Advanced Hemodynamic Monitoring During Cesarean Section for Placenta Accreta Spectrum in a Pregnant Patient With Cardiac Disease and an Elevated BMI

Placenta accreta spectrum (PAS) in parturients with significant cardiovascular disease presents major anesthetic and hemodynamic challenges, particularly when complicated by obesity and a high risk of hemorrhage.We report the successful perioperative management of a 42-year-old parturient at 35 weeks of gestation with repaired patent foramen ovale, hypertensive cardiomyopathy with reduced left ventricular ejection fraction (40%), regional left ventricular wall motion abnormalities, moderate mitral regurgitation, obesity, and lumbar degenerative disc disease who underwent cesarean delivery under advanced hemodynamic monitoring.Regional anesthesia was selected over general anesthesia to minimize myocardial depression, sympathetic stimulation, and postoperative respiratory complications.A low-dose combined spinal-epidural technique was administered with gradual epidural extension to a T4 sensory level.Continuous invasive hemodynamic monitoring using the Hypotension Prediction Index (HPI; HemoSphere, 7.6 advanced monitoring platform from BD; software version 3.1) provided continuous assessment of cardiac output, stroke volume, systemic vascular resistance, dynamic arterial elastance, and left ventricular contractility (dP/dt).Norepinephrine was initiated immediately following intrathecal anesthesia and titrated to maintain arterial pressure and systemic vascular resistance close to baseline values, thereby minimizing the risk of neuraxial anesthesiainduced hypotension and potential myocardial hypoperfusion.The surgical procedure was complicated by dense pelvic adhesions, difficult bladder mobilization, and a prolonged skin-to-delivery interval of 12 minutes.Despite these challenges, hemodynamic stability was maintained throughout the procedure.Cardiac output increased from 5.5 L/min at baseline to 6.9 L/min following completion of epidural dosing, while stroke volume remained close to baseline.Although this change occurred temporally after completion of epidural dosing, a direct causal relationship could not be established from the available data.Following delivery, cardiac output decreased to 5.8 L/min without significant hemodynamic instability.Estimated blood loss was 1000 mL, and one unit of packed red blood cells was administered.Rotational thromboelastometry (ROTEM) analysis demonstrated preserved clot firmness and adequate fibrinogen contribution, with no evidence of clinically significant coagulopathy based on the available assessment.The neonate was delivered with an Apgar score of 8.This case highlights the potential value of combining carefully titrated neuraxial anesthesia with advanced hemodynamic monitoring in high-risk obstetric patients with cardiomyopathy and PAS.HPI-guided monitoring facilitated proactive vasopressor therapy and individualized hemodynamic management in a patient with limited cardiovascular reserve.Together, continuous hemodynamic assessment and point-ofcare ROTEM provided complementary information for cardiovascular and coagulation management.Further studies are needed to determine the role of HPI-guided management in parturients at high risk for hemorrhage and cardiovascular instability.