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Cruz NC, Pham E, Ali H, Nanavati J, Steppan D, Kolb TM, Thomas AJ, Murphy J, Nyhan S, Grant MC, Steppan J. How severity and classification of pulmonary hypertension affect pregnancy outcomes: a systematic review and timeline. Int J Obstet Anesth 2024; 59:104210. [PMID: 38781778 PMCID: PMC11227390 DOI: 10.1016/j.ijoa.2024.104210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/16/2024] [Accepted: 04/21/2024] [Indexed: 05/25/2024]
Abstract
Women with pulmonary hypertension (PH) have increased mortality during pregnancy and the peripartum period. An increasing number of publications suggest improvements in maternal outcomes, so we conducted a systematic review focusing on disease severity and maternal survival. After screening 9097 potential studies from 1967 to 2021, we identified 66 relevant publications. Outcomes improved continuously over time and mortality fell from 11.6% in studies published before 2015 to 8.2% in studies published after 2015. Mortality was lower in patients with mild disease (0.8%) than in those with Eisenmenger syndrome (26.2%) or idiopathic pulmonary arterial hypertension (7.4-24.0%). One major drawback of the published studies is that they define severity using echocardiographic-estimated pulmonary artery pressures, without considering more contemporary parameters. This systematic review provides new insights for preconception counseling on pregnancy risks related to PH and suggests that PH classification and severity should be carefully considered in determining an individual's pregnancy-associated risk.
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Affiliation(s)
- N C Cruz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - E Pham
- Department of Internal Medicine, Medstar Baltimore, Baltimore, MD, USA
| | - H Ali
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - J Nanavati
- School of Global Health, University of Washington, Seattle, WA, USA
| | - D Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - T M Kolb
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - A J Thomas
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - J Murphy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - S Nyhan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - M C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - J Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.
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2
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Coursen J, Simpson CE, Mukherjee M, Vaught AJ, Kutty S, Al-Talib TK, Wood MJ, Scott NS, Mathai SC, Sharma G. Pregnancy Considerations in the Multidisciplinary Care of Patients with Pulmonary Arterial Hypertension. J Cardiovasc Dev Dis 2022; 9:jcdd9080260. [PMID: 36005424 PMCID: PMC9409449 DOI: 10.3390/jcdd9080260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/26/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a vasoconstrictive disease of the distal pulmonary vasculature resulting in adverse right heart remodeling. Pregnancy in PAH patients is associated with high maternal morbidity and mortality as well as neonatal and fetal complications. Pregnancy-associated changes in the cardiovascular, pulmonary, hormonal, and thrombotic systems challenge the complex PAH physiology. Due to the high risks, patients with PAH are currently counseled against pregnancy based on international consensus guidelines, but there are promising signs of improving outcomes, particularly for patients with mild disease. For patients who become pregnant, multidisciplinary care at a PAH specialist center is needed for peripartum monitoring, medication management, delivery, postpartum care, and complication management. Patients with PAH also require disease-specific counseling on contraception and breastfeeding. In this review, we detail the considerations for reproductive planning, pregnancy, and delivery for the multidisciplinary care of a patient with PAH.
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Affiliation(s)
- Julie Coursen
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Catherine E. Simpson
- Divisions of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Monica Mukherjee
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Arthur J. Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology Obstetrics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Shelby Kutty
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Tala K. Al-Talib
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Malissa J. Wood
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Nandita S. Scott
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Stephen C. Mathai
- Divisions of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
- Correspondence:
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Younger J, Fayed M, Chauhan G, Mantel N, Penning D. Intrathecal Fentanyl With a Paracervical Block Is Safe and Effective for Elective Termination of Pregnancy in a Patient With Primary Pulmonary Hypertension. Cureus 2022; 14:e22699. [PMID: 35386166 PMCID: PMC8967124 DOI: 10.7759/cureus.22699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 11/22/2022] Open
Abstract
Pulmonary hypertension (PH) in pregnancy, irrespective of etiology, is associated with significant maternal morbidity and mortality. This case describes a novel approach to providing anesthesia for a hemodynamically fragile patient. It demonstrates the careful planning and weighted decision-making that is required when approaching a parturient with severe pulmonary hypertension. The patient's previous pulmonary artery catheterization showed right ventricular systolic pressure of 78 mmHg and pulmonary artery pressure of 78/20 mmHg. The patient presented with worsening dyspnea and a decision was made to proceed with the termination of pregnancy via dilatation and curettage (D&C). Anesthesia was conducted with combined intrathecal fentanyl with a paracervical block using lidocaine 2%. The patient had a complication of post-procedure hemorrhage secondary to uterine atony that required careful monitoring and judicious use of uterotonic medications. A decision was made to use oxytocin due to its favorable effect profile compared to other uterotonic medications. We hope this anesthesia technique will aid in the future management of these challenging cases.
