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Yang JZ, Fernandes TM, Kim NH, Poch DS, Kerr KM, Lombardi S, Melber D, Kelly T, Papamatheakis DG. Pregnancy and pulmonary arterial hypertension: a case series and literature review. Am J Obstet Gynecol MFM 2021; 3:100358. [PMID: 33785463 DOI: 10.1016/j.ajogmf.2021.100358] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/23/2021] [Accepted: 03/16/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite the development of advanced therapies for pulmonary arterial hypertension, pregnancy remains contraindicated in these patients owing to high maternal and fetal morbidity and mortality. Limited data exist regarding pregnancy management and outcome in this unique patient population. We describe a series of pregnant patients diagnosed as having pulmonary arterial hypertension before or during pregnancy who delivered at a tertiary center with a comprehensive and established pulmonary vascular disease program. OBJECTIVE This study aimed to describe a single institution's experience and review the existing literature for pregnancy management and outcomes in patients with pulmonary arterial hypertension. STUDY DESIGN A review of all patients with pulmonary arterial hypertension who were admitted for delivery between 2005 and 2019 at our institution was performed. All data were extracted from the electronic health record and included patient demographics, pulmonary arterial hypertension subtype, pulmonary arterial hypertension-targeted therapies, and mode of delivery and anesthesia. RESULTS A total of 7 patients were identified; 5 patients had a prepartum diagnosis of pulmonary arterial hypertension, whereas 2 patients were diagnosed as having pulmonary arterial hypertension during the third trimester. All patients were started on prostacyclins and the majority were on combination pulmonary arterial hypertension-targeted therapy. The maternal mortality rate was 29%. Elective cesarean delivery was performed in more than 70% of cases, whereas 1 patient required an urgent cesarean delivery and 1 patient had a successful vaginal delivery. Most patients had epidural anesthesia. Notably, 2 patients required extracorporeal membrane oxygenation after delivery and both died. There were no cases of neonatal mortality. CONCLUSION Our cases series and the published literature to date show that pregnancy in pulmonary arterial hypertension remains poorly tolerated despite marked advancements in pulmonary arterial hypertension-targeted therapies and postpartum care. A multidisciplinary team approach remains essential for the management of these patients.
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Affiliation(s)
- Jenny Z Yang
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (Drs Yang, Fernandes, Kim, Poch, and Kerr; Ms Lombardi; and Dr Papamatheakis).
| | - Timothy M Fernandes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (Drs Yang, Fernandes, Kim, Poch, and Kerr; Ms Lombardi; and Dr Papamatheakis)
| | - Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (Drs Yang, Fernandes, Kim, Poch, and Kerr; Ms Lombardi; and Dr Papamatheakis)
| | - David S Poch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (Drs Yang, Fernandes, Kim, Poch, and Kerr; Ms Lombardi; and Dr Papamatheakis)
| | - Kim M Kerr
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (Drs Yang, Fernandes, Kim, Poch, and Kerr; Ms Lombardi; and Dr Papamatheakis)
| | - Sandra Lombardi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (Drs Yang, Fernandes, Kim, Poch, and Kerr; Ms Lombardi; and Dr Papamatheakis)
| | - Dora Melber
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences (Drs Melber and Kelly), University of California, San Diego, La Jolla, CA
| | - Thomas Kelly
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences (Drs Melber and Kelly), University of California, San Diego, La Jolla, CA
| | - Demosthenes G Papamatheakis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (Drs Yang, Fernandes, Kim, Poch, and Kerr; Ms Lombardi; and Dr Papamatheakis)
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Rashidi F, Sate H. Pregnancy outcome in a pregnant patient with idiopathic Pulmonary Arterial Hypertension: a case report and review of the literature. J Med Case Rep 2018; 12:31. [PMID: 29433561 PMCID: PMC5810109 DOI: 10.1186/s13256-017-1547-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 12/18/2017] [Indexed: 12/20/2022] Open
Abstract
Background Idiopathic pulmonary arterial hypertension is a rare and progressive condition which is aggravated by the physiologic changes during pregnancy. Because of high mortality rate, most physicians recommend early termination of pregnancy in patients with idiopathic pulmonary arterial hypertension. Case presentation Here we describe a case of a 30-year-old primigravida Caucasian housewife with functional class 1 idiopathic pulmonary arterial hypertension and a positive vasoreactive response to adenosine who had a full-term non-complicated delivery. Right-sided heart catheterization before the pregnancy showed severe pulmonary hypertension with mean pulmonary arterial pressure of 60 mmHg, and pulmonary vascular resistance of 12.2 WU. Vasoreactivity was positive after infusion of 200 μg/kg per minute adenosine. During pregnancy, she did not receive medication other than prophylactic enoxaparin. She had an elective cesarean section under general anesthesia at 39 weeks of gestation without complication and delivered a healthy baby. After delivery, her hemodynamic status was stable. One month postpartum, she was in a stable clinical condition in functional class 1. Conclusions In pregnant patients with pulmonary arterial hypertension, decreased mortality has been observed over recent years particularly in patients with well-controlled pulmonary pressure and a positive vasoreactivity test.
