Pulmonary Hypertension in Pregnancy: A Review

Analysis of the clinical characteristics and outcomes of pregnant women with different degrees of pulmonary hypertension

OBJECTIVES

To investigate the clinical situation and pregnancy outcome of pregnant women with pulmonary arterial hypertension (PAH).

METHODS

A retrospective analysis was conducted on 125 pregnant women with varying degrees of PAH who were treated in the Department of Obstetrics and Gynecology of the First Affiliated Hospital of the University of Science and Technology between January 2016 and January 2023. The patients were divided into the mild group (58 cases), the moderate group (42 cases), and the severe group (25 cases) based on the pulmonary artery systolic blood pressure (PASBP) measurements. Mild was considered as PASBP 30-49 mmHg, moderate as PASBP 50-79 mmHg, and severe as PASBP ≥80 mmHg. The clinical data, cardiac function grade, etiology, and pregnancy outcome of the pregnant women with different degrees of severity of PASBP were analyzed.

RESULTS

Out of the 125 cases, the primary cause of PAH was congenital heart disease in 46 cases, followed by idiopathic heart disease in 32 cases, preeclampsia in 30 cases, rheumatic heart disease in 10 cases, and perinatal cardiomyopathy in 7 cases. A significant correlation was observed between the severity of PAH and the cardiac function grade, indicating that higher PASBP levels were associated with worse cardiac function (New York Heart Association functional classification system) (p < .05). Most deliveries were conducted via cesarean section, predominantly under intraspinal anesthesia. It was found that as the severity of PAH increased, there was a corresponding escalation in the incidence of adverse outcomes, including preterm birth, neonatal asphyxia, the need for intensive-care-unit transfer for both mothers and newborns, maternal death, perinatal death, extended postoperative hospital stay, and increased hospital expenses (p < .05).

CONCLUSIONS

The higher the pulmonary artery pressure, the worse the prognosis and outcome in pregnant patients with severe PAH.

Cardiovascular-obstetric state-of-the-art review: pulmonary hypertension in pregnancy

ABSTRACT

Pulmonary hypertension in pregnancy has been associated with negative maternal and fetal outcomes over the past decades. With the emergence of novel treatment modalities, morbidity and mortality of women who have pulmonary hypertension in pregnancy have improved. In this review, we aim to explore the contemporary updates in the management of pre-capillary and post-capillary pulmonary hypertension in pregnancy.

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.

Pregnancy in Patients with Pulmonary Arterial Hypertension in Light of New ESC Guidelines on Pulmonary Hypertension

Pulmonary arterial hypertension (PAH) is defined as an elevated mean pulmonary artery pressure (mPAP) of >20 mmHg together with a pulmonary arterial wedge pressure (PAWP) of ≤15 mmHg and pulmonary vascular resistance (PVR) of>2 Wood units (WU). Although the total mortality of pregnant women with PAH has decreased significantly in recent years and is reported to be around 12% in some databases, total mortality is still at an unacceptably high percentage. Moreover, some subgroups, such as patients with Eisenmenger's syndrome, have a particularly high mortality rate of up to 36%. Pregnancy in patients with PAH is contraindicated; its appearance is an indication for a planned termination. Education of patients with PAH, including counseling on effective contraception, is essential. During pregnancy, blood volume, heart rate, and cardiac output increase, while PVR and systemic vascular resistance decrease. The hemostatic balance is shifted towards hypercoagulability. Among PAH-specific drugs, the use of inhaled or intravenous prostacyclins, phosphodiesterase inhibitors, and calcium channel blockers (in patients with preserved vasoreactivity) is acceptable. Endothelin receptor antagonists and riociguat are contraindicated. Childbirth can take place through either vaginal delivery or caesarean section; similarly, neuraxial and general anesthesia have proven indications. In a situation where all pharmacological options have been used in pregnant or postpartum patients in a serious condition, veno-arterial ECMO is a useful therapeutic option. For PAH patients who want to become mothers, an option that does not endanger their lives is adoption.

Inter-Specialty Controversies on the Treatment of Cardiovascular Diseases during Pregnancy: A Questionnaire Study

Background and Objectives: Management of cardiovascular disease (CVD) during pregnancy is challenging and usually requires eminence-based decisions due to limited strong-evidence data in this field. The purpose of our study was to compare the attitudes of anaesthesiologists, cardiologists, and gynaecologists towards the diagnosis and treatment of potentially life-threatening CVDs during pregnancy. Materials and Methods: A cross-sectional, questionnaire-based study was performed among 111 doctors (55 anaesthesiologists, 36 cardiologists, 20 gynaecologists). Personal opinions on the recommendations (n = 19) regarding rare, potentially life-threatening CVDs during pregnancy were recorded using a five-item Likert scale. Results: Opinions regarding eight statements (42%) varied substantially between specialties (p < 0.05). The most distinctive differences between physicians concerned the following recommendations: “thrombolysis should only be used in pulmonary embolism with cardiogenic shock” (agree: 52.7% of anaesthesiologists, 80.4% of cardiologists, 25.0% of gynaecologists; p < 0.001); “women with the antiphospholipid syndrome should restart treatment with vitamin K antagonists from the second trimester of pregnancy” (agree: 12.7% of anaesthesiologists, 69.4% of cardiologists, 20.0% of gynaecologists; p < 0.001); “women with symptomatic pulmonary hypertension should have a Swan–Ganz catheter inserted for labour” (agree: 20.0% of anaesthesiologists, 11.1% of cardiologists, 55.0% of gynaecologists; p = 0.001). Conclusions: Physicians’ opinions regarding diagnostics and treatment of CVDs in pregnancy remain controversial. A multidisciplinary approach is recommended to ensure the safety and effectiveness of management in these unique medical conditions.

[New aspects of rare rheumatic diseases during pregnancy]

For some rare rheumatic diseases the data situation on fertility and pregnancy is still scant. This article attempts to present the data known so far and to derive and supplement some treatment recommendations from the data. A stable disease situation before the pregnancy drastically reduces the risk of complications for mother and child; therefore, an appropriate and timely adjustment of treatment in consultation with patients and gynecologists is important.