninder Singh, Barkha Jaiswal, Sarvesh Singh Lobana, Ria Jamwal, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8884749/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Rheumatic heart disease (RHD) remains a significant cause of maternal morbidity and mortality, particularly in low- and middle-income countries. Severe mitral stenosis (MS) with pulmonary hypertension during pregnancy presents formidable challenges for anesthetic management. Case Presentation: A 27-year-old primigravida at 30 weeks gestation presented with acute cardiac decompensation secondary to severe rheumatic MS (mitral valve area 1 cm²), severe mitral and tricuspid regurgitation, and pulmonary hypertension (86 mmHg). She deteriorated from NYHA class II to IV with hypoxemia (SpO₂ 84%). A multidisciplinary team coordinated her care, optimizing her preoperatively in the ICU. Emergency cesarean section was performed under low-dose spinal anesthesia (bupivacaine 2.5 mg with fentanyl 50 mcg) supplemented with bilateral transversus abdominis plane (TAP) block. Hemodynamic stability was maintained without cardiac decompensation. The patient was discharged on postoperative day 7 in stable condition. Conclusion This case demonstrates that low-dose neuraxial anesthesia combined with TAP block offers a safe anesthetic approach for cesarean delivery in patients with severe valvular heart disease and pulmonary hypertension, provided meticulous hemodynamic monitoring and multidisciplinary care are ensured. Trial registration Not applicable. Rheumatic heart disease Mitral stenosis Pulmonary hypertension Pregnancy Low-dose spinal anesthesia TAP block Figures Figure 1 Figure 2 Introduction Rheumatic heart disease (RHD) continues to pose a significant global health burden, affecting approximately 40 million people worldwide, with disproportionate impact on women of childbearing age in endemic regions [ 1 , 2 ]. The hemodynamic alterations of pregnancy—including a 30–50% increase in blood volume, elevated cardiac output, and decreased systemic vascular resistance—create a particularly hazardous milieu for women with stenotic valvular lesions [ 3 ]. Mitral stenosis is the most commonly encountered valvular lesion during pregnancy, with the majority being rheumatic in origin [ 4 ]. A systematic review and meta-analysis by Liaw et al. (2021) demonstrated that RHD during pregnancy is associated with high rates of adverse outcomes, including preterm birth (9.35–42.97%), low birth weight (12.98–39.70%), and perinatal death (0.00-9.41%) [ 1 ]. The risk is substantially elevated in women with NYHA class III/IV symptoms, with a 2.86-fold increased risk of preterm birth and 3.23-fold increased risk of perinatal death [ 1 ]. Furthermore, moderate-to-severe MS is independently associated with higher rates of intrauterine growth restriction and preterm delivery [ 1 ]. Pulmonary hypertension superimposed on valvular heart disease dramatically worsens maternal prognosis. Contemporary data indicate maternal mortality rates of 12% overall in patients with pulmonary arterial hypertension during pregnancy, with the highest mortality occurring within 0–4 days postpartum due to right heart failure, cardiac arrest, and pulmonary hypertensive crises [ 5 , 6 ]. The combination of severe MS and pulmonary hypertension thus represents an extreme-risk scenario demanding expert multidisciplinary management. The anesthetic approach for cesarean delivery in such patients must balance the need for adequate surgical anesthesia against the catastrophic consequences of hemodynamic instability. We present a case of successful anesthetic management of emergency cesarean section in a patient with severe rheumatic MS and pulmonary hypertension using low-dose spinal anesthesia combined with bilateral TAP block. Case Presentation A 27-year-old primigravida (gravida 1, para 0) at 30 weeks gestation was referred to our tertiary care center with progressive dyspnea and palpitations. She reported mild exertional intolerance before pregnancy (NYHA functional class II) but had deteriorated over the preceding weeks to the point of orthopnea and dyspnea at rest (NYHA class IV). On presentation, vital signs revealed blood pressure 129/89 mmHg, heart rate 120 beats/min, respiratory rate 30 breaths/min, and oxygen saturation 84% on room air, which improved to 96% with 5 L/min oxygen via face mask. Cardiovascular examination demonstrated mid-diastolic (grade 3/6) and holosystolic (grade 4/6) apical murmurs consistent with mitral stenosis and mitral regurgitation, respectively. Bilateral basal crepitations indicated pulmonary congestion, and yellowish skin discoloration suggested hepatic congestion secondary to right heart failure. Obstetric examination confirmed 30 weeks gestation with a viable fetus. Laboratory workup revealed hemoglobin 8.51 g/dL indicating anemia, total leukocyte count 10,550/mm³, elevated serum bilirubin (total 2.9 mg/dL, direct 1.4 mg/dL), and alkaline phosphatase 416 IU/L—findings consistent with congestive hepatopathy. Renal function and coagulation profiles were within normal limits. Electrocardiogram showed sinus tachycardia with left ventricular hypertrophy and left atrial abnormality, while thyroid function testing revealed elevated TSH. Transthoracic echocardiography confirmed severe rheumatic heart disease with critical mitral stenosis (mitral valve area 1 cm²), severe mitral regurgitation, severe tricuspid regurgitation, moderate aortic regurgitation, severe pulmonary hypertension (systolic pulmonary artery pressure 86 mmHg), dilated left atrium with thrombus/vegetation, and