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Affiliation(s)
- Farid Rashidi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Imam Reza General Hospital, 29 Bahaman St, Tabriz, Iran.
| | - Hossein Sate
- Department of Cardiology, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Abstract
The prevalence of pregnant women with cardiovascular heart disease is increasing. Transthoracic echocardiography is safe during pregnancy, and it is an important diagnostic tool in pregnant women with established heart disease in order to monitor ventricular and valvular anatomy and function. In addition, it can be used to delineate cardiac anatomy in complex congenital heart disease and help stratify maternal risk during pregnancy. This review will focus on the use of echocardiography in the diagnosis and management of pregnant women with common congenital lesions and with prosthetic valves.
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Affiliation(s)
- Meena Narayanan
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Uri Elkayam
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tasneem Z Naqvi
- Division of Cardiology, Department of Medicine, College of Medicine, Mayo Clinic, CK27, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
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Dasgupta S, Das S, Majumdar B, Basu SM. Caesarean section in Eisenmenger’s syndrome: anaesthetic management with titrated epidural and nebulised alprostadil. Southern African Journal of Anaesthesia and Analgesia 2016. [DOI: 10.1080/22201181.2016.1145432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Alvarez Escudero J, Calvo Vecino JM, Veiras S, García R, González A. Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery: reducing risk of heart failure patients in noncardiac surgery. ACTA ACUST UNITED AC 2015; 62:359-419. [PMID: 26164471 DOI: 10.1016/j.redar.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 12/29/2022]
Affiliation(s)
- J Alvarez Escudero
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - J M Calvo Vecino
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain; Associated Professor and Head of the Department of Anesthesiology, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain.
| | - S Veiras
- Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - R García
- Department of Anesthesiology, Puerta del Mar University Hospital. Cadiz, Spain
| | - A González
- Department of Anesthesiology, Puerta de Hierro University Hospital. Madrid, Spain
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Sahni S, Palkar AV, Rochelson BL, Kępa W, Talwar A. Pregnancy and pulmonary arterial hypertension: A clinical conundrum. Pregnancy Hypertens 2015; 5:157-64. [DOI: 10.1016/j.preghy.2015.01.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 01/25/2015] [Indexed: 12/27/2022]
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Idrees MM, Swiston J, Nizami I, Al Dalaan A, Levy RD. Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Medical and surgical management for pulmonary arterial hypertension. Ann Thorac Med 2014; 9:S79-91. [PMID: 25077002 PMCID: PMC4114282 DOI: 10.4103/1817-1737.134043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 01/14/2023] Open
Abstract
Prior to the availability of the pulmonary arterial hypertension (PAH)-specific therapy, PAH was a dreadful disease with a very poor prognosis. Better understanding of the complex pathobiology of PAH has led to a major therapeutic evolution. International regulatory agencies have approved many specific drugs with different pharmacologic pathways and routes of administration. In the year 2013, two new drugs with great potentials in managing PAH have been added to the treatment options, macitentan and riociguat. Additional drugs are expected to come in the near future. A substantial body of evidence has confirmed the effectiveness of pulmonary arterial hypertension (PAH)-specific therapies in improving the patients’ symptomatic status and slowing down the rate of clinical deterioration. Although the newer modern medications have significantly improved the survival of patients with PAH, it remains a non-curable and fatal disease. Lung transplantation (LT) remains the only therapeutic option for selected patients with advanced disease who continue to deteriorate despite optimal therapy.
