Perioperative Management of a Pregnant Patient With Severe Mitral Stenosis and Pulmonary Hypertension for Repeat Cesarean Section: The Role of Standby Extracorporeal Membrane Oxygenation

Managing pregnant patients with severe mitral stenosis (MS) and pulmonary hypertension (PH) remains a challenge, requiring a multidisciplinary approach to mitigate maternal and fetal risks. We report a case of a 29-year-old female, gravida 6 para 5, at 37 weeks' gestation with severe rheumatic MS, significant PH, and right ventricular (RV) dysfunction who underwent an elective repeat cesarean delivery. Due to her elevated risk of hemodynamic collapse, invasive monitoring, incremental epidural anesthesia, and standby extracorporeal membrane oxygenation (ECMO) were utilized. Intraoperative vasopressor and uterotonic selection was optimized to maintain systemic perfusion while minimizing pulmonary vascular resistance. The procedure was successfully completed without complications, with close inpatient monitoring post-partum; both maternal and neonatal outcomes were favorable. This case highlights the value of detailed perioperative preparation, multidisciplinary coordination, and personalized anesthetic and pharmacologic management in pregnancies complicated by severe cardiac disease.