1) Background: Pulmonary arterial hypertension (PAH) in pregnancy is a life-threatening condition associated with very high maternal and fetal mortality due to acute right heart failure. Anesthetic management for cesarean section in these patients is a major challenge, particularly when general anesthesia is chosen.
2) Case summary: A 30-year-old primigravida at 35 weeks of gestation was admitted with exertional dyspnea. She had a history of patent ductus arteriosus and pulmonary arterial hypertension associated with congenital heart disease (Eisenmenger syndrome). On admission she had mild dyspnea and an SpO2 of 92%; echocardiography showed a patent ductus arteriosus with a bidirectional shunt, an estimated pulmonary artery pressure of 116 mmHg and signs of right ventricular dysfunction.
3) Interventions and clinical course: An elective cesarean section was indicated at 36 weeks and 5 days of gestation because of progressive respiratory failure and right ventricular dysfunction, together with fetal growth restriction. Endotracheal general anesthesia was chosen to proactively secure the airway and control ventilation. The mother received 4 days of postoperative intensive care, and the neonate required no respiratory support. She was discharged on postoperative day 14.
4) Conclusion: In this case, general anesthesia was successfully performed using an induction strategy that maintained hemodynamic stability with a continuous intravenous noradrenaline infusion, lung-protective ventilation and continuous invasive hemodynamic monitoring. As this is a single case report, further data from other centers are needed before general recommendations can be made.