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Eisenmenger Pregnancy Management — EECC MCQ

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HardCongenital Heart Disease (Adult)Eisenmenger Pregnancy ManagementEECC

A 35-year-old woman with Eisenmenger syndrome and a large VSD becomes pregnant against medical advice at 8 weeks gestation. She is SpO₂ 82% at rest. She decides to continue the pregnancy. What is the most dangerous period and management approach?

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Correct answer: C — The peripartum and early postpartum period carries the highest mortality risk due to sudden SVR changes during delivery and fluid shifts postpartum; management requires a specialist centre with a multidisciplinary team, avoidance of systemic hypotension, and planned delivery strategy

Pregnancy in Eisenmenger syndrome (mWHO IV) carries maternal mortality of 20-50%, with the highest risk during: (1) labour and delivery — bearing down increases RV afterload and can cause acute RV failure; systemic vasodilation (epidural anaesthesia, blood loss) reduces SVR and increases right-to-left shunting, causing profound cyanosis and circulatory collapse; (2) early postpartum — autotransfusion from the uterus increases pulmonary vascular resistance and volume load; sudden loss of aortocaval compression increases venous return to a failing RV. The 2025 ESC CVD in Pregnancy Guidelines recommend: (1) expert centre with ICU capability; (2) continuation of PAH-specific therapy (avoid endothelin receptor antagonists — teratogenic); (3) regional anaesthesia (carefully titrated epidural — avoid sudden SVR drop); (4) planned vaginal delivery with assisted second stage in most cases; (5) avoid Syntocinon bolus (causes PVR increase); (6) extended postpartum monitoring (72h minimum).

Reference: ESC (2025): CVD in Pregnancy Guidelines