Graded Epidural Anesthesia, Norepinephrine–Milrinone Support, and Fluid Restriction in a Parturient with Severe Tricuspid Regurgitation, Pulmonary Hypertension, Lupus, and Patent Foramen Ovale: An Observational Analytic Case Study

Abstract

Background. Maternal cardiovascular disease carries high morbidity and mortality. Delivery is especially dangerous when severe tricuspid regurgitation, pulmonary hypertension, lupus and an intracardiac right-to-left shunt coexist.

Objective. To describe the anesthetic management, hemodynamic course and early outcome of one parturient with these conditions who needed emergency Cesarean delivery.

Methods. A 30-year-old gravida 3 para 2 woman at 37+1 weeks presented with antepartum hemorrhage. She had systemic lupus erythematosus (SLEDAI 4), severe functional tricuspid regurgitation (effective regurgitant orifice area 0.4 cm², basal right ventricular diameter 8.1 cm), high-probability pulmonary hypertension (estimated systolic pulmonary artery pressure 74.7 mmHg) and a patent foramen ovale with right-to-left shunting. Cesarean delivery used graded epidural anesthesia with 0.5% levobupivacaine, infusions of norepinephrine, milrinone, dobutamine and furosemide, 500 mL of crystalloid and dilute oxytocin. The CARE guideline was followed.

Results. Mean arterial pressure ranged from 64 to 95 mmHg. A 2.56 kg infant was delivered with Apgar scores of 7, 8 and 9. After delivery, PaO₂ fell to 41 mmHg and recovered within 12 minutes with oxygen and vasoactive titration. Vasoactive support stopped by postoperative day 2. On day 3 the patient moved to the ward with lactate 0.9 mmol/L and estimated systolic pulmonary artery pressure 61.7 mmHg.

Conclusion. Graded epidural anesthesia with norepinephrine and milrinone support and restricted fluids was followed by hemodynamic stability and survival of mother and infant. One case cannot establish causation, and follow-up ended on day 3.