preserved left ventricular ejection fraction (60%). Given the complexity of this case, multidisciplinary meetings involving cardiology, high-risk obstetrics, cardiac surgery, and anesthesiology were convened. The patient was admitted to the intensive care unit where aggressive medical optimization was initiated, including furosemide infusion for diuresis, tablet digoxin (Lanoxin) for rate control, levothyroxine (Thyronorm) for hypothyroidism, and antibiotic prophylaxis given the suspicious left atrial mass. After stabilization, the decision was made to proceed with emergency cesarean section at 30–32 weeks gestation, with cardiopulmonary bypass on standby in the cardiac operating room. The complete timeline of clinical course and multidisciplinary management is illustrated in Fig. 2 . On the day of surgery, the patient was transferred to the cardiac operating theater where standard American Society of Anesthesiologists monitoring was established along with invasive arterial blood pressure monitoring. The patient was positioned in left lateral uterine displacement to prevent aortocaval compression, avoiding Trendelenburg positioning. A carefully titrated low-dose spinal anesthetic was administered consisting of hyperbaric bupivacaine 0.5% 2.5 mg combined with fentanyl 50 mcg. Following confirmation of adequate dermatomal coverage, ultrasound-guided bilateral TAP blocks were performed using 0.25% bupivacaine 20 mL on each side to supplement intraoperative and postoperative analgesia (Fig. 1 ). Sensory and motor blockade were achieved gradually without precipitous hemodynamic changes, and heart rate and blood pressure remained within acceptable parameters throughout the procedure with no episodes of heart failure or arrhythmia. The cesarean section proceeded uneventfully, and a live preterm infant was delivered. Two units of packed red blood cells were transfused to correct anemia. Postoperatively, the patient was transferred to the ICU where multimodal analgesia consisting of intravenous paracetamol and tramadol was continued. Oxygen supplementation was provided with intermittent non-invasive ventilation utilized as needed for respiratory support. By postoperative day 3, the patient had stabilized significantly and was weaned from supplemental oxygen. She was discharged on postoperative day 7 in satisfactory condition with instructions for cardiology and obstetric follow-up. Discussion This case illustrates several critical principles in managing severe valvular heart disease during pregnancy. The presentation of our patient—rapid functional class deterioration, hypoxemia, pulmonary congestion, and hepatic congestion—reflects the well-documented inability of the stenotic mitral valve to accommodate the increased cardiac output demands of pregnancy [ 4 , 7 ]. As emphasized by Abdelrahman and Yousif (2019) in their comprehensive review, cardiac decompensation in MS typically occurs in the late second or third trimester when hemodynamic burden peaks, and again postpartum due to autotransfusion following delivery [ 4 ]. Our patient's trajectory from NYHA class II to class IV over the course of pregnancy exemplifies this pathophysiology, and her presentation aligns closely with the high-risk phenotype described in the literature. The meta-analysis by Liaw et al. demonstrated that NYHA class III/IV status and moderate/severe MS are strong predictors of adverse maternal and fetal outcomes [ 1 ]. Similarly, Shafiq and Sheikh (2023) reported a case of undiagnosed severe MS presenting as maternal cardiac arrest at 28 weeks gestation, underscoring the potentially catastrophic nature of this condition when unrecognized or inadequately managed [ 7 ]. Unlike that case, our patient presented before catastrophic decompensation, allowing time for multidisciplinary optimization—a factor likely contributing to the favorable outcome. The presence of severe pulmonary hypertension (86 mmHg) substantially elevated our patient's risk profile and warranted particular attention in perioperative planning. Low et al. (2021) reported in their systematic review of pulmonary arterial hypertension in pregnancy that maternal mortality rates remain at 12% overall, with 61% of deaths occurring within the first 4 postpartum days [ 5 ]. The authors emphasized that right heart failure and pulmonary hypertensive crises are the leading causes of mortality in this population [ 5 ]. Similarly, Lv et al. (2023) in their retrospective Chinese cohort found that idiopathic pulmonary arterial hypertension carried the highest mortality (50% in their cohort), though secondary pulmonary hypertension due to left heart disease—as in our patient—also conferred significant risk with 35.1% of patients requiring ICU admission [ 6 ]. Our strategy of ICU preoperative optimization with diuresis and rate control, combined with cardiopulmonary bypass standby, reflects adherence to these evidence-based principles and likely contributed to the successful outcome. The choice of anesthetic technique is paramount in patients with severe MS and pulmonary hypertension. Traditional teaching cautioned against neuraxial anesthesia due to concerns about sudden sympathectomy causing hypotension, tachycardia, and decompensation [ 8 ]. However, contemporary evidence increasingly supports carefully titrated neuraxial techniques over general anesthesia in appropriately selected patients. Rex and Devroe (2022), in their comprehensive review of cardiac disease in pregnancy published in Best Practice & Research Clinical Anaesthesiology, concluded that there is no difference