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Background and Aims An 18-year-old female,presented to labour ward, G2P0 36+6 weeks pregnant,with history of cardiac transplant for idiopathic dilated cardiomyopathy diagnosed at age of 13 and transplanted at age 13,with dual chamber pacemaker, with good exercise tolerance.Due to worsening acute kidney injury,secondary to a combination of Tacrolimus and obstructive hydro nephrosis of the right kidney,urgent category 2 caesarean section delivery was needed to avoid sepsis.

Methods Prior to theatre,pacemaker was checked,preoperative ECG showed a pacemaker dependant rhythm and USS of renal tract showed a moderate hydronephrosis of right kidney.Preoperative potassium was raised, treated with a dextrose-insulin infusion.Irradiated blood was crossmatched. Two wide bore cannulas and arterial line were inserted. Patient was consented and a spinal anaesthetic was administered.Intraoperative cell salvage was used due to anaemia in pregnancy. Postoperatively, patient was managed in labour ward HDU with strict fluid balance.Kidney functions gradually improved and Tacrolimus levels was monitored.

Results Preconception councelling is paramount.pregnancy should be delayed at least 1 year after a heart transplant.Higher incidence of pre- eclampsia,eclampsia and gestational diabetes have been reported.Monitoring of immunosuppressant levels is vital.

Conclusions Pregnancy after heart transplantation brings many new considerations to the anaesthetist especially as this is a rare occurrence! this case report shows the importance of a multidisciplinary team approach whilst keeping the patient at the centre of combined decision making. Patients require a tailored anaesthetic plan and careful perioperative preparation to ensure safe patient care. Punnoose, L.R. et al. (2020) ‘Pregnancy outcomes in heart transplant recipients,’ The Journal of Heart and Lung Transplantation, 39(5), pp. 473–480.

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