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Affiliation(s)
- Majdy M Idrees
- Pulmonary Medicine, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - John Swiston
- Pulmonary Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Imran Nizami
- Department of Organs Transplant, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Abdullah Al Dalaan
- Pulmonary Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Robert D Levy
- Pulmonary Medicine, Vancouver General Hospital, Vancouver, BC, Canada
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Khan J, Idrees MM. Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Pregnancy in pulmonary hypertension. Ann Thorac Med 2014; 9:S108-12. [PMID: 25076988 PMCID: PMC4114271 DOI: 10.4103/1817-1737.134050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 11/04/2022] Open
Abstract
Pregnancy in pulmonary hypertension (PH) is known to be associated with high morbidity and mortality. The physiological changes occur during normal pregnancy, such as increase blood volume and cardiac output (CO) may be detrimental in PH patients. Several practice guidelines advise against pregnancy and even recommend termination of pregnancy. Occasionally PH may be diagnosed for the first time during pregnancy, as stress of pregnancy can unmask previously undiagnosed PH in an asymptomatic individual. This narrative review provides a detailed discussion about the physiologic parameters associated in pregnancy and their negative effect on the right ventricle. It also gives practical evidence-based recommendations about different management issues in PH pregnant patients.
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Affiliation(s)
- Javed Khan
- Department of Pulmonary Medicine, King Fahd Armed Forced Hospital, Jeddah, Saudi Arabia
| | - Majdy M Idrees
- Prince Sultan Medical Military City, Riyadh, Saudi Arabia
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Pieper PG, Lameijer H, Hoendermis ES. Pregnancy and pulmonary hypertension. Best Pract Res Clin Obstet Gynaecol 2014; 28:579-91. [DOI: 10.1016/j.bpobgyn.2014.03.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 03/06/2014] [Indexed: 12/13/2022]
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Duarte AG, Thomas S, Safdar Z, Torres F, Pacheco LD, Feldman J, deBoisblanc B. Management of pulmonary arterial hypertension during pregnancy: a retrospective, multicenter experience. Chest 2013; 143:1330-1336. [PMID: 23100080 DOI: 10.1378/chest.12-0528] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a rare disease with a predilection for young women that is associated with right ventricular failure and premature death. PAH can complicate pregnancy with hemodynamic instability or sudden death during parturition and postpartum. Our aim was to examine the impact of PAH on pregnancy outcomes in the modern era. METHODS We conducted a retrospective evaluation of pregnant patients with PAH managed between 1999 and 2009 at five US medical centers. Patient demographics, medical therapies, hemodynamic measurements, manner of delivery, anesthetic administration, and outcomes were assessed. RESULTS Among 18 patients with PAH, 12 continued pregnancy and six underwent pregnancy termination. Right ventricular systolic pressure in patients managed to parturition was 82 ± 5 mm Hg and in patients with pregnancy termination was 90 ± 16 mm Hg. Six patients underwent pregnancy termination at mean gestational age of 13 ± 1.0 weeks with no maternal deaths or complications. Twelve patients elected to continue their pregnancy and were hospitalized at 29 ± 1.4 weeks. PAH-specific therapy was administered to nine (75%) at time of delivery consisting of sildenafil, IV prostanoids, or combination therapy. All parturients underwent Cesarean section at 34 weeks with one in-hospital death and one additional death 2 months postpartum for maternal mortality of 16.7%. CONCLUSIONS Compared with earlier reports, maternal morbidity and mortality among pregnant women with PAH was reduced, yet maternal complications remain significant and patients should continue to be counseled to avoid pregnancy.