in maternal outcomes between general and regional anesthesia, and that incremental neuraxial techniques should be preferred when not otherwise contraindicated [ 8 ]. Our approach utilized an ultra-low-dose spinal technique (bupivacaine 2.5 mg with fentanyl 50 mcg), which provides several physiological advantages in this patient population. Liao et al. (2016) demonstrated that low-dose combined spinal-epidural anesthesia successfully avoids the hemodynamic instability associated with conventional spinal doses in patients with cardiac disease, including those with thyrotoxic heart disease [ 9 ]. The minimal local anesthetic dose produces a gradual, controllable sympathetic block, preserving preload and avoiding precipitous afterload reduction—both critical considerations in the setting of fixed cardiac output from MS and a pressure-overloaded right ventricle from pulmonary hypertension. To compensate for the limited analgesic duration of low-dose spinal anesthesia, we supplemented with bilateral TAP blocks (Fig. 1 ), and this multimodal approach has been validated extensively for post-cesarean analgesia. Kupiec et al. (2018) demonstrated in their randomized trial that TAP block significantly reduces postoperative pain scores at 3, 6, and 12 hours and decreases tramadol consumption after cesarean delivery without hemodynamic complications [ 10 ]. Joseph et al. (2020) confirmed in their comparative study that TAP block with ropivacaine provides approximately 6.5 hours of effective analgesia, substantially reducing opioid requirements and facilitating early mobilization [ 11 ]. In our hemodynamically fragile patient, minimizing opioid use was particularly advantageous as it avoided respiratory depression and preserved consciousness for monitoring neurological status, while the regional technique provided excellent somatic pain control without systemic effects. The favorable outcome in this case fundamentally reflects the coordinated efforts of a multidisciplinary cardio-obstetrics team. DeFilippis et al. (2023), in their JACC Heart Failure state-of-the-art review, emphasized that heart failure and cardiomyopathy are significant contributors to pregnancy-related deaths and that the multidisciplinary cardio-obstetrics team is crucial to optimizing maternal, obstetrical, and fetal outcomes [ 12 ]. Our approach—involving cardiology, high-risk obstetrics, cardiac surgery, and anesthesiology in joint decision-making from the outset—exemplifies this model of care. The availability of cardiopulmonary bypass standby provided an additional safety net for emergent rescue, though fortunately it was not required. This case has several limitations inherent to single case reports, including the inability to generalize findings and the absence of long-term maternal and neonatal follow-up data. The presence of left atrial thrombus/vegetation was concerning for infective endocarditis or cardioembolic risk; however, urgent delivery took precedence given the severity of maternal cardiac compromise. Additionally, the preterm delivery at 30 weeks carries significant neonatal implications requiring specialized care, highlighting the maternal-fetal tradeoffs inherent in such high-risk scenarios. Conclusion This case demonstrates that emergency cesarean delivery can be safely accomplished in patients with severe rheumatic mitral stenosis and pulmonary hypertension through meticulous planning and execution. The combination of low-dose spinal anesthesia with bilateral TAP block provided effective surgical anesthesia and postoperative analgesia while preserving hemodynamic stability. Central to success was the multidisciplinary approach, intensive preoperative optimization, and the availability of cardiac surgical backup. This case adds to the growing body of evidence supporting individualized neuraxial techniques in high-risk cardiac obstetric patients. Abbreviations RHD Rheumatic heart disease MS Mitral stenosis NYHA New York Heart Association SpO₂ Peripheral oxygen saturation TAP Transversus abdominis plane ICU Intensive care unit TSH Thyroid-stimulating hormone CPB Cardiopulmonary bypass NIV Non-invasive ventilation POD Postoperative day NICU Neonatal intensive care unit Declarations Trial registration Not applicable. Ethics approval and consent to participate Ethical approval was not required for this case report in accordance with the institutional policy of Shree Mata Vaishno Devi Narayana Superspeciality Hospital, Kakryal, Reasi, Katra, Jammu and Kashmir, India, as it involved the retrospective review of a single patient's clinical course with no experimental intervention. Written informed consent to participate was obtained from the patient. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of data and materials All data generated or analysed during this study are included in this published article and its figures. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: MS, BJ, SSL, RJ, JAM. The following authors gave final approval of the manuscript: MS, BJ, SSL, RJ, JAM. All authors read and approved the final manuscript. Guarantor Dr. Maninder Singh is the guarantor of this manuscript. The guarantor accepts full responsibility for the finished work and the conduct of the study, had access to the data, and controlled the decision to publish. Acknowledgements Not applicable. References Liaw J, Walker B, Hall L, Gorton S, White AV, Heal C. Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis. PLoS ONE. 2021;16(6):e0253581. 10.1371/journal.pone.0253581 . French KA, Poppas A. Rheumatic Heart Disease in Pregnancy: Global Challenges and Clear Opportunities. Circulation. 