Spinal anesthesia for urgent cesarean section in a parturient with RYR1 mutation-associated malignant hyperthermia susceptibility: a case report

Abstract

Introduction

Malignant hyperthermia (MH) is a rare pharmacogenetic disorder triggered by volatile anesthetics and succinylcholine. MH susceptibility in pregnancy requires prospective anesthetic planning to ensure maternal and fetal safety. This case reports the successful management of an urgent cesarean section under spinal anesthesia in a parturient with pre-pregnancy genetic confirmation of MH susceptibility.

Main symptoms and clinical findings

A 27-year-old primigravida (G1P0) at 38 weeks gestation presented with labor pain. She had a known pathogenic RYR1 variant (c.10561G > A) identified before pregnancy due to significant family history (grandfather’s intraoperative death). Labor failed to progress in the first stage, necessitating an urgent (Category 2) lower segment cesarean section. Preoperative physical and neuromuscular examinations were normal.

Main diagnoses, therapeutic interventions, and outcomes

The patient had autosomal dominant MH susceptibility confirmed by whole exome sequencing. Regional anesthesia was selected as the preferred trigger-free technique; a single-shot spinal anesthetic with 12 mg of 0.5% hyperbaric bupivacaine at L4-L5 achieved a T4 sensory level. Strict MH precautions were implemented: anesthesia machine flushed with 100% oxygen, vaporizers removed, activated charcoal filters applied, CO₂ absorbent replaced, and succinylcholine and volatile agents excluded. Dantrolene was immediately available. Hemodynamics were maintained with left uterine displacement, crystalloid colloid, and phenylephrine infusion. The decision-to-incision interval was 40 min and decision-to-delivery interval 45 min. The intraoperative and 48-hour postoperative course was uneventful, with stable end-tidal CO₂ (32–36 mmHg), normothermia (36.5–37.0 °C), heart rate 80–95 bpm, and no muscle rigidity. A healthy neonate (birth weight 3.1 kg, Apgar 8/9) was delivered. The patient was discharged on postoperative day three in stable condition.

Conclusion

This case demonstrates that spinal anesthesia is a safe and effective trigger-free technique for urgent cesarean section in MH-susceptible parturient when strict precautions are followed. Pre-pregnancy genetic diagnosis enabled prospective multidisciplinary planning and contributed to excellent maternal and neonatal outcomes.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s40748-026-00288-1.

Introduction

Malignant hyperthermia (MH) is an inherited skeletal muscle disorder that manifests as a life-threatening hypermetabolic crisis when susceptible individuals are exposed to halogenated volatile anesthetics or succinylcholine. The condition is primarily caused by pathogenic variants in the RYR1 gene, which encodes the ryanodine receptor type 1, a calcium release channel in the sarcoplasmic reticulum of skeletal muscle [1]. Trigger exposure leads to uncontrolled calcium release, sustained muscle contraction, rapid ATP depletion, and cellular leakage of potassium, creatine kinase, and myoglobin into the circulation [2]. The estimated prevalence of MH susceptibility ranges from 1 in 10,000 to 1 in 250,000 anesthetic procedures depending on the population studied [3], with mortality rates of 3–5% even with appropriate treatment [1]. Although rare, MH remains a significant anesthetic concern, particularly when genetic susceptibility is unknown.

In the obstetric population, MH susceptibility presents unique challenges. Recent research has explored gynecological and obstetric manifestations in women with RYR1 variants, revealing that affected individuals are more likely to have planned cesarean Sections. (19.80% vs. 8.82% in controls) and may have higher rates of postpartum bleeding (18.18% vs. 5.71%), although the latter did not reach statistical significance [4]. Importantly, MH susceptibility does not impede normal labor, and vaginal delivery can be safely undertaken when triggering agents are avoided [5]. Early regional anesthesia epidural or spinal is recommended during labor as it provides a safe means for emergency procedures without increasing fetal MH risk compared to general anesthesia [5]. If general anesthesia becomes necessary, strict precautions must be implemented, including a vapor-free machine, total intravenous anesthesia, exclusion of all triggering agents, and immediate dantrolene availability [5, 6].