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Affiliation(s)
- Alexander G Duarte
- Division of Pulmonary/Critical Care Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX.
| | - Shibu Thomas
- Division of Pulmonary/Critical Care Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Zeenat Safdar
- Pulmonary/Critical Care Medicine, Baylor College of Medicine, Houston, TX
| | - Fernando Torres
- Pulmonary/Critical Care Medicine, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Luis D Pacheco
- Department of Obstetrics and Gynecology and Department of Anesthesiology, The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Bennet deBoisblanc
- Pulmonary and Critical Care Medicine, LSU Health New Orleans, New Orleans, LA
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11
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Abstract
Pulmonary arterial hypertension (PAH) is characterized by pulmonary vascular remodeling that limits the ability of the pulmonary vascular bed to withstand the physiological changes of pregnancy. Historically, pregnancy in PAH carries a high risk to the parturient. Normal pulmonary vasculature can withstand the hemodynamic and physiological changes associated with pregnancy without the development of respiratory symptomatology. However, in the presence of pulmonary vascular remodeling the capacity to handle these changes is compromised. During pregnancy, increase in cardiac output from the increased intravascular volume can lead to right heart failure. Therefore, all patients with PAH of childbearing potential should receive preconception counseling and be advised to use two methods of contraception. Patients with PAH should be advised against continuing pregnancy if they do become pregnant. According to the literature, deterioration in pregnancy mainly occurs in the second trimester and early in the third trimester; immediately postpartum is the most critical time for patients with PAH. In this review, we will discuss the recent advances in the management of parturient patients with PAH.
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Affiliation(s)
- Zeenat Safdar
- Baylor Pulmonary Hypertension Center, Pulmonary-Critical Care Medicine, Baylor College of Medicine, Houston, TX 77030, USA.
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Manivannan S, Dadlani G, Parsons M, Crisan L, Belogolovkin V, Sastry N, Guglin M. Surgical repair of atrial septal defect with severe pulmonary hypertension during pregnancy: a case report with literature review. Cardiol Young 2012; 22:493-8. [PMID: 22717278 DOI: 10.1017/S1047951112000492] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
We are reporting a case of a 37-year-old pregnant woman with a large secundum atrial septal defect with left-to-right shunt and severe pulmonary hypertension. Her atrial septal defect was undiagnosed before this pregnancy. After carefully considering all the options, we repaired her atrial septal defect with an open heart surgical closure at 20 weeks of gestation. A substantial and consistent reduction in pulmonary arterial pressure after the surgery and subsequent uneventful delivery indicate that surgical repair of atrial septal defects is a viable option that should be considered for such patients.
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13
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Spezielle Arzneimitteltherapie in der Schwangerschaft. Arzneimittel in Schwangerschaft und Stillzeit 2012. [DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Naguib M, Dob D, Gatzoulis M. A functional understanding of moderate to complex congenital heart disease and the impact of pregnancy. Part II: Tetralogy of Fallot, Eisenmenger’s syndrome and the Fontan operation. Int J Obstet Anesth 2010; 19:306-12. [DOI: 10.1016/j.ijoa.2009.10.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Accepted: 10/10/2009] [Indexed: 10/19/2022]
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Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is a rare condition characterized by sustained elevation in pulmonary arterial resistance leading to right heart failure. BACKGROUND PAH afflicts predominantly women. Echocardiography is the initial investigation of choice for non-invasive detection of PAH but right-heart catheterization is necessary to confirm the diagnosis. Conventional treatment includes non-specific drugs (warfarin, diuretics, oxygen). The endothelin-1 receptor antagonist bosentan, the phosphodiesterase-5 inhibitor sildenafil, and prostanoids have been shown to improve symptoms, exercise capacity and haemodynamics. Intravenous prostacyclin is the first-line treatment for the most severely affected patients. Despite the most modern treatment, the overall mortality rate of pregnant women with severe PAH remains high. Therefore, pregnancy is contraindicated in women with PAH and an effective method of contraception is recommended in women of childbearing age. Therapeutic abortion should be offered, particularly when early deterioration occurs. If this option is not accepted, intravenous prostacyclin should be considered promptly. VIEWPOINTS AND CONCLUSION Recent advances in the management of PAH have markedly improved prognosis and have resulted in more women of childbearing age considering pregnancy. A multidisciplinary approach should give new insights into cardiopulmonary, obstetric and anaesthetic management during pregnancy, delivery and the postpartum period.
