Inhaled epoprostenol via high-flow nasal cannula and intravenous treprostinil for management of severe pulmonary arterial hypertension during cesarean delivery with epidural anesthesia: a case report

Current guidelines for managing pulmonary arterial hypertension (PAH) in pregnancy recommend the use of PAH-specific medications, including phosphodiesterase type-5 inhibitors, calcium channel blockers, and prostacyclin analogs. However, there is limited consensus on the optimal agents and routes of administration during delivery. This case report describes a 24-year-old gravida 3 para 1 with Group I PAH, admitted at 29 weeks' gestation, for a planned cesarean delivery at 30 weeks gestation. She presented with worsening dyspnea, syncope, and right ventricular dysfunction. A multidisciplinary team planned her management, which included epidural anesthesia, inhaled epoprostenol (iEpo) via high-flow nasal cannula (HFNC), and intravenous (IV) treprostinil. Intraoperatively, despite continued IV treprostinil, her pulmonary artery pressure (PAP) remained elevated, prompting the initiation of iEpo. This resulted in a significant reduction in PAP, leading to successful delivery and maternal-fetal outcomes without complications. Postoperative management included continued iEpo with a hospital discharge seven days later in stable condition. This report highlights the novel use of iEpo via HFNC for managing PAH during cesarean delivery, suggesting its potential for reducing maternal morbidity and mortality in this high-risk population. Future studies should explore the simultaneous use of inhaled and intravenous prostacyclin analogs in pregnant patients with PAH.