The rarity of MH and its autosomal dominant inheritance pattern (50% offspring risk) underscore the value of pre-pregnancy or early antenatal genetic diagnosis. Identification of a pathogenic RYR1 variant enables prospective multidisciplinary planning, trigger-free anesthetic protocols, and informed genetic counseling for the patient and her family. Despite the importance of such planning, reports of genetically confirmed MH susceptibility in parturient undergoing emergency cesarean section remain limited, particularly those describing pre-pregnancy molecular confirmation that allowed for optimized perioperative management.

This case report describes the successful anesthetic management of an urgency cesarean section under spinal anesthesia in a 27-year-old primigravida with genetically confirmed MH susceptibility due to a pathogenic RYR1 variant (c.10561G > A) identified before pregnancy. The case highlights the value of pre-pregnancy genetic testing, the safety of spinal anesthesia with strict trigger-free precautions, and the importance of multidisciplinary preparation in achieving favorable maternal and neonatal outcomes.

Case presentation

This case report was prepared in strict accordance with the CARE (CAse REport) guidelines, an internationally recognized framework developed to enhance the accuracy, transparency, and usefulness of case reports. The CARE checklist was followed to systematically organize all key sections of the report. The use of the CARE guidelines ensures that this report provides a clear, complete, and structured account of the clinical case, facilitating its use for peer-to-peer communication, clinical education, and hypothesis generation for future research [7].

Patient information

The patient is a 27-year-old Saudi Arabian primigravida (G1P0) at 38 weeks of gestation, with height 152 cm, weight 58 kg, and BMI 25.1 kg/m². She is employed at Qassim University and Medical City. She presented with progressive labor pain over several hours associated with irregular uterine contractions, reporting no other systemic symptoms.

Her medical history includes depression previously treated with fluoxetine, which was discontinued prior to conception following psychiatric review; she remained clinically stable throughout pregnancy without antidepressant therapy. She has no known drug allergies and no history of neuromuscular disease, exercise intolerance, muscle cramps, weakness, or previous episodes suggestive of malignant hyperthermia. She has no history of previous anesthesia or surgery.

Family history is significant for malignant hyperthermia or anesthesia-related complications, as her grandfather was suspected to have malignant hyperthermia and died suddenly during a surgical procedure. Additional family history includes cerebral atrophy, infertility, and Down syndrome.

The patient is a non-smoker, denies alcohol or substance use, and has maintained adequate antenatal follow-up.

Genetic testing and counseling

Whole exome sequencing was performed before pregnancy because the couple was consanguineous and had a significant family history of multiple conditions, including cerebral atrophy, infertility, Down syndrome, and diabetes. Additionally, the family history included a grandfather who died suddenly during surgery, raising concern for hereditary malignant hyperthermia susceptibility. The genetic testing identified a pathogenic RYR1 variant (NM_000540.2:c.10561G > A, p.(Gly3521Ser)) in a heterozygous state, confirming autosomal dominant malignant hyperthermia susceptibility (Supplementary report). This pre-conception diagnosis allowed for prospective multidisciplinary planning, including formal antenatal anesthesia consultation, counseling regarding MH risk, and preparation for trigger-free anesthetic management during delivery.

Antenatal planning process

Following confirmation of the pathogenic RYR1 variant before pregnancy, a formal multidisciplinary planning meeting was conducted involving anesthesiology, obstetrics, and genetics teams. The following management plan was established prospectively:

• Obstetric Planning: Vaginal delivery was initially planned, as MH susceptibility does not impede normal labor and vaginal delivery is safe when triggering agents are avoided. However, because of the risk of cesarean section, contingency anesthetic plans were prepared for all possible obstetric scenarios.

