Epidural Anesthesia for a Cesarean Section in a Parturient Patient with Congestive Heart Failure and Respiratory Insufficiency - A case report

We report a case in which epidural anesthesia was successfully administered during a cesarean section of a 35 years old parturient patient with severe congestive heart failure and respiratory in sufficiency at 33 weeks of gestation. The patient had a past history of mitral regurgitation and mitral valve prolapse treated by mitral valve replacement ten years prior. When limited motion of the prosthetic mitral valve developed, congestive heart failure recurred and was aggravated by the pregnancy. In addition, the patient presented with symptoms of respiratory insufficiency including NYHA III dyspnea, orthopnea, severe pulmonary hypertension (systolic pulmonary arterial pressure: 112 mmHg) due to severe aortic regurgitation, pleural effusion and pulmonary edema on admission. Four-days after admission, with premature labor pain and fetal distress, the patient underwent an emergency cesarean section. Due to the orthopnea, the patient could not breathe in the supine position, and we chose to give epidural anesthesia at a sitting position for preserving self-respiration and to prevent a ventilation-perfusion mismatch that would possibly develop during general anesthesia. Moreover, we could control postoperative pain and maintain a minimal, gradual hemodynamic change throughout the epidural anesthesia. During surgery, the hemodynamic instabilities were controlled by the use of dopamine, dobutamine, ephedrine and milrinone. We safely finished the cesarean section under epidural anesthesia and the patient was sent to the intensive care unit postoperatively to manage congestive heart failure and respiratory insufficiency. (Korean J Anesthesiol 2007; 53: 656～9)