Perioperative anesthetic management of perforated appendicitis in a pregnant patient with severe pulmonary hypertension: a rare case report

Background The incidence of severe pulmonary hypertension associated with a valvular heart disease in pregnancy is very rare. This patient may have presented with different defects like Eisenmneger syndrome, systematic- to-pulmonary shunts, and other defects. This case report contributes to the existing literature by providing insight into the perioperative anesthetic management of early first - trimester pregnant patient with severe pulmonary hypertension and mixed valvular heart disease who presented with perforated appendicitis. Case presentation We report a 26-year-old woman in early pregnancy presenting with abdominal pain diagnosed as perforated appendicitis. She had a history of palpitations, shortness of breath, orthopnea, fatigue, and chest pain at exertion prior to this complaint. She had a grade II holosystolic murmur at the second intercostal space and apex but no radiating on cardiac examination. Echocardiography revealed severe pulmonary hypertension (estimated pulmonary artery pressure 91 mmHg) with mixed valvular heart disease (moderate mitral stenosis, severe mitral regurgitation, mild aortic regurgitation, and mild-to-moderate tricuspid regurgitation. Conclusion General anesthesia effectively managed severe pulmonary hypertension and mixed valvular heart disease using etomidate (0.3 mg/kg), balanced with opioids, and minimizing airway stimulation with 1% lidocaine and midazolam before intubation.