• Anesthetic Planning by Scenario:

1. Elective cesarean section: Planned single-shot spinal anesthesia with 12 mg hyperbaric bupivacaine. Combined spinal-epidural (CSE) was considered as an alternative, but the anticipated surgical duration was expected to be within the duration of a single spinal block.

2. Category 2 cesarean section (urgent, no immediate threat to life): Single-shot spinal anesthesia was planned as first-line, with trigger-free general anesthesia (TIVA) prepared as backup. The urgency allowed sufficient time for neuraxial blockade.

3. Category 1 cesarean section (immediate threat to life): In the event of catastrophic fetal or maternal compromise, trigger-free general anesthesia with propofol and remifentanil would have been induced immediately, with all MH precautions already in place.

• Contingency Organization: A trigger-free general anesthesia cart was pre-prepared in the operating room, containing propofol, non-depolarizing muscle relaxants (rocuronium), and all necessary MH-compatible drugs. Dantrolene was stocked and ready for rapid reconstitution. The anesthesia machine was decontaminated and kept ready with vaporizers removed and charcoal filters in place. All team members were briefed on their roles in the event of an acute MH crisis.

Genetic counseling was provided addressing both the RYR1 and WFS1 findings. As noted in the Igenomix report (Supplementary report), the father (partner) was found to carry a heterozygous pathogenic variant in the WFS1 gene (NM_006005.3:c.124 C > T, p.(Arg42Ter)), while the mother (our patient) was found to carry a heterozygous variant of uncertain significance in the same gene (NM_006005.3:c.1346 C > A, p.(Thr449Asn)). These findings were identified incidentally during whole exome sequencing performed to investigate malignant hyperthermia susceptibility. The couple carries a 25% risk of transmitting these variants in a compound heterozygous state to their offspring, though the clinical penetrance remains uncertain given that the maternal variant is currently classified as a variant of uncertain significance (VUS). Phenotypic surveillance for autosomal dominant WFS1-associated phenotypes was recommended, and offspring surveillance was discussed accordingly. No clinical features of Wolfram syndrome including diabetes mellitus, diabetes insipidus, optic atrophy, sensorineural deafness, or autonomic dysfunction were identified in either partner at genetic evaluation or during antenatal assessment. Both variants were assessed by the genetics team and considered a separate finding from the primary indication for referral.

Clinical findings

On general physical examination, the patient was alert, oriented, comfortable, and in no distress. Airway assessment revealed Mallampati class II, adequate mouth opening, adequate thyromental distance, and full neck range of motion with no anticipated difficult airway. Cardiovascular and respiratory examinations were normal. Neuromuscular examination showed normal tone and strength, with no fasciculations or signs of myopathy; specific RYR1-related screening revealed no muscle weakness, scoliosis, ptosis, wasting, or joint contractures.

Obstetric assessment demonstrated a reactive cardiotocography tracing, fetal heart sounds without decelerations, and irregular uterine contractions. Laboratory investigations revealed hemoglobin 11.5 g/dL, platelet count 253 × 10³/µL, INR 1.01, and aPTT 32.3 s. Preoperative vital signs in the operating room were blood pressure 105/65 mmHg, heart rate 90 beats/minute, respiratory rate 16 breaths/minute, oxygen saturation 99% on room air, temperature 36.7 °C, and end-tidal CO₂ 32–36 mmHg (measured via nasal sidestream capnography in the spontaneously breathing patient).

Diagnostic assessment

Diagnostic assessment confirmed autosomal dominant malignant hyperthermia susceptibility via pre-pregnancy whole exome sequencing identifying a pathogenic RYR1 variant (c.10561G > A). All admission testing including group B Streptococcus screen, anomaly scan, routine laboratory tests, and cardiotocography were normal except for O Rh-negative blood type with a positive indirect Coombs test, indicating alloantibodies. Blood products were available if required; postpartum administration of anti-D immunoglobulin was planned according to institutional obstetric protocol and neonatal Rh status. No transfusion was required intraoperatively or postoperatively.

