cardiac lesions worsen during gestation as cardiovascular and physiological changes of pregnancy results in depressed cardiovascular functions . women deteriorate from new york heart association class 1 - 3 or 4 due to physiologic changes , to support the growth , development and delivery of the baby . there is considerable debate as to the optimal anesthetic management for lower segment cesarean section ( lscs ) , with some recommending use of regional anesthesia , while others prefer general anesthesia . the choice of anesthesia should be appropriate to ensure the well - being of mother and fetus . we report the titrated epidural analgesia with assisted second stage of labor for smooth vaginal delivery in a patient with severe mitral and aortic valve stenosis . a 32-year - old parturient ( gravida 2 , para 1 ) was admitted in our tertiary care hospital at 32 weeks gestation . her past pregnancy was uneventful , with spontaneous vaginal delivery at term under epidural analgesia . her current pregnancy is uneventful except intermittent dyspnea beginning in the second trimester . as per the cardiologist , she was a very high risk for normal vaginal delivery due to severe valvular obstructive lesions . when reviewed by a cardiologist at 32 week 's gestation , she has a systolic ejection murmur graded 6/6 at the second left intercostal space radiating to the neck . the electrocardiogram showed normal sinus rhythm ( nsr ) of 95/min with a normal axis , left ventricular hypertrophy and blood pressure ( bp ) of 120/60 mmhg . echocardiography revealed severe mitral ( valve area : 0.6 cm ) and aortic valve stenosis ( aortic area : 0.8 cm ) with mild pulmonary hypertension ( 40 mm hg ) . hematological and biochemical investigations were normal . a multidisciplinary meeting involving obstetrician , cardiologist and anesthesiologist was held to determine the appropriate management strategy . she was counseled for epidural analgesia for labor , on the premise that elective induction at 39 weeks preceded by an epidural analgesia would minimize physiological changes and subsequent complications during delivery . at 39 week 's gestation the options for analgesia during labor and delivery , and anesthesia for lscs , were discussed in detail with the patient along with the risks and benefits . she requested epidural analgesia , and written informed consent was obtained . at 39.2 weeks elective induction of labor was planned , and patient was shifted to obstetric theatre for placement of the epidural catheter . baseline hemodynamic parameters were noted ( pulse : 76/min nsr , bp : 124/76 mm hg , spo2 : 100% ) . intravenous access secured with 18 gauge cannula and ringer lactate was started at 2 ml / kg / h . under local anesthesia , right radial artery ( 20 guage jelco ) and right internal jugular vein ( teleflex medical arrow 7 f triple lumen ) epidural procedure explained to the patient . under all aseptic precaution with patient in sitting position 1.5 ml of 2% lignocaine infiltrated in l2-l3 interspace . epidural space entered with b. braun 18 g tuohys epidural needle with loss of water resistance technique , and 20 guage epidural catheter was passed up to 4 cm mark through the needle . the catheter was secured in place at 10 cm mark following negative aspiration for blood and cerebrospinal fluid . the patient was moved to the supine position with moderate left lateral tilt to avoid aorto - caval compression . patient was transferred to cardiac intensive care unit ( icu ) and dinoprostone gel was inserted per vaginally by gynecologist . she went into an active phase of labor after 6 h of cerviprime instillation with uterine activity of 2 - 3 contractions/10 min . vaginal examination revealed that cervix was 4 cm dilated and 60% effaced . a carefully titrated mixture of fentanyl 2 g / ml and 0.125% bupivacaine was given through the epidural catheter with continuous monitoring of vital parameters . a total of 16 ml was given to ensure that the patient had analgesia up to t10 dermatomal level without motor blockade . the patient remained pain free and hemodynamically stable throughout the first stage of labor ( pulse rate : 65 - 80/min , systolic bp : 80 - 120 , cvp : 4 - 6 cm of water , spo2 : 98 - 100% ) . to avoid the cardiovascular stress with pushing and straining in the second stage of labor when the cervix was fully dilated , and all the prerequisites for a forceps delivery were met , they were applied to assist in a smooth vaginal delivery . prior to this , the patient was made to sit and a second dose of the epidural analgesia ( 8 ml of 0.125% bupivacaine and 2 g / ml fentanyl ) was administered so that predominant analgesia of the perineum could be achieved . a 2800 g female who had apgar scores of 9/10 after 1 and 5 min , respectively , was delivered vaginally . 