Sudden onset of severe pulmonary edema after emergency cesarean section
© The Author(s) 2016
Received: 14 June 2016
Accepted: 2 September 2016
Published: 22 September 2016
Mitral valve stenosis (MS) associated with rheumatic disease no longer represents a major heart problem during the perinatal period in Japan. Here we present a case of acute heart failure due to MS after emergency cesarean section (CS). The patient was transferred due to the development of fetal distress at 36 weeks gestation and underwent an emergency CS under general anesthesia. She developed acute heart failure immediately postoperatively and was diagnosed with MS associated with pulmonary artery hypertension for the first time. She underwent percutaneous transvenous mitral commissurotomy and was discharged from our hospital in good condition.
PTMC using the Inoue balloon catheter has become an accepted treatment option for patients with severe symptomatic MS. PTMC provides palliation for pregnant women with MS, with a reported success rate of nearly 100 %. Successful balloon valvuloplasty increases the valve area to >1.5 cm2 without a substantial increase in mitral regurgitation . A report showed that mean MVA before the procedure (range, 0.75 to 1.2 cm2) increased after the procedure to 1.7 to 2.2 cm2. These results are comparable to the results reported on non-pregnant patients with MS . In the present case, MS was not diagnosed before the patient was transferred to our hospital, and the patient presented with no pathological events, such as congestive heart failure and arrhythmia. Moreover, there was no time to diagnose MS from the time of arrival to CS due to fetal distress. Consequently, appropriate medication or invasive MS intervention was not performed until the postpartum period.
In the present case, the patient was diagnosed with MS associated with pulmonary edema for the first time during the postpartum period. It can explain decompensation in a postpartum woman with critical MS as follows. The sudden increase in the pre-load immediately following delivery, due to autotransfusion from the uterus, may flood the central circulation, resulting in severe pulmonary edema. In addition, given that autotransfusion of blood continues for 24–72 h post-delivery, there is an extended risk of pulmonary edema for several days post-delivery . Maternal mortality occurs most frequently during this time period . However, MS onset was within 2 h after delivery. It might be too early to explain only with this theory. In the present case, we performed general anesthesia in the patient as she underwent rapid induction. General anesthesia is disadvantageous as it increases pulmonary arterial pressure and tachycardia during endotracheal intubation. In addition, the harmful effects of positive pressure ventilation on venous return may ultimately lead to heart failure . Regional anesthesia has proven to be a safe technique in cardiac patients undergoing CS . That said, we have no information regarding MS development with anesthesia induction, so it may be prudent to perform regional anesthesia for now.
We experienced and managed a patient who was diagnosed with MS associated with pulmonary edema for the first time after emergency CS. An adequate perioperative management by a multidisciplinary team comprising an anesthesiologist, cardiologist, critical care physician, and obstetrician may lead to a reduction in perinatal mortality and morbidity.
Mitral valve stenosis
Percutaneous transvenous mitral commissurotomy
right ventricular systolic pressure
Research fund of the Department of Anesthesiology, Osaka Medical College
Availability of data and materials
YS collected data and drafted the manuscript; TS, OU, TA, NK, JN, and TM revised the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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