Background :Rheumatoid arthritis is a chronic inflammatory disorder affecting 1 – 2 % of the population. Multisystemic nature of the disease and multiple drug therapy make anesthetic management including airway management and positioning of these patients challenging. We report a case of primigravida with twin gestation, K/c/o Rheumatoid arthritis undergone bilateral total knee replacement coming for elective cesarean section and its anesthetic implications.

Methods : 33 years old female, primigravidawith twin gestation at 39 weeks- 3 days; K/c/o Rheumatoid arthritis for past 6 years who had undergone bilateral total knee replacement 4 years back was admitted to Bapuji Hospital Davangere, Karnataka. Pt conceived after 3 months of infertility treatment with clomifene citrate. Pt is on treatment with T.Hydroxychloroquine,T.Sulfasalazine, T.Folic acid, T.Calcium and T.Iron.

Results : Due to bilateral total knee replacement, it was difficult to achieve conventional left lateral position for giving spinal anesthesia. Patient was put in sitting position and spinal anesthesia was given.

Discussion :Regional blocks may be difficult due to severe lumbar and thoracic spine arthritis and loss of anatomical landmarks from contractures or deformities.For patients undergoing spinal anesthesia, a higher than normal block can also be anticipated.

Conclusion – Anesthesia for a patient with severe rheumatoid arthritis and deformities is challenging. It requires a good knowledge of the multisystemic involvement of the disease, multiple drugs used and their anesthetic implications. Meticulous planning and attention to every minute detail is necessary for safe perioperative outcome of these patients.