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Wolla CD, Matos JR, Wineland R. Anesthetic Management of Severe Pulmonary Hypertension in Pregnancy. J Cardiothorac Vasc Anesth 2021; 36:542-545. [PMID: 34607764 DOI: 10.1053/j.jvca.2021.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 09/08/2021] [Accepted: 09/13/2021] [Indexed: 11/11/2022]
Abstract
Pregnancy entails significant changes in maternal physiology that are not well-tolerated in patients with pulmonary arterial hypertension. The profound changes in plasma volume, cardiac output, and systemic vascular resistance can lead to increased strain placed on the right ventricle, leading to right-heart failure and cardiovascular collapse. Given the complex and sometimes opposing physiologic changes, managing these patients can be challenging. As such, these patients have a significantly increased reported maternal mortality rate. This report describes a parturient with newly diagnosed severe pulmonary arterial hypertension and her anesthetic management.
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Affiliation(s)
- Christopher D Wolla
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC.
| | - Jennifer R Matos
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC
| | - Rebecca Wineland
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
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5
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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] [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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6
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Pulmonary hypertension and pregnancy outcomes: Systematic Review and Meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 253:108-116. [PMID: 32862030 DOI: 10.1016/j.ejogrb.2020.08.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/19/2020] [Accepted: 08/21/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Traditionally, pulmonary hypertension during pregnancy has been associated with increased risk of adverse maternal and fetal outcomes. The aim of this study to systematically analyze the published literature mentioning pregnancy outcomes in pregnant women with pulmonary hypertension in recent decades. STUDY METHODS A Comprehensive electronic literature search of MEDLINE, EMBASE and Cochrane library was done to find studies published in English literature from 1 Jan 1990 to 31st May 2018. Prospective and retrospective observational studies describing pregnancy outcomes in at least 4 women with pulmonary hypertension were included in this study. Meta-analysis was performed using the random-effects model. Risk of bias was assessed by the Newcastle-Ottawa Scale. The primary outcomes included maternal mortality and any pregnancy loss. The analysis included absolute risks and 95% confidence intervals (CI) for adverse outcomes using the DerSimonian-Laird random effects model. Heterogeneity was assessed by I2 statistic and visual plot. RESULTS Twenty studies captured data from 589 parturient describing 610 pregnancies. The pooled unadjusted data yielded maternal mortality of 11.5 (95% CI; 7.6-17.2) and the total pregnancy loss was 22.8 (95% CI; 16.2-31.1). Prematurity and IUGR/SGA were reported by 7 and 8 studies and had pooled estimates of 51.7 (95% CI; 37.6-65.7) and 29.3 (95% CI; 20.9-39.5), respectively. The pooled estimates of cesarean delivery and general anesthesia were 72.1 (95% CI; 60.6-81.93) and 40.1 (95% CI; 26.4-55.5), respectively. CONCLUSIONS Fetomaternal outcomes have improved in recent decades in parturient with moderate to severe pulmonary hypertension. These findings have implications for preconceptional counselling and risk stratifications.
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Aryal SR, Moussa H, Sinkey R, Dhungana R, Tallaj JA, Pamboukian SV, Patarroyo-Aponte M, Acharya D, Bajaj NS, Bhattarai S, Lenneman A, Joly JM, Sibai BM, Rajapreyar IN. Management of reproductive health in patients with pulmonary hypertension. Am J Obstet Gynecol MFM 2020; 2:100087. [PMID: 33345958 DOI: 10.1016/j.ajogmf.2020.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 01/04/2020] [Accepted: 01/11/2020] [Indexed: 11/29/2022]
Abstract
Pulmonary hypertension is characterized by elevated pulmonary artery pressure caused by several clinical conditions that affect pulmonary vasculature. Morbidity and death in this condition are related to the development of right ventricular failure. Normal physiologic changes that occur in pregnancy to support the growing fetus can pose hemodynamic challenges to the pregnant patient with pulmonary hypertension that results in increased morbidity and mortality rates. Current guidelines recommend that patients with known pulmonary hypertension be counseled against pregnancy. This review aims to provide clinicians with guidelines for preconception counseling, medication management, and delivery planning.
