Perioperative anesthetic management of emergency caesarean section in previously undiagnosed eisenmenger syndrome: A case report

Background Eisenmenger syndrome is characterized by severe pulmonary arterial hypertension with reversal or bidirectional shunting secondary to congenital cardiac defects. Pregnancy in patients with Eisenmenger syndrome remains associated with extremely high maternal mortality risk, rendering it a modified WHO class IV contraindication. Anesthetic management during caesarean delivery is exceptionally high-risk because minor hemodynamic alterations may significantly worsen right-to-left shunting and precipitate cardiovascular collapse. Case Presentation A 19-year-old primigravida at 38 weeks’ gestation presented with breathlessness, labour pain, and leaking per vaginam . Clinical examination revealed cyanosis, digital clubbing, tachycardia, and oxygen saturation of 88% on room air. Transthoracic echocardiography demonstrated a large 17 mm×15 mm perimembranous ventricular septal defect with bidirectional shunting and severe pulmonary arterial hypertension suggestive of Eisenmenger physiology. Due to acute fetal distress and the advanced stage of unoptimized maternal labor, an emergency caesarean section was immediately performed under general anesthesia. Management and Outcome Systemic vascular resistance was aggressively preserved using a carefully titrated pre-induction norepinephrine infusion, low-dose volatile maintenance (0.5–1.0 MAC sevoflurane), and a highly restrictive, goal-directed fluid plan (700 mL total crystalloid). A healthy male infant was successfully delivered. Advanced multimodal analgesia via ultrasound-guided bilateral transverse abdominis plane (TAP) blocks prevented pain-induced PVR elevations. The patient was monitored in a high-dependency unit for 7 days, initiated on postoperative tadalafil and thromboprophylaxis, and discharged home in stable condition without cardiovascular complications.