Combined Spinal-Epidural Analgesia in the Management of Labouring Parturients with Mitral Stenosis

We report the use of combined spinal-epidural analgesia during labour in three parturients with moderately severe mitral stenosis. In each case, rapid analgesia was achieved using intrathecal fentanyl 25 micrograms without major haemodynamic changes. Maintenance analgesia was then established gradually using a dilute epidural infusion of bupivacaine 0.1% and fentanyl 0.0002%, with the avoidance of large or rapid boluses of local anaesthetic. Supplementary analgesia in the latter stages of labour was provided using slow epidural boluses of fentanyl, with or without a low concentration of bupivacaine, which was sufficient to allow controlled instrumental deliveries. We conclude that combined spinal-epidural analgesia is a useful technique for providing analgesia and maintaining haemodynamic stability in parturients with mitral stenosis.