The patient was counseled on the excellent prognosis with trigger-free anesthesia and the 50% inheritance risk for offspring. Differential diagnoses of other RYR1-related myopathies were excluded by normal neuromuscular examination.

Therapeutic intervention

She presented with progressive labor pain over several hours associated with irregular uterine contractions, reporting no other systemic symptoms. The patient underwent an urgent (Category 2) lower segment cesarean section for failure to progress during the first stage of labor, without evidence of immediate maternal or fetal compromise. The decision-to-incision interval was 40 min, and the decision-to-delivery interval was 45 min.

Anesthetic technique

Single-shot spinal anesthesia was selected because it provides rapid, reliable surgical anesthesia for urgent cesarean delivery while avoiding exposure to triggering agents associated with malignant hyperthermia. No labor epidural analgesia had been established by the time the decision for cesarean section was made: The patient declined epidural analgesia due to personal preference and anxiety regarding needle-based procedures, a decision that was respected after discussion of risks and benefits and departmental practice does not routinely offer prophylactic early labor epidural analgesia to MH-susceptible parturients in the absence of additional obstetric or anesthetic risk factors. Given the urgency of surgery and the absence of an existing labor epidural catheter (as it allowed rapid establishment of a dense surgical block), spinal anesthesia represented the most efficient neuraxial technique. The procedure was performed with the patient in the sitting position at the L4-L5 interspace using a 27-gauge pencil-point needle, with administration of 12 mg of 0.5% hyperbaric bupivacaine (no intrathecal opioid was administered, reflecting institutional practice). A T4 sensory level was successfully achieved. A trigger-free general anesthetic plan was prepared as a backup should neuraxial anesthesia fail.

Malignant hyperthermia precautions

The anesthesia workstation was prepared according to malignant hyperthermia precautions: vaporizers were removed, the circuit was flushed with 100% oxygen, activated charcoal filters were applied, the CO₂ absorbent was replaced, all volatile anesthetic agents and succinylcholine were excluded, and dantrolene was immediately available. Traditional 20 mg dantrolene vials were stocked and readily accessible.

Hemodynamic management and perioperative fluids

Hemodynamic support was maintained with left uterine displacement, crystalloid colloid, and a phenylephrine infusion titrated to maintain systolic blood pressure ≥ 100 mmHg. Perioperative fluid management included a spinal co-load of 500 mL Ringer’s lactate, approximately 110 mL for maintenance, 200 mL for third space losses, 100 mL replacement for urine output of 100 mL, and blood loss replacement with 1.5 L crystalloid for an estimated blood loss of 500 mL.

Obstetric management

Following delivery, oxytocin was administered as a 3 IU intravenous slow bolus over at least 30 s, followed by a continuous infusion at 4 IU/hour according to institutional protocol.

Operative data

The surgical duration was 40 min, and the total anesthesia duration was 1 h.

Follow-up and outcomes

The intraoperative and postoperative courses were entirely favorable. No clinical signs of malignant hyperthermia were observed, with stable end-tidal CO₂ (32–36 mmHg), normothermia (36.5–37.0 °C), heart rate 80–95 bpm, and no muscle rigidity. Estimated blood loss was normal.

The patient underwent extended postoperative monitoring for 48 h in the postnatal ward as an institutional precaution because of genetically confirmed malignant hyperthermia susceptibility and the rarity of the condition in obstetric practice. Monitoring included temperature, heart rate, urine output, muscle tone, and clinical surveillance for delayed symptoms. No delayed malignant hyperthermia manifestations were observed. Dantrolene administration was not required.

Neonatal outcomes were excellent: birth weight 3.1 kg, Apgar scores of 8 at 1 min and 9 at 5 min, and no neonatal intensive care unit admission required.

The patient was discharged home on postoperative day three, hemodynamically stable, ambulating, afebrile, and with well-controlled pain. No adverse or unanticipated events were observed.