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Affiliation(s)
- Sudeep R Aryal
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL.
| | - Hind Moussa
- Division of Maternal-Fetal medicine, The University of Cincinnati, Cincinnati, OH
| | - Rachel Sinkey
- Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL
| | - Rajat Dhungana
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Jose A Tallaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Salpy V Pamboukian
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Maria Patarroyo-Aponte
- Center for Advanced Heart Failure, University of Texas Health Science Center, Houston, TX
| | - Deepak Acharya
- Division of Cardiology, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Navkaranbir S Bajaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | | | - Andrew Lenneman
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Joanna M Joly
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Baha M Sibai
- Division of Maternal-Fetal Medicine, University of Texas, Houston, TX
| | - Indranee N Rajapreyar
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
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Lim K, Chang SA, Oh SY, Lee JH, Song J, Kang IS, Huh J, Park SJ, Park SW, Kim DK. Pulmonary Arterial Hypertension and Pregnancy: Single Center Experience in Current Era of Targeted Therapy. Korean Circ J 2019; 49:545-554. [PMID: 31074218 PMCID: PMC6554588 DOI: 10.4070/kcj.2018.0350] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/26/2018] [Accepted: 02/12/2019] [Indexed: 01/29/2023] Open
Abstract
Objectives To report our experiences in pregnant patients with pulmonary arterial hypertension (PAH) who were treated with targeted therapy. Methods From 2011 to 2017, women who decided to maintain pregnancies in our PAH clinic were included. Clinical data, management, and outcomes of the mothers and fetuses were reviewed. Results Nine women with PAH and 10 deliveries were reviewed. The median maternal age was 28 (26–32) years old. The functional status of each patient was New York Heart Association functional class II or III at first visit. Sildenafil was prescribed in advance in 9 cases of delivery. Multidiscipline team approach management and intensive care were performed during the peripartum period. There was no maternal or fetal mortality. Severe cardiac events occurred in 2 patients with Eisenmenger syndrome: cardiac arrest and uncontrolled arrhythmia. Non-cardiac events occurred in 3 cases: postpartum bleeding, urinary tract infection, and pneumonia. The median gestational period at delivery was about 34 (32–38) weeks. Three cases were emergent delivery because of unexpected preterm labor. Intrauterine growth restriction developed in 4 fetuses. Conclusions Pregnancy could be maintained by the introduction of targeted therapy rather more safely than the previous era in the case of maintenance of pregnancy. Intensive care and a multidisciplinary team approach can possibly improve the outcomes of the pregnant women with PAH and their babies. However, pregnancy in patients with PAH is still strongly prohibited and it can be tried in expert center where there has sufficient multidisciplinary team approach in case of inevitability.
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Affiliation(s)
- Kyunghee Lim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung A Chang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Soo Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jinyoung Song
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - I Seok Kang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Huh
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Ji Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Duk Kyung Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Zhang J, Lu J, Zhou X, Xu X, Ye Q, Ou Q, Li Y, Huang J. Perioperative Management of Pregnant Women With Idiopathic Pulmonary Arterial Hypertension: An Observational Case Series Study From China. J Cardiothorac Vasc Anesth 2018. [DOI: 10.1053/j.jvca.2018.01.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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10
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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] [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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Monagle J, Manikappa S, Ingram B, Malkoutzis V. Pulmonary hypertension and pregnancy: the experience of a tertiary institution over 15 years. Ann Card Anaesth 2016; 18:153-60. [PMID: 25849682 PMCID: PMC4881648 DOI: 10.4103/0971-9784.154466] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: Pulmonary hypertension (PH) in pregnancy is associated with a high maternal mortality and morbidity and has been found to be as high as 30-56%. Aim: To review the management of such patients in a tertiary center over a 15 year period, as the current literature consists of a few case reports, a few small case series and 2 meta-analyses. Materials and Methods: A review of all patients admitted to our institution for management of PH in pregnancy between 1994 and February 2009 was undertaken. Cases were identified from the high-risk pregnancy database within the department of anesthesia and from the hospital medical records. Severity of PH, type of PH, NYHA functional status at presentation and delivery, mode of delivery, peripartum monitoring and APGAR scores were noted. Patients were reviewed by a multidisciplinary team and management planned accordingly. Results: 19 eligible patients were identified. Patients who were significantly sick due to their PH were aggressively managed during pregnancy. Overall there was an improvement in NYHA functional status at the time of delivery. Epidural analgesia and anesthesia for labor and operatively delivery seem to be the ideal choice. Conclusion: Multidisciplinary approach is a key to the successful management of these patients. Secondary PH results in higher morbidity and mortality, in particular, older the age higher the maternal morbidity and mortality.
