A deliberate approach of epidural volume expansion with hydroxyethyl starch in a patient with mitral stenosis posted for caesarean section: A case report

Pallavi Deulkar; Amol Singam; Neeta Verma

doi:10.31893/multiscience.2025456

Keywords:

pregnancy

cardiac disease

hydroxyethyl starch

combined spinal-epidural anaesthesia

cesarean section

mitral stenosis

Abstract

Pregnancy complicated by cardiac disease poses significant challenges in perioperative management, particularly during cesarean section. Mitral stenosis, characterized by impaired left ventricular filling, can exacerbate these challenges due to its impact on maternal hemodynamics. The choice of anesthesia in such cases requires careful consideration to ensure both maternal safety and optimal fetal outcomes. We present a case of successful anesthesia management utilizing a combined spinal-epidural technique with hydroxyethyl starch (HES) volume expansion in a parturient with mitral stenosis undergoing elective cesarean section. This case illustrates not only the efficacy of the chosen method but also highlights a nuanced interpretation of the results that may subtly reflect biases towards certain practices or outcomes. Through this careful approach, we demonstrate the effectiveness of HES in managing anesthesia in a complex clinical scenario while acknowledging the potential for interpretative bias in the evaluation of such techniques. This case highlights the importance of individualized anesthetic approaches and multidisciplinary collaboration in the perioperative care of pregnant patients with cardiac comorbidities.
References
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3. Elkayam, U., Goland, S., Pieper, P. G., & Silversides, C. K. (2016). High-Risk Cardiac Disease in Pregnancy: Part II. Journal of the American College of Cardiology, 68(5), 502–516. https://doi.org/10.1016/j.jacc.2016.05.050
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9. Marko, N. F. (2012). Hyperosmolar therapy for intracranial hypertension: Time to dispel antiquated myths. American Journal of Respiratory and Critical Care Medicine, 185(5), 467–468. https://doi.org/10.1164/rccm.201109-1698ED
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12. Patel, M., Ninave, S., Bele, A., Deulkar, P., & Alaspurkar, N. (2023). Anaesthetic Management of Parturient with Severe Mitral Stenosis Planned for Elective Caesarean Section for Safe Confinement. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH, 17(3), UD01–UD03. http://research.europeanlibrarypress.com/id/eprint/1263/
13. Saghafinia, M., Jalali, A., Eskandari, M., Eskandari, N., & Lak, M. (2017). The Effects of Hydroxyethyl Starch 6% and Crystalloid on Volume Preloading Changes following Spinal Anesthesia. Advanced Biomedical Research, 6, 115. https://doi.org/10.4103/abr.abr_151_16
14. Siu, S. C., Sermer, M., Colman, J. M., Alvarez, A. N., Mercier, L. A., Morton, B. C., Kells, C. M., Bergin, M. L., Kiess, M. C., Marcotte, F., Taylor, D. A., Gordon, E. P., Spears, J. C., Tam, J. W., Amankwah, K. S., Smallhorn, J. F., Farine, D., Sorensen, S., & Cardiac Disease in Pregnancy (CARPREG) Investigators. (2001). Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation, 104(5), 515–521. https://doi.org/10.1161/hc3001.093437 Deulkar et al. (2025) 6
15. Tyagi, A., Kumar, A., Girotra, G., & Sethi, A. K. (2011). Combined spinal epidural and epidural volume extension: Interaction of patient position and hyperbaric bupivacaine. Journal of Anaesthesiology, Clinical Pharmacology, 27(4), 459–464. https://doi.org/10.4103/0970-9185.86577

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

How to cite

Deulkar, P., Singam, A., & Verma, N. (2025). A deliberate approach of epidural volume expansion with hydroxyethyl starch in a patient with mitral stenosis posted for caesarean section: A case report. Multidisciplinary Science Journal, 7(9), 2025456. https://doi.org/10.31893/multiscience.2025456

[1] Arzola, C., & Wieczorek, P. M. (2011). Efficacy of low-dose bupivacaine in spinal anaesthesia for Caesarean delivery: Systematic review and meta-analysis. British Journal of Anaesthesia, 107(3), 308–318. https://doi.org/10.1093/bja/aer200

[2] Carvalho, B., Durbin, M., Drover, D. R., Cohen, S. E., Ginosar, Y., & Riley, E. T. (2005). The ED50 and ED95 of intrathecal isobaric bupivacaine with opioids for cesarean delivery. Anesthesiology, 103(3), 606–612. https://doi.org/10.1097/00000542-200509000-00025

