Background: Rheumatic Heart Disease is still a burden especially in the third world countries. Its progressive condition with a concomitant infective endocarditis will surely push towards heart failure. Pregnancy complicates the existing condition and presents a great anaesthetic challenge. To date, there is no best mode of delivery in pregnant cardiac patients. However, vaginal delivery is not contraindicated and cesarean section is indicated if there is hemodynamic compromise.
Case: A 39-year old, G8P7 (5-2-0-3) managed as a case of Rheumatic heart disease, infective endocarditis, valvular heart disease, severe aortic regurgitation, severe mitral regurgitation, in failure. She was initially managed medically with antibiotics and heart failure regimen, and on the course of medical management, went into distress and was intubated. Initial ECG revealed new-onset complete LBBB, thus referred to EPS service. She responded well with medical management, and was subsequently extubated and transferred to ward for expectant management. Nephrology consultation was done due to rising creatinine (Appendix A), she was managed as a case of pre-renal acute kidney injury and serial creatinine determination was ordered. Perinatologist monitored the fetal status and dexamethasone was started. On the course of admission, patient went into sudden respiratory distress, which compromised the fetal status, thus she was scheduled for emergency caesarean section with MAVR, TVA with IOTEE.
Conclusion: Management of pregnant patients with heart failure entails a lot of considerations from the maternal well-being to fetal outcomes. Anesthetic management can be a dilemma as anesthetic agents have altered pharmacodynamics with consideration of crossing the placental barrier that affects the immediate fetal status. Thus careful planning via a multi-team approach will ensure a successful outcome.