2018;137(8):817–9. 10.1161/CIRCULATIONAHA.118.033465 . Vaughan G, Dawson A, Peek M, Sliwa K, Carapetis J, Wade V, Sullivan E. Rheumatic Heart Disease in Pregnancy: New Strategies for an Old Disease? Glob Heart. 2021;16(1):84. 10.5334/gh.1079 . Abdelrahman S, Yousif N. Mitral Stenosis in Pregnancy: A Comprehensive Review of a Challenging Cardio-Obstetric Clinical Entity. Rev Recent Clin Trials. 2019;14(2):136–40. 10.2174/1574887114666190207154413 . Low TT, Guron N, Ducas R, Yamamura K, Charla P, Granton J, Silversides CK. Pulmonary arterial hypertension in pregnancy-a systematic review of outcomes in the modern era. Pulm Circ. 2021;11(2):20458940211013671. 10.1177/20458940211013671 . Lv C, Huang Y, Liao G, Wu L, Chen D, Gao Y. Pregnancy outcomes in women with pulmonary hypertension: a retrospective study in China. BMC Pregnancy Childbirth. 2023;23(1):16. 10.1186/s12884-023-05353-7 . Shafiq F, Sheikh H. Successful Resuscitation and Management of Cardiac Arrest in Pregnancy Due to Undiagnosed Severe Mitral Stenosis: A Case Report. Cureus. 2023;15(2):e35036. 10.7759/cureus.35036 . Rex S, Devroe S. Cardiac disease in pregnancy. Best Pract Res Clin Anaesthesiol. 2022;36(1):191–208. 10.1016/j.bpa.2022.02.005 . Liao Z, Xiong Y, Luo L. Low-dose spinal-epidural anesthesia for Cesarean section in a parturient with uncontrolled hyperthyroidism and thyrotoxic heart disease. J Anesth. 2016;30(4):731–4. 10.1007/s00540-016-2186-1 . Kupiec A, Zwierzchowski J, Kowal-Janicka J, Goździk W, Fuchs T, Pomorski M, Zimmer M, Kübler A. The analgesic efficiency of transversus abdominis plane (TAP) block after caesarean delivery. Ginekol Pol. 2018;89(8):421–4. 10.5603/GP.a2018.0072 . Joseph B, Zachariah SK, Abraham SP. The comparison of effects of fentanyl and dexmedetomidine as adjuvants to ropivacaine for ultrasound-guided transversus abdominis plane block for postoperative pain in cesarean section under spinal anesthesia. J Anaesthesiol Clin Pharmacol. 2020;36(3):377–80. 10.4103/joacp.JOACP_313_18 . DeFilippis EM, Bhagra C, Casale J, et al. Cardio-Obstetrics and Heart Failure: JACC: Heart Failure State-of-the-Art Review. JACC Heart Fail. 2023;11(9):1165–80. 10.1016/j.jchf.2023.07.009 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8884749","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":601493880,"identity":"69e418d2-e528-4ddc-90a4-9fb04898d363","order_by":0,"name":"Maninder 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jahangir","middleName":"Ahmad","lastName":"Mir","suffix":""}],"badges":[],"createdAt":"2026-02-15 08:39:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8884749/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8884749/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104207176,"identity":"67a3ff06-9887-4ec9-a4f5-a8b0357ffbc1","added_by":"auto","created_at":"2026-03-09 07:07:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":87137,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eUltrasound-Guided Transversus Abdominis Plane (TAP) Block Technique (A) anterior view with injection sites and (B) cross-sectional anatomy with the TAP block protocol details\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8884749/v1/b6f2d6e912d6b0ec1c5b6c48.png"},{"id":104207175,"identity":"ca6121ca-f9af-41aa-a2f6-6919a1f3d0fc","added_by":"auto","created_at":"2026-03-09 07:07:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":140234,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTimeline of Clinical Course and Multidisciplinary Management\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8884749/v1/521997b9a0df2270e6e804f9.png"},{"id":105440524,"identity":"1ee72725-58da-42da-a4bf-511f3cf97180","added_by":"auto","created_at":"2026-03-26 05:41:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":761862,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8884749/v1/b4d3d91f-d129-41aa-a1d3-1badee82fa0c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Successful Anesthetic and Perioperative Management of Severe Rheumatic Mitral Stenosis with Pulmonary Hypertension in a Pregnant Woman: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRheumatic heart disease (RHD) continues to pose a significant global health burden, affecting approximately 40\u0026nbsp;million people worldwide, with disproportionate impact on women of childbearing age in endemic regions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The hemodynamic alterations of pregnancy\u0026mdash;including a 30\u0026ndash;50% increase in blood volume, elevated cardiac output, and decreased systemic vascular resistance\u0026mdash;create a particularly hazardous milieu for women with stenotic valvular lesions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Mitral stenosis is the most commonly encountered valvular lesion during pregnancy, with the majority being rheumatic in origin [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA systematic review and meta-analysis by Liaw et al. (2021) demonstrated that RHD during pregnancy is associated with high rates of adverse outcomes, including preterm birth (9.35\u0026ndash;42.97%), low birth weight (12.98\u0026ndash;39.70%), and perinatal death (0.00-9.41%) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The risk is substantially elevated in women with NYHA class III/IV symptoms, with a 2.86-fold increased risk of preterm birth and 3.23-fold increased risk of perinatal death [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Furthermore, moderate-to-severe MS is independently associated with higher rates of intrauterine growth restriction and preterm delivery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePulmonary hypertension superimposed on valvular heart disease dramatically worsens maternal prognosis. Contemporary data indicate maternal mortality rates of 12% overall in patients with pulmonary arterial hypertension during pregnancy, with the highest mortality occurring within 0\u0026ndash;4 days postpartum due to right heart failure, cardiac arrest, and pulmonary hypertensive crises [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The combination of severe MS and pulmonary hypertension thus represents an extreme-risk scenario demanding expert multidisciplinary management.