Epidural Ropivacaine, Sildenafil–Beraprost Vasodilation, and Invasive Monitoring for Emergency Cesarean Delivery in an Adolescent with Atrial Septal Defect–Induced Eisenmenger Syndrome: An Observational Analytic Case Study

Abstract

Background: Gravid Eisenmenger syndrome carries 30–60% maternal mortality from falling systemic vascular resistance (SVR), right ventricular (RV) failure, and shunt reversal.

Objective: To describe the cardiopulmonary course, dual oral vasodilation, and graded epidural anesthesia of an adolescent gravida with secundum atrial septal defect (ASD)–induced Eisenmenger syndrome who underwent emergency cesarean section.

Methods: This case report follows an 18-year-old woman (46.0 kg, 152 cm, BMI 19.91 kg/m²; G2P0010Ab0010 at 34–36 weeks; ASA 5E, mWHO Class IV) across five perioperative milestones (T₀–T₄). Relative deviations (Δ%), oxygenation ratios, fluid balance, and mWHO, ASA, and CARPREG II risk scores were calculated.

Results: Echocardiography showed a large secundum ASD with balanced shunt, severe tricuspid and moderate pulmonary regurgitation, reduced RV contractility, and a left ventricular ejection fraction of 51%. She had hypoxemia (SpO₂ 73% on a 15 L/min non-rebreathing mask; SpO₂/FiO₂ 81.11), lung edema, hypoalbuminemia (3.10 g/dL, Δ% −11.43%), and prerenal azotemia (urea 62.3 mg/dL, Δ% +55.75%; creatinine 0.94 mg/dL). She received oral sildenafil (3 × 20 mg/day), oral beraprost (3 × 20 μg/day), and intravenous furosemide (3 × 20 mg/day; target balance −500 mL/24 h). Under arterial and central venous monitoring with milrinone and phenylephrine on standby, graded 0.75% ropivacaine epidural anesthesia was followed by a blood pressure of 104/60 mmHg (MAP 74.67 mmHg). A live infant (Apgar 7 and 8) was delivered; mother and infant survived.

Conclusion: In this patient, sildenafil–beraprost vasodilation, diuresis, invasive monitoring, and graded epidural anesthesia were followed by delivery without shunt crisis. A single case cannot establish causation.