The use of point-of-care assessments and advanced hemodynamic monitoring in a patient with Eisenmenger syndrome for cesarean section: A case report

INTRODUCTION: Eisenmenger syndrome should be diagnosed before pregnancy and surgically corrected if possible. Cesarean section in a patient with Eisenmenger syndrome is high risk as morbidity and mortality are very high. Delivery in hospitals with intensive care units should be recommended. Use of point-of-care assessments and advanced monitors allow accurate management. CASE PRESENTATION: A primigravid with congestive heart failure from a patent ductus arteriosus in Eisenmenger syndrome, presented with threatened preterm labor and uncontrolled hypertension prompting cesarean delivery under epidural anesthesia. Pre-induction focused echocardiography revealed normal right ventricular function and severe pulmonary hypertension. Intraoperatively, hemodynamics became unstable. The decision to use fluids, vasopressor and inotrope was guided by analyses of arterial pulse contour, central venous pressure waveform and blood exams. Hemodynamics improved and a live baby was delivered. Postoperative course was unremarkable. DISCUSSION: The cause of hemodynamic instability must be accurately determined as inappropriate use of fluid or medication may be detrimental to a patient with Eisenmenger syndrome. In this case, advanced hemodynamic monitoring showed changes in central venous pressure, cardiac output and systemic vascular resistance which differentiated the causes of hypotension and desaturation. Point-of-care blood analysis showed acidosis and hypoxia which may have worsened the right-to-left shunt, contributing to the desaturation. Fluid and drug infusions to address identified problems were then guided by advanced monitors. CONCLUSION: The use of point-of-care assessments and advanced hemodynamic monitoring allowed accurate diagnoses and goal-directed therapies leading to improved patient safety and outcomes. The need for prolonged intensive care in this case was prevented.