Graded Epidural Anesthesia, Norepinephrine–Milrinone Support, and Fluid Restriction in a Parturient with Severe Tricuspid Regurgitation, Pulmonary Hypertension, Lupus, and Patent Foramen Ovale: An Observational Analytic Case Study

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Severe functional tricuspid regurgitation, high-probability pulmonary hypertension, systemic lupus erythematosus, and patent foramen ovale in pregnancy (n=1). Intervention: Graded epidural anesthesia with norepinephrine-milrinone support and fluid restriction. Primary outcome: Perioperative hemodynamic stability and estimated systolic pulmonary artery pressure (sPAP) at postoperative day 3.

Q: What does this research mean for the field?

Graded epidural anesthesia combined with norepinephrine–milrinone support and fluid restriction maintains hemodynamic stability (MAP 64–95 mmHg) and reduces systolic pulmonary artery pressure during emergency Cesarean delivery in parturients with severe tricuspid regurgitation, pulmonary hypertension, and a right-to-left shunt. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Fitri Hapsari Dewi; Propan Hanggada Satyamakti Mubarak; Aditya Baskoro

doi:10.37275/jacr.v7i2.978

October 6, 2026Journal of Anesthesiology and Clinical ResearchOpen Access

Graded Epidural Anesthesia, Norepinephrine–Milrinone Support, and Fluid Restriction in a Parturient with Severe Tricuspid Regurgitation, Pulmonary Hypertension, Lupus, and Patent Foramen Ovale: An Observational Analytic Case Study

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Key result

Graded epidural anesthesia with inotrope support and fluid restriction reduces sPAP by ~17% postoperatively.

n=1

Why the study?

Maternal cardiovascular disease carries high morbidity and mortality, and delivery is especially dangerous when severe tricuspid regurgitation, pulmonary hypertension, lupus, and an intracardiac right-to-left shunt coexist.

Key Points

To describe the anesthetic management, hemodynamic course, and early outcome of a parturient with severe tricuspid regurgitation, pulmonary hypertension, lupus, and a patent foramen ovale undergoing emergency Cesarean delivery.
Clinical case of a 30-year-old gravida 3 para 2 woman at 37+1 weeks gestation presenting with antepartum hemorrhage, systemic lupus erythematosus (SLEDAI score 4), severe functional tricuspid regurgitation (EROA 0.4 cm²), high-probability pulmonary hypertension (sPAP 74.7 mmHg), and a patent foramen ovale with right-to-left shunting.
Anesthetic management for emergency Cesarean delivery utilized graded epidural anesthesia with 0.5% levobupivacaine to T4, infusions of norepinephrine, milrinone, dobutamine, and furosemide, restrictive crystalloid administration (500 mL), and dilute oxytocin according to CARE guidelines.
Maternal mean arterial pressure was maintained between 64 and 95 mmHg, resulting in the delivery of a 2.56 kg infant with Apgar scores of 7, 8, and 9.
Post-delivery autotransfusion provoked acute right-to-left shunting and transient hypoxemia with PaO₂ dropping to 41.0 mmHg, which fully recovered within 12 minutes following FiO₂ increase and vasoactive titration.
Vasoactive support was discontinued by postoperative day 2, and the patient transferred to the general ward on postoperative day 3 with an estimated sPAP of 61.7 mmHg and a lactate level of 0.9 mmol/L.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 30-year-old female parturient at 37+1 weeks gestation with systemic lupus erythematosus, severe functional tricuspid regurgitation, pulmonary hypertension, and a patent foramen ovale undergoing emergency Cesarean delivery, followed for 3 days postoperatively.

I

Intervention

Graded epidural anesthesia at L2-L3 using 0.5% preservative-free levobupivacaine in 3 mL fractional aliquots every 5 minutes up to 12 mL (60 mg) with fentanyl 50 µg (followed by postoperative epidural infusion of 0.375% levobupivacaine at 3 mL/h), paired with continuous intraoperative infusions of norepinephrine (5.2 mL/h; 0.05-0.08 µg/kg/min), milrinone (1.0 mL/h; 0.375 µg/kg/min without bolus), dobutamine (2.4 mL/h; 2.5 µg/kg/min), and furosemide (0.5 mL/h; 5 mg/h), IV dexamethasone 5 mg bolus, restrictive fluid therapy (500 mL of 0.9% NaCl crystalloid), and a dilute slow oxytocin infusion (5 IU in 500 mL normal saline at 10 mIU/min).