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Affiliation(s)
- O Sanchez
- Service de pneumologie et soins intensifs, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, faculté de médecine, université Paris-Descartes, 20, rue Leblanc, 75015 Paris, France.
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Pandey R, Garg R, Nath MP, Rajan S, Punj J, Darlong V, Chandralekha. Eisenmenger's syndrome in pregnancy: use of Proseal laryngeal mask airway (PLMA) and epidural analgesia for elective cesarean section. Acta Anaesthesiol Taiwan 2009; 47:204-7. [PMID: 20015822 DOI: 10.1016/s1875-4597(09)60056-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We describe the successful anesthetic management of cesarean section in a patient with Eisenmenger's syndrome secondary to an atrial septal defect. Although conception is discouraged in women with Eisenmenger's syndrome, in inevitable circumstances, careful and meticulous planning of anesthesia can help the parturient survive the ordeal of a cesarean section. The cardiac output must be maintained and systemic vascular resistance must not be allowed to fall. This should ensure that there is minimal change in the right to left shunt. In our patient, the scenario of Eisenmenger's syndrome was complicated by biventricular hypertrophy. We achieved the goals in our patient by using general anesthesia with the Proseal laryngeal mask airway, a combination of ketamine and propofol, and epidural analgesia.
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Affiliation(s)
- Ravindra Pandey
- Department of Anesthesiology and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
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Bedard E, Dimopoulos K, Gatzoulis MA. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension? Eur Heart J 2008; 30:256-65. [DOI: 10.1093/eurheartj/ehn597] [Citation(s) in RCA: 374] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Siddiqui S, Latif N. PGE1 nebulisation during caesarean section for Eisenmenger's syndrome: a case report. J Med Case Rep 2008; 2:149. [PMID: 18466628 PMCID: PMC2405798 DOI: 10.1186/1752-1947-2-149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Accepted: 05/09/2008] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Eisenmenger's syndrome in pregnancy can lead to death in 50% to 65% of parturients. Expensive invasive monitoring and medication have improved management and outcomes. Cheaper alternatives for the management of high-risk patients who present with no prenatal care are still not available. CASE PRESENTATION We describe the obstetric anaesthesia management of a 34-year-old, 34-weeks pregnant woman who presented with a recent diagnosis of severe Eisenmenger's syndrome. A combined spinal epidural anaesthesia was used together with invasive cardiac monitoring as well as PGE1 nebulisation after delivery of the baby. This helped achieve a reduction of shunt, improvement of hypoxia and reduction of pulmonary pressures. CONCLUSION We found this to be a cheaper and safe alternative in the management of such patients who present with no adequate prior management.
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Affiliation(s)
- Shahla Siddiqui
- Department of Anaesthesia, Aga Khan University, Karachi, Pakistan.