Timeline (including diagnostic assessment, therapeutic intervention, and outcomes)

The clinical course from pre-pregnancy genetic diagnosis through antenatal care, urgency cesarean section, and postoperative follow-up is summarized in Table 1. Key events include the identification of the pathogenic RYR1 variant before pregnancy, admission at 38 weeks for labor pain, failure to progress leading to urgency cesarean section under spinal anesthesia with strict malignant hyperthermia precautions, and uneventful recovery with discharge on postoperative day three.

Table 1.

Clinical timeline from pre-pregnancy genetic diagnosis to hospital discharge, including diagnostic assessment, therapeutic intervention, and maternal and neonatal outcomes

Stage	Event / Description
Pre-pregnancy	Whole exome sequencing identified pathogenic RYR1 variant (c.10561G > A), confirming autosomal dominant MH susceptibility.
Antenatal	Routine follow-up with planned trigger-free anesthesia strategy; genetic counseling provided for RYR1 and incidental WFS1 findings.
38 weeks gestation	Presented with labor pain; admitted with reactive CTG and irregular contractions.
First stage of labor	Failure to progress → decision for urgent (Category 2) cesarean section.
Preoperative	Informed consent obtained; 8-hour fast confirmed. MH precautions implemented: vaporizers removed, circuit flushed with 100% O₂, activated charcoal filters applied, CO₂ absorbent replaced, succinylcholine and volatile agents excluded, dantrolene available.
Intraoperative	Spinal anesthesia: 12 mg 0.5% hyperbaric bupivacaine at L4-L5 (no opioid), T4 level achieved. Hemodynamics: left uterine displacement, crystalloid colloid, phenylephrine infusion titrated to SBP ≥ 100 mmHg. Surgical duration: 40 min; anesthesia duration: 60 min. Uneventful delivery of healthy neonate. Oxytocin administered per protocol.
Immediate recovery	Patient transferred stable; no MH signs: EtCO₂ 32–36 mmHg (nasal capnography), normothermia 36.5–37.0 °C, HR 80–95 bpm, no rigidity. Estimated blood loss 500 mL.
Postoperative (0–48 h)	Extended monitoring per institutional protocol: normal temperature, HR, urine output (no myoglobinuria), normal muscle tone, no wound complications. No delayed MH symptoms. Dantrolene not required.
Postoperative day 3	Discharged home: hemodynamically stable, ambulating, afebrile, pain controlled. Neonatal outcomes: birth weight 3.1 kg, Apgar 8/9, no NICU admission.

Discussion and conclusion

This case demonstrates the successful perioperative management of a parturient with genetically confirmed malignant hyperthermia (MH) susceptibility undergoing urgent cesarean section. The distinguishing feature of this report is the pre-pregnancy molecular confirmation of a pathogenic RYR1 variant (c.10561G > A) through whole exome sequencing, which enabled prospective multidisciplinary planning before an urgency scenario arose. While several previous reports have described successful neuraxial anesthesia in MH-susceptible parturient, most have relied on clinical diagnosis, family history, or intraoperative contracture testing rather than pre-pregnancy genetic confirmation.

This case adds to the literature by demonstrating how early genetic diagnosis triggered by a significant family history of intraoperative death allows for optimized trigger-free anesthetic preparation, informed consent, and coordinated obstetric- anesthetic planning well in advance of delivery. Recent literature emphasizes that RYR1 mutations are the primary cause of MH susceptibility, with missense variants being most common, while insertions and duplications account for less than 10% of pathogenic variants [2]. The clinical variability observed in MH, including rare stress-induced episodes, highlights the importance of genetic confirmation [2]. Furthermore, emerging research on gynecological and obstetric manifestations in RYR1-variant carriers indicates higher rates of pregnancy complications, including placenta previa and preeclampsia, as well as increased likelihood of planned cesarean section compared to controls [4]. In this context, our patient’s urgent cesarean section for failure to progress, along with her positive indirect Coombs test, adds to the understanding of obstetric complexities in MH-susceptible women. The uneventful delivery of a healthy neonate (birth weight 3.1 kg, Apgar 8/9) aligns with the favorable neonatal outcomes reported in RYR1-carrier mothers, despite a tendency toward lower birthweights and shorter gestations in some studies [4].