O

Outcome

Perioperative hemodynamic course (including beat-to-beat mean arterial pressure, serial arterial blood gases, and echocardiographic right ventricular and shunt dynamics) and early maternal and neonatal survival up to postoperative day 3.surrogate

Limitations

Single-patient case report cannot establish causation
Follow-up ended on postoperative day 3 at ward transfer
Multiple interventions were applied simultaneously, so the individual contribution of each element cannot be separated
Right heart catheterization was not performed to invasively confirm pulmonary vascular resistance
Inferential hypothesis testing and p-values were not used because they are not valid for a single subject
Follow-up ended on postoperative day 3
Right heart catheterization was not performed

Implication

This case report illustrates that graded epidural anesthesia paired with norepinephrine-milrinone vasoactive support and strict fluid restriction can maintain hemodynamic stability and achieve short-term maternal and neonatal survival during emergency Cesarean delivery in a high-risk parturient with severe tricuspid regurgitation, pulmonary hypertension, lupus, and a right-to-left shunting patent foramen ovale.

Abstract

Background. Maternal cardiovascular disease carries high morbidity and mortality. Delivery is especially dangerous when severe tricuspid regurgitation, pulmonary hypertension, lupus and an intracardiac right-to-left shunt coexist. Objective. To describe the anesthetic management, hemodynamic course and early outcome of one parturient with these conditions who needed emergency Cesarean delivery. Methods. A 30-year-old gravida 3 para 2 woman at 37+1 weeks presented with antepartum hemorrhage. She had systemic lupus erythematosus (SLEDAI 4), severe functional tricuspid regurgitation (effective regurgitant orifice area 0.4 cm², basal right ventricular diameter 8.1 cm), high-probability pulmonary hypertension (estimated systolic pulmonary artery pressure 74.7 mmHg) and a patent foramen ovale with right-to-left shunting. Cesarean delivery used graded epidural anesthesia with 0.5% levobupivacaine, infusions of norepinephrine, milrinone, dobutamine and furosemide, 500 mL of crystalloid and dilute oxytocin. The CARE guideline was followed. Results. Mean arterial pressure ranged from 64 to 95 mmHg. A 2.56 kg infant was delivered with Apgar scores of 7, 8 and 9. After delivery, PaO₂ fell to 41 mmHg and recovered within 12 minutes with oxygen and vasoactive titration. Vasoactive support stopped by postoperative day 2. On day 3 the patient moved to the ward with lactate 0.9 mmol/L and estimated systolic pulmonary artery pressure 61.7 mmHg. Conclusion. Graded epidural anesthesia with norepinephrine and milrinone support and restricted fluids was followed by hemodynamic stability and survival of mother and infant. One case cannot establish causation, and follow-up ended on day 3.

Discussion

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Cite This Study

Dewi et al. (2026) conducted a case report in Severe functional tricuspid regurgitation, high-probability pulmonary hypertension, systemic lupus erythematosus, and patent foramen ovale in pregnancy (n=1). Graded epidural anesthesia with norepinephrine-milrinone support and fluid restriction was evaluated on Perioperative hemodynamic stability and estimated systolic pulmonary artery pressure (sPAP) at postoperative day 3. Graded epidural anesthesia with norepinephrine-milrinone support and fluid restriction maintained MAP at 64–95 mmHg and reduced sPAP by 17.4% (74.7 to 61.7 mmHg) by day 3.

synapsesocial.com/papers/6ae28e56cbadf70daf6c41da https://doi.org/10.37275/jacr.v7i2.978

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Graded Epidural Anesthesia, Norepinephrine–Milrinone Support, and Fluid Restriction in a Parturient with Severe Tricuspid Regurgitation, Pulmonary Hypertension, Lupus, and Patent Foramen Ovale: An Observational Analytic Case Study

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Graded Epidural Anesthesia, Norepinephrine–Milrinone Support, and Fluid Restriction in a Parturient with Severe Tricuspid Regurgitation, Pulmonary Hypertension, Lupus, and Patent Foramen Ovale: An Observational Analytic Case Study

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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