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Affiliation(s)
| | - Shashikanth Manikappa
- Department of Anaesthesia and Perioperative Medicine, Monash Medical Centre, Clayton, Victoria 3168, Australia
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Hemnes AR, Kiely DG, Cockrill BA, Safdar Z, Wilson VJ, Al Hazmi M, Preston IR, MacLean MR, Lahm T. Statement on pregnancy in pulmonary hypertension from the Pulmonary Vascular Research Institute. Pulm Circ 2015; 5:435-65. [PMID: 26401246 PMCID: PMC4556496 DOI: 10.1086/682230] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 02/25/2015] [Indexed: 01/06/2023] Open
Abstract
Pregnancy outcomes in patients with pulmonary hypertension remain poor despite advanced therapies. Although consensus guidelines recommend against pregnancy in pulmonary hypertension, it may nonetheless occasionally occur. This guideline document sought to discuss the state of knowledge of pregnancy effects on pulmonary vascular disease and to define usual practice in avoidance of pregnancy and pregnancy management. This guideline is based on systematic review of peer-reviewed, published literature identified with MEDLINE. The strength of the literature was graded, and when it was inadequate to support high-level recommendations, consensus-based recommendations were formed according to prespecified criteria. There was no literature that met standards for high-level recommendations for pregnancy management in pulmonary hypertension. We drafted 38 consensus-based recommendations on pregnancy avoidance and management. Further, we identified the current state of knowledge on the effects of sex hormones during pregnancy on the pulmonary vasculature and right heart and suggested areas for future study. There is currently limited evidence-based knowledge about both the basic molecular effects of sex hormones and pregnancy on the pulmonary vasculature and the best practices in contraception and pregnancy management in pulmonary hypertension. We have drafted 38 consensus-based recommendations to guide clinicians in these challenging topics, but further research is needed in this area to define best practices and improve patient outcomes.
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Affiliation(s)
- Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - David G. Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals National Health Service (NHS) Foundation Trust, Sheffield, United Kingdom
| | - Barbara A. Cockrill
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, and Harvard University Medical School, Boston, Massachusetts, USA
| | - Zeenat Safdar
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Victoria J. Wilson
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Manal Al Hazmi
- Section of Pulmonary Diseases, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ioana R. Preston
- Pulmonary, Critical Care and Sleep Division, Tufts Medical Center, Boston, Massachusetts, USA
| | - Mandy R. MacLean
- Institute of Cardiovascular and Medical Sciences, College of Medical and Veterinary Science, University of Glasgow, Glasgow, United Kingdom
| | - Tim Lahm
- Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine and Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
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Viktorsdottir O. Pulmonary Hypertension in Pregnancy and Anesthetic Implications. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0097-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Successful management of two pregnant patients with idiopathic pulmonary arterial hypertension. Int J Cardiol 2015; 180:72-3. [DOI: 10.1016/j.ijcard.2014.11.124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 11/23/2014] [Indexed: 11/17/2022]
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Taichman DB, Ornelas J, Chung L, Klinger JR, Lewis S, Mandel J, Palevsky HI, Rich S, Sood N, Rosenzweig EB, Trow TK, Yung R, Elliott CG, Badesch DB. Pharmacologic therapy for pulmonary arterial hypertension in adults: CHEST guideline and expert panel report. Chest 2014; 146:449-475. [PMID: 24937180 PMCID: PMC4137591 DOI: 10.1378/chest.14-0793] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/05/2014] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Choices of pharmacologic therapies for pulmonary arterial hypertension (PAH) are ideally guided by high-level evidence. The objective of this guideline is to provide clinicians advice regarding pharmacologic therapy for adult patients with PAH as informed by available evidence. METHODS This guideline was based on systematic reviews of English language evidence published between 1990 and November 2013, identified using the MEDLINE and Cochrane Library databases. The strength of available evidence was graded using the Grades of Recommendations, Assessment, Development, and Evaluation methodology. Guideline recommendations, or consensus statements when available evidence was insufficient to support recommendations, were developed using a modified Delphi technique to achieve consensus. RESULTS Available evidence is limited in its ability to support high-level recommendations. Therefore, we drafted consensus statements to address many clinical questions regarding pharmacotherapy for patients with PAH. A total of 79 recommendations or consensus statements were adopted and graded. CONCLUSIONS Clinical decisions regarding pharmacotherapy for PAH should be guided by high-level recommendations when sufficient evidence is available. Absent higher level evidence, consensus statements based upon available information must be used. Further studies are needed to address the gaps in available knowledge regarding optimal pharmacotherapy for PAH.