\u003c/p\u003e \u003cp\u003eThe anesthetic approach for cesarean delivery in such patients must balance the need for adequate surgical anesthesia against the catastrophic consequences of hemodynamic instability. We present a case of successful anesthetic management of emergency cesarean section in a patient with severe rheumatic MS and pulmonary hypertension using low-dose spinal anesthesia combined with bilateral TAP block.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 27-year-old primigravida (gravida 1, para 0) at 30 weeks gestation was referred to our tertiary care center with progressive dyspnea and palpitations. She reported mild exertional intolerance before pregnancy (NYHA functional class II) but had deteriorated over the preceding weeks to the point of orthopnea and dyspnea at rest (NYHA class IV). On presentation, vital signs revealed blood pressure 129/89 mmHg, heart rate 120 beats/min, respiratory rate 30 breaths/min, and oxygen saturation 84% on room air, which improved to 96% with 5 L/min oxygen via face mask. Cardiovascular examination demonstrated mid-diastolic (grade 3/6) and holosystolic (grade 4/6) apical murmurs consistent with mitral stenosis and mitral regurgitation, respectively. Bilateral basal crepitations indicated pulmonary congestion, and yellowish skin discoloration suggested hepatic congestion secondary to right heart failure. Obstetric examination confirmed 30 weeks gestation with a viable fetus.\u003c/p\u003e \u003cp\u003eLaboratory workup revealed hemoglobin 8.51 g/dL indicating anemia, total leukocyte count 10,550/mm\u0026sup3;, elevated serum bilirubin (total 2.9 mg/dL, direct 1.4 mg/dL), and alkaline phosphatase 416 IU/L\u0026mdash;findings consistent with congestive hepatopathy. Renal function and coagulation profiles were within normal limits. Electrocardiogram showed sinus tachycardia with left ventricular hypertrophy and left atrial abnormality, while thyroid function testing revealed elevated TSH. Transthoracic echocardiography confirmed severe rheumatic heart disease with critical mitral stenosis (mitral valve area 1 cm\u0026sup2;), severe mitral regurgitation, severe tricuspid regurgitation, moderate aortic regurgitation, severe pulmonary hypertension (systolic pulmonary artery pressure 86 mmHg), dilated left atrium with thrombus/vegetation, and preserved left ventricular ejection fraction (60%).\u003c/p\u003e \u003cp\u003eGiven the complexity of this case, multidisciplinary meetings involving cardiology, high-risk obstetrics, cardiac surgery, and anesthesiology were convened. The patient was admitted to the intensive care unit where aggressive medical optimization was initiated, including furosemide infusion for diuresis, tablet digoxin (Lanoxin) for rate control, levothyroxine (Thyronorm) for hypothyroidism, and antibiotic prophylaxis given the suspicious left atrial mass. After stabilization, the decision was made to proceed with emergency cesarean section at 30\u0026ndash;32 weeks gestation, with cardiopulmonary bypass on standby in the cardiac operating room. The complete timeline of clinical course and multidisciplinary management is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOn the day of surgery, the patient was transferred to the cardiac operating theater where standard American Society of Anesthesiologists monitoring was established along with invasive arterial blood pressure monitoring. The patient was positioned in left lateral uterine displacement to prevent aortocaval compression, avoiding Trendelenburg positioning. A carefully titrated low-dose spinal anesthetic was administered consisting of hyperbaric bupivacaine 0.5% 2.5 mg combined with fentanyl 50 mcg. Following confirmation of adequate dermatomal coverage, ultrasound-guided bilateral TAP blocks were performed using 0.25% bupivacaine 20 mL on each side to supplement intraoperative and postoperative analgesia (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Sensory and motor blockade were achieved gradually without precipitous hemodynamic changes, and heart rate and blood pressure remained within acceptable parameters throughout the procedure with no episodes of heart failure or arrhythmia. The cesarean section proceeded uneventfully, and a live preterm infant was delivered. Two units of packed red blood cells were transfused to correct anemia.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePostoperatively, the patient was transferred to the ICU where multimodal analgesia consisting of intravenous paracetamol and tramadol was continued. Oxygen supplementation was provided with intermittent non-invasive ventilation utilized as needed for respiratory support. By postoperative day 3, the patient had stabilized significantly and was weaned from supplemental oxygen. She was discharged on postoperative day 7 in satisfactory condition with instructions for cardiology and obstetric follow-up.