A 31-year-antenatal lady with critical mitral stenosis presented for emergency caesarean section with fetal distress. She had acute onset atrial fibrillation. She was given a combined spinal epidural (CSE) anaesthesia and her arrhythmia was successfully managed after delivery of the baby with intravenous calcium channel blocker. Mitral stenosis is the most common valvular heart disease complicating pregnancy in developing countries. The physiological changes during pregnancy may exacerbate their cardiac symptoms. They may present with complications like congestive cardiac failure, atrial fibrillation, or pulmonary thromboembolism during the antenatal, intrapartum, or postpartum period. Here we discuss the management of parturient woman with high maternal and fetal risk presenting for emergency caesarean. The merits of regional anaesthesia and the importance of invasive monitoring are also discussed. 1. Introduction A 31-year-old lady presented to the antenatal clinic at 34 weeks of gestation with increasing shortness of breath. She was a known case of rheumatic heart disease with mitral stenosis and had undergone balloon mitral valvotomy 12 years ago and closed mitral commissurotomy 7 years ago. She was gravida 8, para 2 with 5 spontaneous abortions and had undergone caesarean section twice since the commissurotomy but had only one living issue who was 3 years old. The other had died a neonatal death. She was on oral Digoxin 0.25？mg od and penicillin prophylaxis since the past seven years. During the present pregnancy, her dyspnea had progressed from NYHA class II to class III. She was put on bed rest and started on diuretics. As part of her workup for elective caesarean section for obstetric reasons, she presented for preanaesthesia evaluation. On auscultation of the heart, she had a mid-diastolic murmur in the mitral area and loud P2. She had no signs of congestive cardiac failure. Her electrocardiogram showed a normal sinus rhythm with a heart rate of 80/min. She had a normal coagulation profile with prothrombin time 13/13, activated partial thromboplastin time 29/31, and platelet count 210 × 109/litre. Her haemoglobin was 11.7？g%. She was advised a fresh echocardiograph and the risk of anaesthesia was explained to her. The next day she presented for emergency CS with onset of preterm labour and a nonreassuring fetal heart rate. She was immediately taken to the operating room. On examination, the patient was dyspneic at rest and unable to lie supine. She had pedal edema and her jugular venous pulse was raised. A 2D echocardiography done only that
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