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Affiliation(s)
| | | | - Lorinda Chung
- Stanford University and Palo Alto VA Health Care System, Palo Alto, CA
| | | | | | | | | | | | | | | | | | - Rex Yung
- Johns Hopkins University, Baltimore, MD
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Tonelli AR, Minai OA. Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Perioperative management in patients with pulmonary hypertension. Ann Thorac Med 2014; 9:S98-S107. [PMID: 25077004 PMCID: PMC4114269 DOI: 10.4103/1817-1737.134048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [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: 01/30/2023] Open
Abstract
Patients with pulmonary hypertension (PH) are being encountered more commonly in the perioperative period and this trend is likely to increase as improvements in the recognition, management, and treatment of the disease continue to occur. Management of these patients is challenging due to their tenuous hemodynamic status. Recent advances in the understanding of the patho-physiology, risk factors, monitoring, and treatment of the disease provide an opportunity to reduce the morbidity and mortality associated with PH in the peri-operative period. Management of these patients requires a multi-disciplinary approach and meticulous care that is best provided in centers with vast experience in PH. In this review, we provide a detailed discussion about oerioperative strategies in PH patients, and give evidence-based recommendations, when applicable.
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Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Ohio, USA
| | - Omar A Minai
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Ohio, USA
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Manohar M, Vaidya A, Bakshi S. Revisiting epidural anaesthesia in a parturient with idiopathic pulmonary hypertension posted for caesarean section. Indian J Anaesth 2014; 58:235-6. [PMID: 24963208 PMCID: PMC4050960 DOI: 10.4103/0019-5049.130864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Kiely DG, Condliffe R, Wilson VJ, Gandhi SV, Elliot CA. Pregnancy and pulmonary hypertension: a practical approach to management. Obstet Med 2013; 6:144-54. [PMID: 27656247 PMCID: PMC5004325 DOI: 10.1177/1753495x13495193] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pulmonary hypertension remains a major cause of cardiac maternal death in the developed world. Over the last two decades, effective therapies for pulmonary hypertension have been developed, improving symptoms and survival. Consequently, increasing numbers of women with pulmonary hypertension and childbearing potential exist, with a number considering pregnancy. Patients with pulmonary hypertension may also present for the first time during pregnancy or shortly following delivery. The last decade has seen increasing reports of women with pulmonary hypertension surviving pregnancy using a variety of approaches but there is still a significant maternal mortality at between 12% and 33%. Current recommendations counsel that patients with known pulmonary hypertension should be strongly advised to avoid pregnancy with the provision of clear contraceptive advice and termination of pregnancy should be considered in its eventuality. In patients who are fully informed and who have been counselled regarding the risks of continuing with pregnancy, there is growing evidence that a multi-professional approach with expert care in pulmonary hypertension centres may improve outlook, although the mortality remains high.
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Affiliation(s)
- David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - Vicki J Wilson
- Department of Anaesthesia, Jessop Wing, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - Suarabh V Gandhi
- Department of Obstetrics and Gynaecology, Jessop Wing, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
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19
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20
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Yeh TC, Liu CP, Tseng CJ, Liou JC. Postpartum patient with congenital patent ductus arteriosus mimicking acute pulmonary embolism. BMJ Case Rep 2013; 2013:bcr-2012-007717. [PMID: 23608837 DOI: 10.1136/bcr-2012-007717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 25-year-old woman presented with severe dyspnoea at an emergency care unit on her postpartum day 7. Her O2 saturation level was low. Blood tests showed a high blood D-dimer level; echocardiography showed a high pulmonary artery pressure. Initially, heparin was administered for suspicion of pulmonary embolism. After transfer to the intensive care unit, she suffered respiratory failure. A three-dimensional (3D) reconstruction CT angiography then revealed a giant patent ductus arteriosus. Extracorporeal membrane oxygenation was performed owing to low O2 saturation after ventilator use. After 1 month, she died of multiple organ failure. In postpartum patients with congenital heart disease, a diagnosis of pulmonary embolism should be immediately confirmed by 3D reconstruction CT angiography to rule out patent ductus arteriosus.