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case illustrates several critical principles in managing severe valvular heart disease during pregnancy. The presentation of our patient\u0026mdash;rapid functional class deterioration, hypoxemia, pulmonary congestion, and hepatic congestion\u0026mdash;reflects the well-documented inability of the stenotic mitral valve to accommodate the increased cardiac output demands of pregnancy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. As emphasized by Abdelrahman and Yousif (2019) in their comprehensive review, cardiac decompensation in MS typically occurs in the late second or third trimester when hemodynamic burden peaks, and again postpartum due to autotransfusion following delivery [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Our patient's trajectory from NYHA class II to class IV over the course of pregnancy exemplifies this pathophysiology, and her presentation aligns closely with the high-risk phenotype described in the literature. The meta-analysis by Liaw et al. demonstrated that NYHA class III/IV status and moderate/severe MS are strong predictors of adverse maternal and fetal outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Similarly, Shafiq and Sheikh (2023) reported a case of undiagnosed severe MS presenting as maternal cardiac arrest at 28 weeks gestation, underscoring the potentially catastrophic nature of this condition when unrecognized or inadequately managed [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Unlike that case, our patient presented before catastrophic decompensation, allowing time for multidisciplinary optimization\u0026mdash;a factor likely contributing to the favorable outcome.\u003c/p\u003e \u003cp\u003eThe presence of severe pulmonary hypertension (86 mmHg) substantially elevated our patient's risk profile and warranted particular attention in perioperative planning. Low et al. (2021) reported in their systematic review of pulmonary arterial hypertension in pregnancy that maternal mortality rates remain at 12% overall, with 61% of deaths occurring within the first 4 postpartum days [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The authors emphasized that right heart failure and pulmonary hypertensive crises are the leading causes of mortality in this population [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Similarly, Lv et al. (2023) in their retrospective Chinese cohort found that idiopathic pulmonary arterial hypertension carried the highest mortality (50% in their cohort), though secondary pulmonary hypertension due to left heart disease\u0026mdash;as in our patient\u0026mdash;also conferred significant risk with 35.1% of patients requiring ICU admission [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Our strategy of ICU preoperative optimization with diuresis and rate control, combined with cardiopulmonary bypass standby, reflects adherence to these evidence-based principles and likely contributed to the successful outcome.\u003c/p\u003e \u003cp\u003eThe choice of anesthetic technique is paramount in patients with severe MS and pulmonary hypertension. Traditional teaching cautioned against neuraxial anesthesia due to concerns about sudden sympathectomy causing hypotension, tachycardia, and decompensation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, contemporary evidence increasingly supports carefully titrated neuraxial techniques over general anesthesia in appropriately selected patients. Rex and Devroe (2022), in their comprehensive review of cardiac disease in pregnancy published in Best Practice \u0026amp; Research Clinical Anaesthesiology, concluded that there is no difference in maternal outcomes between general and regional anesthesia, and that incremental neuraxial techniques should be preferred when not otherwise contraindicated [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Our approach utilized an ultra-low-dose spinal technique (bupivacaine 2.5 mg with fentanyl 50 mcg), which provides several physiological advantages in this patient population. Liao et al. (2016) demonstrated that low-dose combined spinal-epidural anesthesia successfully avoids the hemodynamic instability associated with conventional spinal doses in patients with cardiac disease, including those with thyrotoxic heart disease [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The minimal local anesthetic dose produces a gradual, controllable sympathetic block, preserving preload and avoiding precipitous afterload reduction\u0026mdash;both critical considerations in the setting of fixed cardiac output from MS and a pressure-overloaded right ventricle from pulmonary hypertension.\u003c/p\u003e \u003cp\u003eTo compensate for the limited analgesic duration of low-dose spinal anesthesia, we supplemented with bilateral TAP blocks (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e), and this multimodal approach has been validated extensively for post-cesarean analgesia. Kupiec et al. (2018) demonstrated in their randomized trial that TAP block significantly reduces postoperative pain scores at 3, 6, and 12 hours and decreases tramadol consumption after cesarean delivery without hemodynamic complications [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Joseph et al. (2020) confirmed in their comparative study that TAP block with ropivacaine provides approximately 6.5 hours of effective analgesia, substantially reducing opioid requirements and facilitating early mobilization [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In our hemodynamically fragile patient, minimizing opioid use was particularly advantageous as it avoided respiratory depression and preserved consciousness for monitoring neurological status, while the regional technique provided excellent somatic pain control without systemic effects.