11th. INTERNATIONAL CONFERENCE ON MATHEMATICS, ENGINEERING, NATURAL AND MEDICAL SCIENCES, 30 - 31 January 2021, pp.17
In this case report, we present our anesthesia management in a twin pregnant patient with mitra
MS, pulmonary hypertension (PH) and placenta accrete (PA) for caesarean section.
A 36-years-old multigravida parturient with a dichorionic diamniotic pregnancy at 24 weeks
gestation was presented to the anesthetic department for caesarean section with a diagnosis of
severe MS, PH and PA.
The transthoracic echocardiography revealed MS with a mitral valve area of 1 cm2
, ¼ mitral
regurgitation, ¾ tricuspid regurgitation, and PH with a systolic pulmonary artery pressure of 88
mmHg. The left atrium was dilated, the left ventricular ejection fraction was 65%.
General anesthesia was planned for the cesarean section. An invasive arterial line and central
venous catheterization were applied. Anesthesia was induced by 250 mg pentothal and 100 mcg
fentanyl, and maintained with 1-1,5 % sevoflurane.
The placenta was found to invade the bladder. During the hysterectomy, the patient experienced
transient hypotensive episodes. Dopamine was administered to prevent low mean artery
pressure (MAP) by titrating at 5-10 µg/kg/min dopamine doses. A total of 4500 ml crystalloid
and a 1000 ml colloid were given and 7 units of packed red cells, 4 units of fresh frozen plasma
(FFP), 1 unit platelet concentrate, and 8 units of cryoprecipitate were transfused
intraoperatively. The surgery lasted at 4 hours and the estimated blood loss was around 5000
As hemostasis was achieved and the patient was hemodynamically stable, she was extubated
and transferred to the intensive care unit (ICU) in the stable condition. Postoperative care was
Pregnancy places a high physiologic demand on the cardiovascular system. Maternal mortality
rate rises up to 16-30 % in women with PH1,2. Our patient had a PA, which significantly
complicated the management of anesthesia.
Anesthesia management for cesarean section in a twin pregnancy with severe MS, PH and PA
should begin with preoperative assessment that needs to continue through the surgery and the
postpartum period. Choosing intraoperative suitable hemodynamic monitoring, tailoring the
anesthetic technique, and optimizing cardiovascular and respiratory functions using appropriate
drugs and fluids are the crucial factors for the management of anesthesia in this patient
Keywords: Twin pregnancy, placenta accrete, mitral stenosis, pulmonary hypertension, sectio.