Spinal Anesthesia for Cesarean Delivery in Selected Patients with Severe Pulmonary Hypertension: A Case Report

Introduction: Pregnancy in patients with pulmonary hypertension carries a very high maternal risk and is classified as modified World Health Organization class IV, particularly when associated with congenital heart disease. Case Description: We report a 28-year-old woman at 35 weeks of gestation with a large secundum atrial septal defect, severe tricuspid regurgitation, and significant pulmonary hypertension who underwent elective cesarean delivery. She presented in a relatively stable clinical condition without signs of decompensated right heart failure, but with limited functional capacity and low oxygen saturation on room air. Echocardiography demonstrated right-sided chamber dilatation, a predominantly left-to-right shunt with intermittent bidirectional flow, a D-shaped left ventricle, and preserved left ventricular systolic function. Delivery was planned in a tertiary referral center with intensive care support and multidisciplinary management. Single-shot spinal anesthesia with hyperbaric prilocaine was performed under invasive arterial monitoring, with a restrictive fluid strategy, careful vasopressor titration, and careful avoidance of factors that could increase pulmonary vascular resistance or c..ompromise hemodynamic stability. Intraoperatively, hemodynamic status remained within acceptable limits without severe hypotension, arrhythmia, or signs of acute right ventricular failure. A live neonate was delivered with good early outcome, and the patient remained stable during postoperative care in the maternal intensive care unit until discharge on postoperative day 3. Conclusion: This case suggests that spinal anesthesia may be feasible in carefully selected patients with severe pulmonary hypertension when supported by meticulous hemodynamic control, invasive monitoring, and multidisciplinary perioperative care