The anesthetic management of this case adhered strictly to current guidelines for MH-susceptible patients. Regional anesthesia, specifically spinal anesthesia with 12 mg of 0.5% hyperbaric bupivacaine, was the preferred technique as it completely avoids volatile anesthetics and succinylcholine [8, 9]. This approach is recommended for parturient with MH susceptibility, as early regional anesthesia provides a safe means for emergency procedures without increasing fetal risk [5]. The choice of single-shot spinal anesthesia in this case was appropriate given the urgency of delivery (Category 2), the absence of a pre-existing labor epidural catheter, and the need for a rapidly established dense surgical block. Although the European Malignant Hyperthermia Group (EMHG) updated guidelines (May 2026) advocate for epidural analgesia in labor for MH-susceptible parturient as a catheter in situ permits conversion to surgical anesthesia without recourse to general anesthesia no labor epidural had been established in our patient prior to the decision for surgery [10, 11].

As in the antenatal plan, early labor epidural analgesia had declined by the patient, and institutional practice in this unit does not routinely offer prophylactic epidural analgesia to MH-susceptible parturients in the absence of additional risk factors; single-shot spinal anesthesia was therefore the most time-efficient neuraxial option once the decision for cesarean section was made. CSE was considered but not selected given the urgent clinical situation, as CSE would have prolonged the procedure time compared to single-shot spinal., anticipated surgical duration well within the expected duration of the spinal block, and standard institutional practice for Category 2 cesarean deliveries in this unit and The attending anesthesiologist had extensive experience with single-shot spinal anesthesia for cesarean delivery and was confident in achieving an adequate block for the anticipated duration. Although the updated EMHG guidelines (May 2026) recommend early epidural analgesia during labor to facilitate rapid conversion to surgical anesthesia if needed, this was not applicable as the patient declined epidural analgesia. The absence of an epidural catheter did not compromise safety, as a trigger-free general anesthesia backup was fully prepared and immediately available.

A trigger-free general anesthetic backup plan was prepared and available throughout. Importantly, the updated EMHG guidelines (May 2026) also confirm that exposure of an MH-susceptible mother to trigger agents does not directly increase fetal MH risk, though avoidance of triggers remains essential for maternal safety [10, 11]. No intrathecal opioid was added to the subarachnoid injectate, reflecting institutional anesthetic practice for this unit rather than a decision driven by MH susceptibility. The omission of intrathecal opioids increases the risk of intraoperative visceral discomfort, and their inclusion for example fentanyl 15–25 µg for intraoperative analgesia or morphine 100–150 µg for postoperative analgesia is supported by evidence and endorsed by current obstetric anesthesia guidelines; this is acknowledged as a limitation of the anaesthetic technique used in this case.

Preparation of the anesthesia workstation for MH-susceptible patients requires meticulous adherence to established protocols [6]. In this case, the anesthesia machine was flushed with 100% oxygen at 10 L/min for 20 min, vaporizers were physically removed, the CO₂ absorbent was replaced, and activated charcoal filters were applied to both the inspiratory and expiratory limbs of the breathing circuit. Activated charcoal filters reduce residual volatile anesthetic concentrations to below trigger threshold within minutes and represent a validated, time-efficient method of machine decontamination endorsed by the EMHG, particularly when a dedicated vapor-free machine is unavailable [6, 12].