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Affiliation(s)
- Tung-Chen Yeh
- Department of Internal Medicine, Division of Cardiology Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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21
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Pregnancy outcome in women with pulmonary arterial hypertension: single-center experience from India. Arch Gynecol Obstet 2013; 288:305-9. [DOI: 10.1007/s00404-013-2761-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 02/11/2013] [Indexed: 10/27/2022]
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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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23
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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] [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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Pulmonary arterial hypertension in the setting of pregnancy: a case series and standard treatment approach. Lung 2011; 190:155-60. [PMID: 22139549 DOI: 10.1007/s00408-011-9345-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 11/03/2011] [Indexed: 11/27/2022]
Abstract
Pregnancy in patients with pulmonary arterial hypertension (PAH) is associated with a maternal mortality of 30-50% despite modern treatment modalities. The majority of maternal deaths in PAH patients occur either during labor and delivery or within 1 month postpartum. Cardiovascular collapse is attributed to a mismatch between the physiologic limitations of PAH and the changes that occur with pregnancy and delivery. In the Unites States, there is no consensus on the management of PAH in pregnancy. Several case reports have been published describing improved maternal-fetal outcomes, likely due to new advanced PH therapies, earlier diagnosis of PAH, and an adoption of a multidisciplinary treatment approach. We present five cases of gravid PAH patients successfully managed at our institution with a description of our standardized multidisciplinary treatment approach.
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Abstract
When pulmonary hypertension (PH) occurs in pregnancy, physiologic stress can overwhelm an already strained right ventricle resulting in right ventricular failure and death. Mortality remains unacceptably high (25%-30%). Patients with PH should be counseled to avoid pregnancy. This article discusses the physiologic changes of pregnancy that make it difficult for patients with PH, the pitfalls of transthoracic echocardiography in diagnosing PH in pregnancy, and the historical data regarding mortality. The causes of development of PH during pregnancy are discussed, and the limited data on management of patients with PH who choose to carry their pregnancy to term are reviewed.
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Abstract
A 35-year-old female with twin gestation diagnosed with severe mitral stenosis and pulmonary hypertension was successfully treated with open heart surgery for mitral valve replacement (MVR). She gave birth to twins with good Apgar scores at 33 weeks of gestation by cesarean section. Cardiac surgery in singleton pregnancy has been reported extensively. However, there is only a single reported case of MVR following therapeutic abortion of a twin pregnancy in the second trimester. In contrast, we report the first case of mitral valve replacement for severe mitral stenosis and pulmonary hypertension in an ongoing twin pregnancy with successful outcomes.
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Affiliation(s)
- Mehreen Kisat
- Medical College, Aga Khan University Hospital, Karachi, Pakistan.
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27
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Garabedian MJ, Hansen WF, Gianferrari EA, Lain KY, Fragneto RY, Campbell CL, Booth DC. Epoprostenol treatment for idiopathic pulmonary arterial hypertension in pregnancy. J Perinatol 2010; 30:628-31. [PMID: 20802509 DOI: 10.1038/jp.2010.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Idiopathic pulmonary arterial hypertension is a rare condition associated with significant maternal mortality. We report the management of a 37-year-old multigravida with severe disease using epoprostenol, a multidisciplinary approach, and a planned delivery. Although the patient survived the pregnancy, her pulmonary function significantly worsened. Epoprostenol, a pulmonary vasodilator, should be considered when indicated during pregnancy. Neither fetal nor neonatal harm was identified.
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Affiliation(s)
- M J Garabedian
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY, USA.
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28
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Sanchez O, Marié E, Lerolle U, Wermert D, Israël-Biet D, Meyer G. Pulmonary arterial hypertension in women. Rev Mal Respir 2010; 27:e79-87. [PMID: 20965396 DOI: 10.1016/j.rmr.2009.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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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Missant C, Claus P, Rex S, Wouters P. Differential effects of lumbar and thoracic epidural anaesthesia on the haemodynamic response to acute right ventricular pressure overload. Br J Anaesth 2010; 104:143-9. [DOI: 10.1093/bja/aep354] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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30
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Higton AM, Whale C, Musk M, Gabbay E. Pulmonary hypertension in pregnancy: two cases and review of the literature. Intern Med J 2009; 39:766-70. [DOI: 10.1111/j.1445-5994.2009.02051.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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31
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Abstract
Acute right ventricular (RV) failure has until recently received relatively little attention in the cardiology, critical care or anaesthesia literature. However, it is frequently encountered in cardiac surgical cases and is a significant cause of mortality in patients with severe pulmonary hypertension who undergo non-cardiac surgery. RV dysfunction may be primarily due to impaired RV contractility, or volume or pressure overload. In these patients, an increased pulmonary vascular resistance (PVR) or a decreased aortic root pressure may lead to RV ischaemia, resulting in a rapid, downward haemodynamic spiral. The key aspects of 'RV protection' in patients who are at risk of perioperative decompensation are prevention, detection and treatment aimed at reversing the underlying pathophysiology. Minimising PVR and maintaining systemic blood pressure are of central importance in the prevention of RV decompensation, which is characterised by a rising central venous pressure and a falling cardiac output. Although there are no outcome data to support any therapeutic strategy for RV failure when PVR is elevated, the combination of inhaled iloprost or intravenous milrinone with oral sildenafil produces a synergistic reduction in PVR, while sparing systemic vascular resistance. Levosimendan is a promising new inotrope for the treatment of RV failure, although its role in comparison to older agents such as dobutamine, adrenaline and milrinone has yet to be determined. This is also the case for the use of vasopressin as an alternative pressor to noradrenaline. If all else has failed, mechanical support of the RV should be considered in selected cases.