\u003c/p\u003e \u003cp\u003eThe favorable outcome in this case fundamentally reflects the coordinated efforts of a multidisciplinary cardio-obstetrics team. DeFilippis et al. (2023), in their JACC Heart Failure state-of-the-art review, emphasized that heart failure and cardiomyopathy are significant contributors to pregnancy-related deaths and that the multidisciplinary cardio-obstetrics team is crucial to optimizing maternal, obstetrical, and fetal outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our approach\u0026mdash;involving cardiology, high-risk obstetrics, cardiac surgery, and anesthesiology in joint decision-making from the outset\u0026mdash;exemplifies this model of care. The availability of cardiopulmonary bypass standby provided an additional safety net for emergent rescue, though fortunately it was not required. This case has several limitations inherent to single case reports, including the inability to generalize findings and the absence of long-term maternal and neonatal follow-up data. The presence of left atrial thrombus/vegetation was concerning for infective endocarditis or cardioembolic risk; however, urgent delivery took precedence given the severity of maternal cardiac compromise. Additionally, the preterm delivery at 30 weeks carries significant neonatal implications requiring specialized care, highlighting the maternal-fetal tradeoffs inherent in such high-risk scenarios.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case demonstrates that emergency cesarean delivery can be safely accomplished in patients with severe rheumatic mitral stenosis and pulmonary hypertension through meticulous planning and execution. The combination of low-dose spinal anesthesia with bilateral TAP block provided effective surgical anesthesia and postoperative analgesia while preserving hemodynamic stability. Central to success was the multidisciplinary approach, intensive preoperative optimization, and the availability of cardiac surgical backup. This case adds to the growing body of evidence supporting individualized neuraxial techniques in high-risk cardiac obstetric patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRheumatic heart disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMitral stenosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNYHA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNew York Heart Association\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSpO₂\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeripheral oxygen saturation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTransversus abdominis plane\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensive care unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTSH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThyroid-stimulating hormone\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiopulmonary bypass\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-invasive ventilation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostoperative day\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNeonatal intensive care unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e Ethical approval was not required for this case report in accordance with the institutional policy of Shree Mata Vaishno Devi Narayana Superspeciality Hospital, Kakryal, Reasi, Katra, Jammu and Kashmir, India, as it involved the retrospective review of a single patient\u0026apos;s clinical course with no experimental intervention. Written informed consent to participate was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e All data generated or analysed during this study are included in this published article and its figures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: MS, BJ, SSL, RJ, JAM. The following authors gave final approval of the manuscript: MS, BJ, SSL, RJ, JAM. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGuarantor\u003c/strong\u003e Dr. Maninder Singh is the guarantor of this manuscript. The guarantor accepts full responsibility for the finished work and the conduct of the study, had access to the data, and controlled the decision to publish.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLiaw J, Walker B, Hall L, Gorton S, White AV, Heal C. Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis. PLoS ONE. 2021;16(6):e0253581. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0253581\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0253581\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrench KA, Poppas A. Rheumatic Heart Disease in Pregnancy: Global Challenges and Clear Opportunities. Circulation. 2018;137(8):817\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/CIRCULATIONAHA.118.033465\u003c/span\u003e\u003cspan address=\"10.1161/CIRCULATIONAHA.118.033465\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaughan G, Dawson A, Peek M, Sliwa K, Carapetis J, Wade V, Sullivan E. Rheumatic Heart Disease in Pregnancy: New Strategies for an Old Disease? Glob Heart. 2021;16(1):84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5334/gh.1079\u003c/span\u003e\u003cspan address=\"10.5334/gh.1079\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdelrahman S, Yousif N. Mitral Stenosis in Pregnancy: A Comprehensive Review of a Challenging Cardio-Obstetric Clinical Entity. Rev Recent Clin Trials. 