Anesthesia Management of Simultaneous Cesarean Section and Valve Replacement: A Tight-rope Walk Twice!

Background: Rheumatic valvular stenosis is the most common valvular heart disease which is encountered in pregnant patients in our country.Combination of severe mitral or aortic stenosis (AS) and physiological changes that accompany pregnancy amplifies problems.Case report: Two patients with severe rheumatic valve stenosis underwent simultaneous cesarean section (CS) and valve replacement (VR) surgeries.Heart rate (HR) control with diltiazem was required in one patient who was in atrial fibrillation (AF).Anesthesia was induced with etomidate and rocuronium.Cesarean section was performed followed by VR.Conclusion and clinical significance: Management of anesthesia for such cases is a challenge, as there is a risk of worsening cardiac failure at multiple stages, increasing maternal and fetal morbidity and mortality.The conventional high-dose opioid-based anesthesia strategy followed for VR in stenotic lesions may cause neonatal respiratory depression requiring ventilatory support.A tight balance between maintaining maternal hemodynamics, uterine blood flow, and fetal oxygenation is required for good maternal and fetal outcomes.