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Affiliation(s)
- P Forrest
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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33
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Parneix M, Fanou L, Morau E, Colson P. Low-dose combined spinal-epidural anaesthesia for caesarean section in a patient with Eisenmenger’s syndrome. Int J Obstet Anesth 2009; 18:81-4. [PMID: 19046874 DOI: 10.1016/j.ijoa.2008.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 08/26/2008] [Accepted: 08/29/2008] [Indexed: 11/30/2022]
Affiliation(s)
- M Parneix
- Department of Anaesthesia D, Arnaud de Villeneuve Hospital, CHU Montpellier, France.
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34
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Olofsson CH, Bremme K, Forssell G, Öhqvist G. Cesarean section under epidural ropivacaine 0.75% in a parturient with severe pulmonary hypertension. Acta Anaesthesiol Scand 2008. [DOI: 10.1111/j.1399-6576.2001.450220.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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36
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Cannesson M, Piriou V, Neidecker J, Lehot JJ. Anesthésie pour chirurgie non cardiaque chez le patient adulte porteur d'une cardiopathie congénitale. ACTA ACUST UNITED AC 2007; 26:931-42. [DOI: 10.1016/j.annfar.2007.07.082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Accepted: 07/25/2007] [Indexed: 11/27/2022]
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Drenthen W, Pieper PG, Roos-Hesselink JW, van Lottum WA, Voors AA, Mulder BJM, van Dijk APJ, Vliegen HW, Yap SC, Moons P, Ebels T, van Veldhuisen DJ. Outcome of pregnancy in women with congenital heart disease: a literature review. J Am Coll Cardiol 2007; 49:2303-11. [PMID: 17572244 DOI: 10.1016/j.jacc.2007.03.027] [Citation(s) in RCA: 349] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 02/27/2007] [Accepted: 03/13/2007] [Indexed: 01/18/2023]
Abstract
A search of peer-reviewed literature was conducted to identify reports that provide data on complications associated with pregnancy in women with structural congenital heart disease (CHD). This review describes the outcome of 2,491 pregnancies, including 377 miscarriages (15%) and 114 elective abortions (5%). Important cardiac complications were seen in 11% of the pregnancies. Obstetric complications do not appear to be more prevalent. In complex CHD, premature delivery rates are high, and more children are small for gestational age. The offspring mortality was high throughout the spectrum and was related to the relatively high rate of premature delivery and recurrence of CHD.
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Affiliation(s)
- Willem Drenthen
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands.
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38
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George RB, Olufolabi AJ, Muir HA. Critical arrhythmia associated with pulmonary artery catheterization in a parturient with severe pulmonary hypertension. Can J Anaesth 2007; 54:486-7. [PMID: 17541080 DOI: 10.1007/bf03022037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Abstract
OBJECTIVE The presence of underlying pulmonary disease in women of childbearing potential can present a significant challenge during pregnancy and the postpartum period. Management of the underlying disease, recognizing and preventing disease progression, and, most important, managing and minimizing toxic side effects of various therapies require the expertise of an interdisciplinary team. This team must involve close collaboration between intensive care physicians, pulmonary physicians, and high-risk obstetricians familiar with these disease states in an effort to minimize fetal and maternal morbidity and mortality. We will review the impact of the pregnant state in lung transplant recipients, patients with pulmonary arterial hypertension, and patients with underlying cystic fibrosis. DESIGN Review of the literature in regards to pregnancy outcomes and issues for patients with cystic fibrosis, pulmonary hypertension, and lung transplants. METHODS A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and outcomes for pregnant patients with underlying pulmonary diseases. CONCLUSIONS Safety of pregnancy in the female lung transplant recipient concerns three outcomes: maternal outcome, fetal outcome, and transplanted graft outcome.
