Pregnancy Termination in Eisenmenger Syndrome: Approach and Misoprostol Use
Direct Answer
Surgical termination via dilation and evacuation (D&E) is the safest method for pregnancy termination in Eisenmenger syndrome patients, and misoprostol (prostaglandin) is absolutely contraindicated due to severe hemodynamic risks. 1
Why Prostaglandins Are Contraindicated
Prostaglandin-induced labor, including misoprostol, must be avoided in Eisenmenger physiology because prostaglandin F compounds increase pulmonary arterial pressure and decrease coronary perfusion, causing life-threatening hemodynamic fluctuations. 1 This creates a catastrophic scenario where:
- Pulmonary vascular resistance increases acutely 1
- Right-to-left shunting worsens dramatically 1
- Systemic oxygen saturation drops precipitously 1
- Coronary perfusion decreases when myocardial oxygen demand is highest 1
The American Heart Association explicitly recommends that patients with severe cardiovascular disease such as pulmonary arterial hypertension should avoid medical termination of pregnancy due to unacceptably high risk. 1
Recommended Termination Method
Surgical D&E is Preferred
The American College of Cardiology recommends surgical termination, specifically dilation and evacuation (D&E), as the safest procedure in both first and second trimesters, with lower rates of hemorrhage and infection compared to medical methods. 1
Critical Timing Consideration
While termination in the second trimester poses high maternal risk (up to 50% mortality), it remains reasonable when balanced against continuation risks, as continuing pregnancy carries even higher mortality. 1
Mandatory Pre-Procedure Requirements
Transfer to Specialized Center
Transfer to a tertiary center with on-site cardiac surgery capabilities is mandatory before attempting termination. 1 The multidisciplinary team must include:
- Adult congenital heart disease cardiologist 1
- Cardiac anesthesiologist 1
- High-risk obstetrician 1
- Cardiac surgeon on standby 1
All procedures (noncardiac surgery and cardiac catheterization) should only be performed in centers with Eisenmenger expertise. 2
Hemodynamic Optimization
Optimization of hemodynamics is crucial before proceeding, including:
- Maintaining oxygen saturation (supplemental O2 to keep saturations >91%) 1
- Avoiding dehydration (increases blood viscosity and thrombosis risk) 1
- Ensuring adequate preload 1
- Maintaining systemic vascular resistance to prevent increased right-to-left shunting 1
Critical Safety Measures
Meticulous attention to avoiding air bubbles in all IV lines is necessary due to right-to-left shunting risk of paradoxical embolization. 1 This is an essential safety measure emphasized across multiple guidelines. 2
Post-Procedure Critical Period
High-Risk Monitoring Window
The first 48-72 hours after termination carry particularly high maternal mortality risk in Eisenmenger patients, requiring ICU-level monitoring. 1 This critical period accounts for the majority of maternal deaths, as hemodynamic shifts continue even after the procedure is complete. 2, 3
Post-Procedure Management
- Antibiotic prophylaxis to prevent endometritis 1
- Rh immunoglobulin if patient is Rh-negative 1
- Aggressive thromboembolism prevention while balancing bleeding risk 1
- Continue pulmonary vasodilator therapy if patient was on it pre-procedure 1
Anesthetic Considerations
Regional anesthesia (epidural) can be used safely and does not adversely affect pulmonary hemodynamics or shunt flow. 4 However, the optimal type and mode of anesthetic administration should be individualized by experts in Eisenmenger physiology care. 2
One case report documented successful termination under regional anesthesia, though the patient required urgent venovenous ECMO due to hemodynamic changes from uterine contractions post-termination. 5 This underscores the unpredictable and high-risk nature of any intervention in these patients.
Post-Termination Contraception
Patients with Eisenmenger syndrome should consider permanent contraception such as tubal ligation or endoscopic sterilization, as pregnancy is absolutely contraindicated. 1 Progesterone-only methods may be considered as interim contraception. 1
Estrogen-containing contraceptives increase VTE risk and are not recommended. 2 Additionally, bosentan (commonly used in Eisenmenger patients) may decrease hormonal contraception efficacy. 2
Key Pitfalls to Avoid
- Never use prostaglandins (including misoprostol) for medical termination 1
- Never perform termination at non-specialized centers 2, 1
- Never allow air bubbles in IV lines 2, 1
- Never underestimate the post-procedure risk period - most deaths occur in the first 72 hours 1
- Never use calcium channel blockers - they are contraindicated in Eisenmenger syndrome 2
Summary Algorithm
- Confirm pregnancy in Eisenmenger patient → Immediate referral to tertiary center with cardiac surgery capabilities 1
- Assemble multidisciplinary team (ACHD cardiologist, cardiac anesthesiologist, high-risk OB, cardiac surgeon) 1
- Optimize hemodynamics (oxygen, hydration, preload, continue pulmonary vasodilators) 1
- Perform surgical D&E (NOT medical termination with prostaglandins) 1
- ICU monitoring for 48-72 hours minimum post-procedure 1
- Arrange permanent contraception before discharge 1