What is the best method of termination for a pregnancy at 16 weeks in a patient with congenital heart disease, atrial septal defect (ASD) with Eisenmengerization, and hypoxemia, who is otherwise hemodynamically stable?

Pregnancy Termination in Eisenmenger Syndrome at 16 Weeks

In a patient with ASD and Eisenmengerization at 16 weeks gestation, surgical termination (hysterotomy or dilation and evacuation) is strongly preferred over medical induction, and the procedure must be performed at a center with cardiac surgery capabilities. 1

Critical Context: Extremely High-Risk Situation

This patient faces maternal mortality risk up to 50% with Eisenmenger physiology, and termination itself—particularly at 16 weeks—carries substantial risk due to volume and hormonal fluctuations. 2 The ACC/AHA guidelines explicitly state that pregnancy termination in the second trimester poses high maternal risk, though it remains reasonable when balanced against continuation risks. 2

Method Selection: Surgical Over Medical

Surgical Termination is Preferred

• Severe cardiovascular disease, especially pulmonary arterial hypertension, is an absolute contraindication for medical termination of pregnancy. 1
• Dilation and evacuation (D&E) is the safest procedure in both first and second trimesters, with lower rates of hemorrhage and infection compared to medical methods. 1
• At 16 weeks, hysterotomy under controlled anesthesia allows better hemodynamic management than the unpredictable volume shifts of labor induction. 3
• In a Chinese series of 27 severe cardiovascular disease cases, 16 patients underwent hysterotomy delivery with only one death (a primary pulmonary hypertension case at 19 weeks), while medical induction methods had less predictable outcomes. 3

Why Medical Induction Should Be Avoided

• Prostaglandin-induced labor causes significant hemodynamic fluctuations that are particularly dangerous in Eisenmenger physiology. 1
• While prostaglandin E1 (misoprostol) or E2 can be used if surgical evacuation is not feasible, prostaglandin F compounds must be avoided as they increase pulmonary arterial pressure and decrease coronary perfusion. 1
• Medical termination lacks the controlled environment and immediate intervention capability needed for this high-risk patient. 1

Perioperative Management Algorithm

Pre-Procedure Requirements

• Transfer to a tertiary center with on-site cardiac surgery capabilities before attempting termination. 1
• Multidisciplinary team including adult congenital heart disease cardiologist, cardiac anesthesiologist, high-risk obstetrician, and cardiac surgeon on standby. 2, 3
• Optimize hemodynamics: maintain oxygen saturation, avoid dehydration (which worsens hyperviscosity), ensure adequate preload. 2

Anesthetic Considerations

• Regional anesthesia (epidural or combined spinal-epidural) is generally preferred over general anesthesia to avoid intubation-related hemodynamic swings. 3
• In the Chinese series, 11 of 16 hysterotomy cases used continuous epidural anesthesia successfully. 3
• Meticulous attention to avoiding air bubbles in all IV lines due to right-to-left shunting risk. 2
• Maintain systemic vascular resistance to prevent increased right-to-left shunting. 2

Intraoperative Monitoring

• Invasive arterial blood pressure monitoring. 3
• Central venous access with air filters on all lines. 2
• Continuous pulse oximetry (though baseline is already 80%). 2
• Consider pulmonary artery catheter for severe cases, though this carries its own risks in Eisenmenger patients. 2

Surgical Technique

• Minimize operative time to reduce hemodynamic stress. 3
• Controlled blood loss—avoid hypovolemia which worsens right-to-left shunting. 3
• Consider concurrent tubal ligation if patient is hemodynamically stable, as future pregnancy must be absolutely avoided and surgical sterilization is safer than pregnancy despite operative risks. 2

Post-Procedure Critical Period

• The first several days after delivery/termination carry particularly high maternal mortality risk in Eisenmenger patients. 2
• ICU-level monitoring for at least 48-72 hours post-procedure. 3
• Continue pulmonary vasodilator therapy if patient was on it pre-procedure. 4
• Antibiotic prophylaxis to prevent endometritis (occurs in 5-20% without prophylaxis). 1
• Rh immunoglobulin if patient is Rh-negative. 1
• Aggressive prevention of thromboembolism while balancing bleeding risk. 2

Critical Pitfalls to Avoid

• Do not attempt this procedure in a community hospital—one death in the Chinese series occurred when a patient was managed at another facility. 3
• Do not use prostaglandin F compounds if medical methods are considered. 1
• Do not delay termination—earlier is safer, though this patient is already at 16 weeks. 2, 1
• Do not allow air in IV lines—right-to-left shunting creates stroke/paradoxical embolism risk. 2
• Do not assume stability post-procedure—mortality peaks in the immediate postpartum period. 2

Contraception Counseling

After recovery, permanent contraception should be strongly considered, as pregnancy is absolutely contraindicated in Eisenmenger syndrome. 2 If tubal ligation was not performed during termination, endoscopic sterilization may be the safer delayed option compared to repeat laparotomy. 2 Progesterone-only methods may be considered as interim contraception, but estrogen-containing contraceptives are absolutely contraindicated. 2, 5