Severe aortic stenosis in a parturient with twins: The challenges

Abstract

Aortic stenosis (AS) in young women is often the result of a congenital bicuspid aortic valve, occurring in 1–2% of the population. Although the anaesthetic management of parturients with AS remains controversial, the high rate of caesarean delivery is consistent among studies. A 30-year-old primi gravida with severe AS presented for elective caesarean section at 36 weeks gestation (twins). She had a failed balloon valvuloplasty 15 years ago and declined further intervention. Prior to induction, invasive lines and prophylactic extracorporeal membrane oxygenation cannulas were placed. A modified rapid sequence intubation technique with propofol/remifentanil target-controlled infusion and suxamethonium was performed. Anaesthesia was maintained using total intravenous anaesthesia. Both twins were delivered uneventfully and oxytocin infusion was commenced. Gradual desaturation to 95% occurred intraoperatively and a focused lung ultrasound and transthoracic echocardiogram were performed. Intravenous frusemide 20 mg was administered empirically. Post-operatively, the patient was extubated and transferred to the Intensive Care Unit for monitoring.Severe AS is associated with high risk of maternal morbidity and mortality. In our case, due to the twin gestation, cardiac output and metabolic demands rise exponentially leading to increased risks. A multidisciplinary approach with appropriate monitoring and point-of-care testing are key to such complex cases to achieve favourable maternal and foetal outcomes.