The implementation of these rigorous precautions, along with exclusion of all triggering agents and immediate availability of dantrolene, followed established protocols [6]. Importantly, the patient did not receive prophylactic dantrolene, consistent with current AAGBI and North American MH Registry recommendations that discourage routine pretreatment and reserve dantrolene only for acute MH crises [1, 13]. Dantrolene was immediately available in the operating suite. Traditional lyophilised 20 mg vials (requiring reconstitution with 60 mL sterile water each) were stocked, with 10 vials prepared. Current guidance no longer defines a maximum ceiling dose of 10 mg/kg; dantrolene should be repeated every 5–10 min as clinically necessary until the crisis resolves, guided by the clinical response [13]. The intraoperative and postoperative monitoring revealed no clinical signs of MH, such as hypercapnia, tachycardia, hyperthermia, or muscle rigidity, which are typical early indicators of a hypermetabolic crisis [1, 6]. This outcome supports the safety of trigger-free regional anesthesia in MH-susceptible parturient, even in the urgent setting of failed labor progress.

The whole exome sequencing report incidentally identified heterozygous WFS1 variants in both partners, with a 25% offspring risk of compound heterozygosity, though clinical penetrance is uncertain. Genetic counseling was provided for both RYR1 and WFS1 findings, and neonatal follow-up was discussed. No clinical features of Wolfram syndrome were identified in either partner. Genetic counseling was provided addressing both the RYR1 and WFS1 findings, phenotypic surveillance for autosomal dominant WFS1-associated phenotypes was recommended, and neonatal follow-up was discussed. These variants were deemed a separate genetic consideration with no direct impact on the anesthetic management of the present case.

Regarding postoperative monitoring, the patient underwent extended monitoring for 48 h in the postnatal ward as an institutional precaution because of genetically confirmed malignant hyperthermia susceptibility and the rarity of the condition in obstetric practice. Monitoring included temperature, heart rate, urine output, muscle tone, and clinical surveillance for delayed symptoms. No evidence of malignant hyperthermia developed. This extended duration exceeds the 1.5 h postoperative observation period considered adequate for MH-susceptible patients who have undergone uneventful trigger-free anesthesia, as reported by Pollock et al. [14]. The longer monitoring period in this case reflects a conservative institutional approach given the urgency surgical context and the absence of any prior anesthetic history in this patient. Recrudescence of MH can occur up to 14 h after control of the initial reaction, though this is relevant only if an MH crisis has occurred [13]. Since no MH episode developed in this patient, routine monitoring for 1.5 h would have been sufficient per published guidelines; the 48-hour observation was thus an institutional precaution rather than a guideline-mandated requirement.

Conclusion

This case demonstrates that trigger-free spinal anesthesia is a safe and effective technique for urgent cesarean delivery in MH-susceptible parturient when strict, guideline-concordant precautions are meticulously observed. The distinctive contribution of this report lies in pre-pregnancy molecular confirmation of MH susceptibility, which enabled prospective multidisciplinary planning before an obstetric urgency arose a context in which diagnostic uncertainty at the time of surgery could have had serious consequences. All identified genetic findings, including co-incidental WFS1 variants, should be addressed comprehensively in genetic counselling. These lessons reinforce that excellent maternal and neonatal outcomes are achievable in MH-susceptible parturient when anesthetic planning is proactive, guideline-concordant, and multidisciplinary.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary Material 1 ^{(529.1KB, pdf)}

Author contributions

M.A. conceptualized the study, managed the clinical case, supervised perioperative anesthetic management, and critically revised the manuscript. M.A. also contributed to data interpretation and approved the final version of the manuscript. All authors reviewed and approved the final manuscript.

Funding

This case report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The findings of this study are supported by data that can be obtained from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This case report did not require formal ethics committee approval as it describes routine clinical management and does not involve any experimental intervention or research protocol. All procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images or genetic data. The patient was informed that her de-identified information would be shared for academic and educational purposes, and she provided voluntary consent. Patient identifiers have been removed or anonymized to protect privacy. De-identified information includes age, gender, gestational age, genetic findings, and clinical course without any identifying personal details. The authors declare that this case report adheres to the CARE guidelines for case reporting and that all efforts have been made to protect patient confidentiality.

Competing interests

The authors declare no competing interests.