20 units oxytocin was started by infusion to prevent the cardiovascular effects of the bolus dose which include hypotension , tachycardia , and fluid retention . following delivery , the patient remained in the icu with continuous monitoring for 24 h. no cardiovascular events were reported , and she was shifted to the postnatal ward . following an uneventful recovery , she was discharged and advised to undergo double valve replacement . cardiovascular stress due to pregnancy , labor and delivery is challenging for anesthesiologist for management of pregnant cardiac patient . in general regurgitant lesions are well tolerated and stenotic lesions are poorly tolerated during pregnancy . lscs is usually performed for cardiac patients to avoid undesirable effects of pain and marked valsalva effect of prolonged efforts at pushing in the second stage of labor . the critical problem in parturient with aortic stenosis is the inability to maintain cardiac output in the presence of decreased systemic vascular resistance ( svr ) . sympathetic blockade associated with epidural anesthesia can cause decreased preload and diastolic pressure leading to myocardial ischemia with cardiac failure . when mitral and aortic stenosis co - exist the clinical features of mitral stenosis usually predominates . the co - existing mitral stenosis reduces left ventricular filling resulting in decreased cardiac output . thus , the use of epidural analgesia in our case with combined stenosis seemed to be beneficial . the physiological changes associated with pregnancy have important consequences on hemodynamic parameters in patients with underlying heart disease . there is 50% increase in cardiac output , mainly in the first and second trimesters . later , the increase in cardiac output is sustained by an increase in heart rate . the requirements for an increase in cardiac output and heart rate can lead to decompensation aortic stenosis . during labor , cardiac output increases by a further 45% above the pre - labor level . with each contraction , up to 500 ml of blood is displaced from the uterus into the circulation . after delivery of the baby , auto - transfusion occurs from the placenta into the maternal circulation . thus the periods of greatest risk for cardiac events are earlythird trimester , during labor and delivery and the immediate postpartum period . case series of women with aortic stenosis have shown that pregnancy is well - tolerated when the patients were asymptomatic before pregnancy . in patients with mild or moderate aortic stenosis no cardiac complications were observed during pregnancy , while cardiac events were observed in 10% of all women with significant aortic valve stenosis . the use of neuraxial block in the patient with clinically significant cardiac disease is a controversial issue because of possible cardiovascular fluctuation with blockade of the autonomic system . historically , anesthesiologists have avoided regional anesthesia in the parturient with cardiovascular disease because of the adverse cardiovascular changes in a patient with a fixed cardiac output . hypotensionin these patients can produce myocardial ischemia . since epidural analgesia reduces catecholamine release and hemodynamic stress , it is used in low concentrations for vaginal delivery in these patients . suntharalingam et al . used the low dose technique with 0.1% bupivacaine and fentanyl and concluded that epidural analgesia may be used for delivery in aortic stenosis with close hemodynamic monitoring . the goals of management for patients with mitral and aortic stenosis are : 
 maintain sinus rhythm.avoid both tachycardia and bradycardia.maintain adequate preload.maintain svr.avoid myocardial depression.avoid aorto - caval compression . our study showed that the vaginal delivery under low dose epidural analgesia is successful and safe alternative to lscs for pregnant cardiac patients . for optimal maternal and fetal outcomes , these patients must be managed through multidisciplinary approach involving obstetrician , anesthesiologists and cardiologists . pregnant patient with significant multivalvular heart disease requires careful preoperative assessment and planning to optimize cardiac function and to decide the mode of delivery and anesthetic technique . high risk pregnant cardiac patient requires intensive care with monitoring as period particularly after the delivery carries high risk of maternal death . if oxytocin is required postdelivery , it should be given by infusion to avoid the potential cardiovascular effects of the bolus dose .
maternal heart disease complicates 0.2 - 3% of pregnancies . 
 the optimal management of the pregnant patient with cardiac disease depends on the co - operative efforts of the obstetrician , the cardiologist and the anesthesiologist involved in peripartum care . 
 a comprehensive understanding of physiology of pregnancy and pathophysiology of underlying cardiac disease is of primary importance in provision of obstetric analgesia or anesthesia for these high - risk groups of patients.we report a successful and uncomplicated use of epidural anesthesia for labor and delivery in patient with combined aortic and mitral stenosis .