[3] Elkayam, U., Goland, S., Pieper, P. G., & Silversides, C. K. (2016). High-Risk Cardiac Disease in Pregnancy: Part II. Journal of the American College of Cardiology, 68(5), 502–516. https://doi.org/10.1016/j.jacc.2016.05.050

[4] Garg, R., Hariharan, U. R., & Malik, I. (2021). Critical Care Management of the Parturient with Cardiac Disease. Indian Journal of Critical Care Medicine: Peer-Reviewed, Official Publication of Indian Society of Critical Care Medicine, 25(Suppl 3), S230–S240. https://doi.org/10.5005/jp-journals-10071-24068

[5] Hartog, C. S., Natanson, C., Sun, J., Klein, H. G., & Reinhart, K. (2014). Concerns over use of hydroxyethyl starch solutions. BMJ (Clinical Research Ed.), 349, g5981. https://doi.org/10.1136/bmj.g5981

[6] Kannan, M., & Vijayanand, G. (2010). Mitral stenosis and pregnancy: Current concepts in anaesthetic practice. Indian Journal of Anaesthesia, 54(5), 439–444. https://doi.org/10.4103/0019-5049.71043

[7] Kinsella, S. M., Carvalho, B., Dyer, R. A., Fernando, R., McDonnell, N., Mercier, F. J., Palanisamy, A., Sia, A. T. H., Van de Velde, M., Vercueil, A., & Consensus Statement Collaborators. (2018). International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia. Anaesthesia, 73(1), 71–92. https://doi.org/10.1111/anae.14080

[8] Lacasse, M.-A., Roy, J.-D., Forget, J., Vandenbroucke, F., Seal, R. F., Beaulieu, D., McCormack, M., & Massicotte, L. (2011). Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: A double-blind randomized trial. Canadian Journal of Anaesthesia = Journal Canadien D’anesthesie, 58(4), 384–391. https://doi.org/10.1007/s12630-010-9450-x

[9] Marko, N. F. (2012). Hyperosmolar therapy for intracranial hypertension: Time to dispel antiquated myths. American Journal of Respiratory and Critical Care Medicine, 185(5), 467–468. https://doi.org/10.1164/rccm.201109-1698ED

[10] Munnur, U., de Boisblanc, B., & Suresh, M. S. (2005). Airway problems in pregnancy. Critical Care Medicine, 33(10 Suppl), S259-268. https://doi.org/10.1097/01.ccm.0000183502.45419.c9

[11] Patel, A., Waheed, U., & Brett, S. J. (2013). Randomised trials of 6% tetrastarch (hydroxyethyl starch 130/0.4 or 0.42) for severe sepsis reporting mortality: Systematic review and meta-analysis. Intensive Care Medicine, 39(5), 811–822. https://doi.org/10.1007/s00134-013-2863-6

[12] Patel, M., Ninave, S., Bele, A., Deulkar, P., & Alaspurkar, N. (2023). Anaesthetic Management of Parturient with Severe Mitral Stenosis Planned for Elective Caesarean Section for Safe Confinement. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH, 17(3), UD01–UD03. http://research.europeanlibrarypress.com/id/eprint/1263/

[13] Saghafinia, M., Jalali, A., Eskandari, M., Eskandari, N., & Lak, M. (2017). The Effects of Hydroxyethyl Starch 6% and Crystalloid on Volume Preloading Changes following Spinal Anesthesia. Advanced Biomedical Research, 6, 115. https://doi.org/10.4103/abr.abr_151_16

[14] Siu, S. C., Sermer, M., Colman, J. M., Alvarez, A. N., Mercier, L. A., Morton, B. C., Kells, C. M., Bergin, M. L., Kiess, M. C., Marcotte, F., Taylor, D. A., Gordon, E. P., Spears, J. C., Tam, J. W., Amankwah, K. S., Smallhorn, J. F., Farine, D., Sorensen, S., & Cardiac Disease in Pregnancy (CARPREG) Investigators. (2001). Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation, 104(5), 515–521. https://doi.org/10.1161/hc3001.093437 Deulkar et al. (2025) 6

[15] Tyagi, A., Kumar, A., Girotra, G., & Sethi, A. K. (2011). Combined spinal epidural and epidural volume extension: Interaction of patient position and hyperbaric bupivacaine. Journal of Anaesthesiology, Clinical Pharmacology, 27(4), 459–464. https://doi.org/10.4103/0970-9185.86577

Abstract

References

How to cite