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Address reprint requests to Dr. Weiss: Department of Anesthesiology, University Hospital, Raemistr 100, CH-8091 Zurich, Switzerland. Address electronic mail to: branko.weiss@ifa.usz.ch plicated delivery of a neonate. She refused treatment at that time. During her second pregnancy, at 15 weeks’ gestation, Doppler echocardiography showed a right atrial diameter of 6.2 cm (normal diameter, 2.2-4.1 cm), a short-axis end-diastolic diameter of the right ventricle of 5.1 cm (normal, 1.9 4.0 cm), a right ventricle with eccentric hypertrophy and fractional area shortening of 3396, and a small, normally contracting left ventricle. The patient was lost to further follow-up examinations and reappeared at 31 weeks’ gestation, severely dyspneic at rest and with dilated neck veins and lower limb edema. Ultrasonograph showed a growth-retarded fetus. The patient’s systemic arterial pressure (AP) was 108/69 mmHg, with a regular heart rate of 94 beatshin. Electrocardiography showed a sinus rhythm, prominent P waves in V,-V,, and a partial right bundle branch block. Oxygen saturation by pulse oximetry (Sp,,) of 88% increased to more than 94% with supplemented nasal oxygen. Hemoglobin was 11.4 g/dl, and platelet count was 177 1030 /~ l . Radial artery and thermodilution pulmonary artery catheters were inserted to test the response to nitric oxide (NO) and to oxygen breathing at inspiratory fraction ( F I ~ ] ~ ) of 1.0. Nitric oxide (40 ppm) failed to improve pulmonary hemodynamics, but oxygen breathing slightly decreased pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) and the catheters were removed. Dalteparin (Fragmin; Pharm Upjohn, Stockholm, Sweden), a lowmolecular-weight heparin, was administered subcutaneously at 5,000 and 7,500 IU/day. .The patient received digoxin, magnesium for its tocolitic properties, and betamethasone at 31 weeks and 32 weeks of gestation to promote fetal lung maturation. Continued right-sided heart dilatation (atrial diameter = 6.3 cm, end-diastolic ventricular diameter = 5.4 cm) and a decrease of right ventricular fractional arrd shortening to 25?4 were found at 32 weeks’ gestation. Ultrasound biometry showed insufficient fetal growth, and the decision was made to proceed with cesarean delivery at 34 weeks’ gestation. In the operating room, the patient was placed in a supine position with left uterine displacement. Radial artery, thermodilution pulmonary artery, and lumbar epidural (L2-3) catheters were placed during local anesthesia. After baseline measurements, 6 I/min 0, by mask increased Sp,,, from 90 to 96%. The hemodynamic parameters, hemo

Pregnant Patient with Primary Pulmonary Hypertension: Inhaled Pulmonary Vasodilators and Epidural Anesthesia for Cesarean Delivery