Postpartum death with maternal congenital heart disease

Shunt flow and pulmonary hemodynamics during labor and delivery in the Eisenmenger syndrome

The Eisenmenger syndrome carries a high mortality rate in a women during delivery and the immediate postpartum period. It has been suggested that marked changes in shunt flow and pulmonary hemodynamics may be responsible. These functions were studied under various physiologic and pharmacologic conditions during labor and delivery in a patient with the Eisenmenger syndrome. Uterine contractions were associated with a decrease in the ratio of pulmonary to systemic blood flow (Qp/Qs) from 1.58 to 1.05. The Qp/Qs ratio also decreased (to 0.83) when forceps were applied during uterine contractions. Epidural anesthesia, oxytocin and the supine position did not adversely affect pulmonary hemodynamics or shunt flow. On the basis of these results, if pregnancy cannot be terminated in a patient with the Eisenmenger syndrome, it is recommended that the patient be given high concentration of oxygen and epidural anesthesia and that serial arterial blood gas determinations be performed to detect changes in shunt flow.

Eisenmenger's syndrome in pregnancy: does heparin prophylaxis improve the maternal mortality rate?

Seven consecutive patients with Eisenmenber's syndrome, cared for by the obstetric team in conjunction with the cardiology service, were reviewed to assess the possible role of prophylactic heparin therapy and intensive care on the outcome of these patients. In each patient, the diagnosis of Eisenmenger's syndrome was established by the demonstration of equal pulmonary arterial and aortic pressures with a predominantly right-to-left shunt at cardiac catheterization. Five of the seven patients died as follows: Three patients died between the fifth and eighth post-partum days, one patient died during the twenty-sixth week of pregnancy, and one patient died on the fifth postoperative day following tubal ligation. All of these five patients received prophylactic heparin therapy. In three patients, heparin therapy was complicated by excessive bleeding during the postoperative or postpartum period. Autopsy examination in two patients revealed no evidence of thrombosis in the main pulmonary arteries and no pulmonary infarction, contrary to the antemortem clinical suspicion. The two survivors did not receive prophylactic heparin. They comprised one patient who had normal delivery and one patient who underwent tubal ligation and induction of abortion. We conclude that the prohibitive mortality rate of Eisenmenger's syndrome during pregnancy, puerpurium, or surgical procedures probably cannot be modified with prophylactic heparin therapy. Anticoagulant treatment does not prevent deterioration of patients and probably compounds the problem by causing significant bleeding.