2019;14(2):136\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2174/1574887114666190207154413\u003c/span\u003e\u003cspan address=\"10.2174/1574887114666190207154413\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLow TT, Guron N, Ducas R, Yamamura K, Charla P, Granton J, Silversides CK. Pulmonary arterial hypertension in pregnancy-a systematic review of outcomes in the modern era. Pulm Circ. 2021;11(2):20458940211013671. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/20458940211013671\u003c/span\u003e\u003cspan address=\"10.1177/20458940211013671\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLv C, Huang Y, Liao G, Wu L, Chen D, Gao Y. Pregnancy outcomes in women with pulmonary hypertension: a retrospective study in China. BMC Pregnancy Childbirth. 2023;23(1):16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-023-05353-7\u003c/span\u003e\u003cspan address=\"10.1186/s12884-023-05353-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShafiq F, Sheikh H. Successful Resuscitation and Management of Cardiac Arrest in Pregnancy Due to Undiagnosed Severe Mitral Stenosis: A Case Report. Cureus. 2023;15(2):e35036. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.35036\u003c/span\u003e\u003cspan address=\"10.7759/cureus.35036\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRex S, Devroe S. Cardiac disease in pregnancy. Best Pract Res Clin Anaesthesiol. 2022;36(1):191\u0026ndash;208. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bpa.2022.02.005\u003c/span\u003e\u003cspan address=\"10.1016/j.bpa.2022.02.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiao Z, Xiong Y, Luo L. Low-dose spinal-epidural anesthesia for Cesarean section in a parturient with uncontrolled hyperthyroidism and thyrotoxic heart disease. J Anesth. 2016;30(4):731\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00540-016-2186-1\u003c/span\u003e\u003cspan address=\"10.1007/s00540-016-2186-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKupiec A, Zwierzchowski J, Kowal-Janicka J, Goździk W, Fuchs T, Pomorski M, Zimmer M, K\u0026uuml;bler A. The analgesic efficiency of transversus abdominis plane (TAP) block after caesarean delivery. Ginekol Pol. 2018;89(8):421\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5603/GP.a2018.0072\u003c/span\u003e\u003cspan address=\"10.5603/GP.a2018.0072\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoseph B, Zachariah SK, Abraham SP. The comparison of effects of fentanyl and dexmedetomidine as adjuvants to ropivacaine for ultrasound-guided transversus abdominis plane block for postoperative pain in cesarean section under spinal anesthesia. J Anaesthesiol Clin Pharmacol. 2020;36(3):377\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/joacp.JOACP_313_18\u003c/span\u003e\u003cspan address=\"10.4103/joacp.JOACP_313_18\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeFilippis EM, Bhagra C, Casale J, et al. Cardio-Obstetrics and Heart Failure: JACC: Heart Failure State-of-the-Art Review. JACC Heart Fail. 2023;11(9):1165\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jchf.2023.07.009\u003c/span\u003e\u003cspan address=\"10.1016/j.jchf.2023.07.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Rheumatic heart disease, Mitral stenosis, Pulmonary hypertension, Pregnancy, Low-dose spinal anesthesia, TAP block","lastPublishedDoi":"10.21203/rs.3.rs-8884749/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8884749/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRheumatic heart disease (RHD) remains a significant cause of maternal morbidity and mortality, particularly in low- and middle-income countries. Severe mitral stenosis (MS) with pulmonary hypertension during pregnancy presents formidable challenges for anesthetic management.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eA 27-year-old primigravida at 30 weeks gestation presented with acute cardiac decompensation secondary to severe rheumatic MS (mitral valve area 1 cm\u0026sup2;), severe mitral and tricuspid regurgitation, and pulmonary hypertension (86 mmHg). She deteriorated from NYHA class II to IV with hypoxemia (SpO₂ 84%). A multidisciplinary team coordinated her care, optimizing her preoperatively in the ICU. Emergency cesarean section was performed under low-dose spinal anesthesia (bupivacaine 2.5 mg with fentanyl 50 mcg) supplemented with bilateral transversus abdominis plane (TAP) block. Hemodynamic stability was maintained without cardiac decompensation. The patient was discharged on postoperative day 7 in stable condition.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case demonstrates that low-dose neuraxial anesthesia combined with TAP block offers a safe anesthetic approach for cesarean delivery in patients with severe valvular heart disease and pulmonary hypertension, provided meticulous hemodynamic monitoring and multidisciplinary care are ensured.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Successful Anesthetic and Perioperative Management of Severe Rheumatic Mitral Stenosis with Pulmonary Hypertension in a Pregnant Woman: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-09 07:07:47","doi":"10.21203/rs.3.rs-8884749/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"490dee70-32c8-4fb2-a327-131b9e4ecc02","owner":[],"postedDate":"March 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-26T05:40:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-09 07:07:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8884749","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8884749","identity":"rs-8884749","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}