Revisiting epidural anaesthesia in a parturient with idiopathic pulmonary hypertension posted for caesarean section

Cesarean Section in a Group 1 Pulmonary Hypertension Parturient Patient: A Case Report

Severe pulmonary hypertension (PH) during pregnancy poses considerable challenges due to the physiological changes and increased cardiovascular demands. Close multidisciplinary management is essential throughout the peripartum period. The critical steps taken to provide anesthesia safely and successfully for a planned cesarian section are outlined, with special care for communication between the cardiothoracic surgery and obstetric team. A 31-year-old G3P1112 (three pregnancies, one term delivery, one pre-term delivery, one abortion, with two living children) patient with a history of systemic lupus erythematosus complicated by Group 1 PH presented to the operating room for a planned 34-week cesarean section. Pulmonary artery systolic pressure (PASP) was noted to be 68 mmHg at this time. Intravenous (IV) treprostinil at 8 ng/kg/min through a tunneled right subclavian line was initiated in her third trimester, and a day before her cesarean section, she was admitted for a lumbar epidural catheter placement. In the operating room, IV treprostinil was continued and a high-flow nasal cannula with inhaled nitric oxide at 20 ppm was initiated. A right internal jugular vein pulmonary artery catheter was placed for close monitoring of her pulmonary artery pressures, with a PASP reading of 64 mmHg at the start of the case. Femoral arterial and venous access was placed by the cardiothoracic surgery team for cardiopulmonary bypass standby. Intra-operative surgical analgesia was achieved by epidural lidocaine. A cesarean section was performed and was uncomplicated despite her post-delivery autotransfusion, where her PASP went as high as 89 mmHg. Uterine atony was managed with an oxytocin infusion. Epidural morphine was administered through the epidural catheter for post-operative analgesia. In the post-operative recovery room, her PASP was back down to baseline at 62 mmHg. The patient proceeded to have an uneventful postpartum hospital stay and was discharged home without any complications. While severe PH poses a challenge in the care of a parturient patient, safe and successful management may be achieved as outlined in this case report.