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20
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Abstract
PURPOSE The treatment of pulmonary arterial hypertension (PAH) in pregnancy is reviewed. SUMMARY PAH is a disease characterized by narrowing of the pulmonary arteries and increased vascular resistance. Women with PAH should avoid becoming pregnant, as the physiological, cardiovascular, and pulmonary changes that occur during pregnancy can exacerbate the condition. However, several viable treatment options are available to improve the outcomes in this patient population, including inhaled nitric oxide, calcium-channel blockers, targeted pulmonary vasodilators, and sildenafil. Epoprostenol, a naturally occurring prostaglandin and vasodilator, is a pregnancy category B drug. Reproductive studies in rats and rabbits have found no impaired fertility or fetal harm at 2.5-4.8 times the recommended human dosage of epoprostenol. Most of the published case reports describe initiating epoprostenol 2-4 ng/kg/min i.v. several weeks before or near the time of delivery. Iloprost is a pregnancy category C drug but has demonstrated benefit in pregnant patients with PAH, with no congenital abnormalities and no postpartum maternal or infant mortality reported. Sildenafil causes vasodilation of the pulmonary vascular bed and vasodilation in the systemic circulation. Two case reports have described the successful treatment with sildenafil, a pregnancy category B drug, of pregnant patients with PAH. Patients with idiopathic PAH or chronic thromboembolic PAH should receive full-dose subcutaneous low-molecular-weight heparin therapy instead of warfarin for bleeding prophylaxis during pregnancy. CONCLUSION Targeted pulmonary vasodilators are viable treatment options for pregnant patients with PAH. Early recognition and management of worsening symptoms are essential to improve outcomes for both the mother and infant.
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Affiliation(s)
- Sheilyn Huang
- Drug Information Service, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
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Gonçalves Marcos IAC. [Pregnancy and lungs]. Rev Port Pneumol 2007; 13:213-37. [PMID: 17492234 DOI: 10.1016/s0873-2159(15)30345-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Respiratory pathology can be relatively frequent during pregnancy. One third of pregnant woman may experience worsening of their asthma condition. Pulmonary tromboembolism is 5 times more frequent in pregnancy. Bacterial, viral and fungal pneumonias are badly tolerated during pregnancy, provoking mother-foetal morbidity, respiratory insufficiency, low born-weight or prematurity. Non-treated tuberculosis may increase maternal mortality and preterm birth by 4 and 9 times respectively. Pregnancy is counter-indicated in women with cystic fibrosis and severe pulmonary function. Despite therapeutic progresses already made, pulmonary hypertension is associated to over 30% of mother-foetal morbidity and mortality. Approximately 1 in 1,000-1,500 pregnancies is affected by mother cancer. High rates of lung cancer morbility in women bring new and important challenges to therapy.
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Abstract
Cardiac disorders complicate less than 1% of all pregnancies. Physiologic changes in pregnancy may mimic heart disease. In order to differentiate these adaptations from pathologic conditions, an in-depth knowledge of cardiovascular physiology is mandatory. A comprehensive history, physical examination, electrocardiogram, chest radiograph, and echocardiogram are sufficient in most cases to confirm the diagnosis. Care of women with cardiac disease begins with preconception counseling. Severe lesions should be taken care of prior to contemplating pregnancy. Management principles for pregnant women are similar to those for the non-pregnant state. A team approach comprised of a maternal fetal medicine specialist, cardiologist, neonatologist, and anesthesiologist is essential to assure optimal outcome for both the mother and the fetus. Although fetal heart disease complicates only a small percentage of pregnancies, congenital heart disease causes more neonatal morbidity and mortality than any other congenital malformation. Unfortunately, screening approaches for fetal heart disease continue to miss a large percentage of cases. This weakness in fetal screening has important clinical implications, because the prenatal detection and diagnosis of congenital heart disease may improve the outcome for many of these fetal patients. In fact, simply the detection of major heart disease prenatally can improve neonatal outcome by avoiding discharge to home of neonates with ductal-dependent congenital heart disease. Fortunately, recent advances in screening techniques, an increased ability to change the prenatal natural history of many forms of fetal heart disease, and an increasing recognition of the importance of a multidisciplinary, team approach to the management of pregnancies complicated with fetal heart disease, together promise to improve the outcome of the fetus with congenital heart disease.
