Combined Spinal-Epidural Analgesia for Laboring Parturient with Mitral Stenosis

Understanding the changes in cardiovascular physiology that occur during pregnancy is important in order to optimize anesthetic management and to avoid adverse maternal and fetal outcomes. The effects of a normal gestation on the cardiovascular system are particularly significant in parturients with cardiac valvular pathology. In this paper, we discuss the anesthetic management of a laboring parturient with mitral stenosis using combined spinal-epidural labor analgesia. The patient received minimal intravenous hydration (5-10 mL/h) to avoid fluid overload and was encouraged to drink clear liquids during labor. High dose of fentanyl (20-25 μg) was injected intrathecally for initial pain control. Preservative-free morphine (0.2-0.3 mg) was then used to manage contraction-related pain while maintaining stable maternal hemodynamics on an epidural infusion. The patient had adequate analgesia and tolerated labor and vaginal delivery without complications. Due to the severity of her mitral stenosis, intrapartum fluid management required guidance by invasive monitoring. A brief literature review of the anesthetic management of parturients with mitral stenosis is also presented to compare and contrast the different combined spinal-epidural techniques and outcomes.