Pregnancy in Pulmonary Arterial Hypertension: A Multidisciplinary Approach

When pulmonary arterial hypertension and pregnancy meet: a multidisciplinary clinical experts review

Pulmonary hypertension (PH) is a rare condition characterized by elevated pulmonary arterial pressure and pulmonary vascular resistance, potentially leading to right ventricular failure. Pulmonary arterial hypertension (PAH) is the most common type of PH in women of childbearing age and, as per the modified World Health Organization (mWHO) classification of maternal cardiovascular risk, it falls into mWHO class IV and pregnancy is contraindicated. These patients face an exceptionally high risk of maternal mortality and morbidity, with estimated maternal cardiac event rates ranging from 40 to 100% during pregnancy, because physiological changes happening in pregnancy exacerbate the disorder. Despite these recommendations, there is a growing incidence of pregnancy among women with PAH. Early referral to specialized centers, personalized therapies and expert multidisciplinary care involving pulmonary hypertension specialists, obstetricians, critical care specialists, anesthesiologists, and neonatologists are crucial steps to ensure positive outcomes for both mother and fetus. This review aims to examine the current understanding of pregnancy in patients with PAH, drawing on the experience of our center in the multidisciplinary management of pregnant women with this condition. In particular, we want to focus the attention of clinicians on the following aspects: early referral of pregnant patients to specialized centers, detailed counseling on the implications of pregnancy, initiation of therapy in treatment-naive patients and potential adjustment of therapy in non-naive patients, periodic risk assessment, evaluation of the appropriate timing of delivery, multidisciplinary management of the most critical periods, which are delivery and the post-partum phase.

Management and outcomes of pulmonary artery hypertension and Eisenmenger syndrome during pregnancy: a prospective observational cohort study

OBJECTIVES

Maternal-fetal morbidity and mortality among pregnant women with pulmonary artery hypertension (PAH) and Eisenmenger syndrome are unacceptable, and management decision-making in these clinical scenarios remains debatable. This study aimed to compare and analyse clinical characteristics, management and pregnancy outcomes in PAH and Eisenmenger syndrome.

DESIGN

Prospective observational cohort study.

SETTINGS

A large tertiary care university hospital.

PATIENTS

Thirty patients with pulmonary artery hypertension and 20 patients with Eisenmenger syndrome.

METHODS

Data pertaining to clinical characteristics, anaesthetic, medical and obstetric management, and outcomes in pregnancy complicated by PAH and Eisenmenger syndrome were collected between July 2020 and June 2022. Each treating unit followed its management protocol in consultation with the multidisciplinary team.

MAIN OUTCOME MEASURES

Maternal mortality and morbidity.

RESULTS

Maternal mortality was lower in the PAH group (6.6% versus 15%; p = 0.33). All mortalities were in the postpartum period. The incidence of new-onset or exacerbation of heart failure (23.3% versus 60%; p = 0.009) and hypoxaemia (13.3% versus 50%; p = 0.005) were significantly lower in the PAH group. In the Eisenmenger syndrome group, a significantly higher number of women received pulmonary hypertension and heart failure medications. Prematurity and neonatal intensive care unit admission were frequently noticed in Eisenmenger syndrome, whereas perinatal mortality, birthweight and APGAR score were comparable.

CONCLUSIONS

Fetomaternal outcomes are inferior in Eisenmenger syndrome compared with PAH and are either lower or comparable to those reported from contemporary cohorts of developed nations.

Women’s Cardiovascular Health: Prioritizing the Majority Minority

Women make up the majority of the global population, and [...]

Pulmonary arterial hypertension in pregnancy

PURPOSE OF REVIEW

Although pregnancy in pulmonary arterial hypertension (PAH) is considered high risk and contraindicated, the incidence is rising. It is paramount to understand the pathophysiology and effective management strategies to ensure optimal outcomes for maternal and fetal survival.

RECENT FINDINGS

In this review, we highlight the outcomes of recent case series of PAH patients in pregnancy, with a focus on proper risk assessment and target goals of PAH therapy. These findings support the notion that the pillars of PAH management, including pulmonary vascular resistance reduction resulting in right heart functional improvement, and widening of the cardiopulmonary reserve, should serve as a blueprint for PAH management in pregnancy.

SUMMARY

Multidisciplinary and tailored management of PAH in pregnancy, with emphasis on optimizing right heart function prior to delivery, can result in excellent clinical outcomes in a referral pulmonary hypertension center.