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Affiliation(s)
- Afshan B Hameed
- Maternal Fetal Medicine and Cardiology, University of California, Irvine, USA
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Abstract
Congenital heart disease has become more prevalent in women of childbearing age and represents about 75% of the heart disease seen in pregnancy. Close monitoring by both obstetricians and cardiologists is advisable for women with complex heart disease, and pregnancy should still be considered contraindicated in several types of congenital heart disease. Women should also be advised of the risk that their offspring may be affected. Women at increased risk for a cardiac event in pregnancy include those with a prior cardiac event or arrhythmia, NYHA functional class > II or cyanosis, left heart obstruction, and systemic ventricular dysfunction. In the absence of adverse predictors, however, women with congenital heart disease can be assured that pregnancy does not pose a significant risk to their health.
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Affiliation(s)
- Gregory A L Davies
- Professor and Chair, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Queen's University, Kingston ON
| | - William N P Herbert
- William Norman Thornton Professor and Chair, Department of Obstetrics and Gynecology, University of Virginia, Charlottesville VA
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Abstract
The original definition of Eisenmenger syndrome refers to an unrestrictive post-tricuspid valve congenital systemic-to-pulmonary shunt. When the pulmonary arterial systolic pressure becomes equal to the systemic arterial systolic pressure, the direction of the shunt becomes pulmonary-to-systemic. The latter leads to progressive cyanosis, and exercise intolerance is initially proportional to the degree of hypoxaemia. Later, congestive heart failure may occur . The management principle is to avoid any factors that destabilise this delicately balanced physiology. Until recently, this could only be achieved by symptomatic therapy; however, when patients are severely incapacitated, transplantation is needed. At present, new drugs, which are more selective pulmonary vasodilators, are available to interfere with the ongoing disease process to improve functional capacity and delay the decision for transplantation.
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Affiliation(s)
- Werner Budts
- Department of Cardiology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Bendayan D, Hod M, Oron G, Sagie A, Eidelman L, Shitrit D, Kramer MR. Pregnancy Outcome in Patients With Pulmonary Arterial Hypertension Receiving Prostacyclin Therapy. Obstet Gynecol 2005; 106:1206-10. [PMID: 16260574 DOI: 10.1097/01.aog.0000164074.64137.f1] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pregnancy is contraindicated in cases of pulmonary hypertension, a highly morbid disease affecting young women of childbearing age. CASES We describe the pregnancies of 3 patients with pulmonary arterial hypertension (idiopathic, Eisenmenger syndrome, and related to systemic lupus erythematosus). They received epoprostenol and low-molecular-weight heparin throughout pregnancy. The patient with Eisenmenger syndrome started epoprostenol in gestational week 16. Cesarean delivery under general anesthesia was performed at 28-33 weeks of gestation; early delivery was necessary in the patient with Eisenmenger syndrome because of fetal growth restriction. All deliveries were uneventful, and birth weights were 1,700, 1,500, and 795 g. There were no postpartum complications. CONCLUSION Pregnancy in women with pulmonary hypertension should still be considered high risk for both mother and child, but stable patients on epoprostenol may successfully complete pregnancy.
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Affiliation(s)
- Daniele Bendayan
- Pulmonary Institute, the Perinatal Division and WHO Collaborating Center for Perinatal Care, Department of Obstetrics and Gynecology, Beilinson Campus, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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26
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Abstract
This article examines the management and outcomes of pregnant women with cystic fibrosis, primary pulmonary hypertension, and sarcoidosis. Pregnancy and the puerperium are associated with important cardiopulmonary changes that can adversely affect the clinical condition. Management of pregnant women with CF should be done with careful attention to complications of altered body weight, diabetes, and liver disease. Primary pulmonary hypertension is characterized by a progressive increase in pulmonary pressure and resistance in the absence of an identified cardiac or pulmonary cause. A multidisciplinary approach to the management of patients with primary pulmonary hypertension is of great importance for a successful maternal and fetal outcome. Good maternal and fetal outcomes are possible in women with restrictive lung disease in general and sarcoidosis in particular. The management of pregnancy, labor, and delivery are not altered by the presence of sarcoidosis.
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Affiliation(s)
- Rubin Cohen
- Department of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
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