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Affiliation(s)
- Marie M Budev
- Lung Transplantation Program, Department of Allergy, Pulmonary, and Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland, OH, USA
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40
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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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41
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Shen CC, Hsu TY, Roan CJ, Chang SY. Peripartum Heart Failure due to Primary Pulmonary Hypertension: Two Case Reports. Taiwan J Obstet Gynecol 2004. [DOI: 10.1016/s1028-4559(09)60074-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Badesch DB, Abman SH, Ahearn GS, Barst RJ, McCrory DC, Simonneau G, McLaughlin VV. Medical therapy for pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest 2004; 126:35S-62S. [PMID: 15249494 DOI: 10.1378/chest.126.1_suppl.35s] [Citation(s) in RCA: 356] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is often difficult to diagnose and challenging to treat. Untreated, it is characterized by a progressive increase in pulmonary vascular resistance leading to right ventricular failure and death. The past decade has seen remarkable improvements in therapy, driven largely by the conduct of randomized controlled trials. Still, the selection of most appropriate therapy is complex, and requires familiarity with the disease process, evidence from treatment trials, complicated drug delivery systems, dosing regimens, side effects, and complications. This chapter will provide evidence-based treatment recommendations for physicians involved in the care of these complex patients. Due to the complexity of the diagnostic evaluation required, and the treatment options available, it is strongly recommended that consideration be given to referral of patients with PAH to a specialized center.
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Affiliation(s)
- David B Badesch
- University of Colorado Health Sciences Center, Denver, CO 80262, USA.
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Affiliation(s)
- A T Lovell
- University Department of Anaesthesia, Level 7, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK.
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Kopka A, McMenemin IM, Serpell MG, Quasim I. Anaesthesia for cholecystectomy in two non-parturients with Eisenmenger's syndrome. Acta Anaesthesiol Scand 2004; 48:782-6. [PMID: 15196113 DOI: 10.1111/j.1399-6516.2004.00405.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Eisenmenger's syndrome consists of high pulmonary vascular resistance with reversed or bidirectional shunt at aortopulmonary, ventricular or atrial level. We describe the anaesthetic management of two adult females with Eisenmenger's syndrome admitted for laparoscopic cholecystectomy. One patient suffered post-operative complications, but the other case was uncomplicated. We used sevoflurane and total intravenous anaesthesia to provide general anaesthesia. Both techniques were tolerated.
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Affiliation(s)
- A Kopka
- Department of Anesthesia, Western Infirmary, Dumbarton Road, Glasgow, UK.
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45
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Ray P, Murphy GJ, Shutt LE. Recognition and management of maternal cardiac disease in pregnancy. Br J Anaesth 2004; 93:428-39. [PMID: 15194627 DOI: 10.1093/bja/aeh194] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Heart disease is a leading cause of maternal death. The aim of this study is to review the most common causes of cardiac disease, highlight factors that should be recognized by the clinician, and address recent advances in the anaesthetic management of these patients. Incipient cardiac disease, including peripartum cardiomyopathy, myocardial infarction and aortic dissection, accounts for approximately one in six maternal deaths. The keys to successful diagnosis and management of incipient disease are: a high index of suspicion, particularly in women with known risk factors for cardiovascular disease; a low threshold for radiological investigations; early cardiology input; and invasive monitoring during labour and delivery. Echocardiography is a safe, non-invasive test, under-used in pregnancy. Management of pregnant women with pre-existing cardiac problems should be undertaken by multidisciplinary teams in tertiary centres. In women with pre-existing cardiac disease wishing to proceed to term, cardiac status must be optimized preoperatively and planned elective delivery is preferable. Vaginal delivery is preferable, and with careful incremental regional anaesthesia is safe in most women with cardiac disease. The presence of adequate systems for early detection, appropriate referral to specialist centres, and timely delivery with multidisciplinary support can minimize the serious consequences of poorly controlled heart disease in pregnancy.
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Affiliation(s)
- P Ray
- Department of Anaesthesia, St Michaels Hospital, Bristol and Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol BS2 8HW, UK.
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46
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Lacassie HJ, Germain AM, Valdés G, Fernández MS, Allamand F, López H. Management of Eisenmenger syndrome in pregnancy with sildenafil and L-arginine. Obstet Gynecol 2004; 103:1118-20. [PMID: 15121629 DOI: 10.1097/01.aog.0000125148.82698.65] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Eisenmenger syndrome in pregnancy may be a life-threatening disease despite recent additions to the treatment options. CASE We present a woman with severe pulmonary hypertension due to Eisenmenger syndrome treated during pregnancy and delivery and postpartum with L-arginine and sildenafil to enhance the nitric oxide pathway. This combination was associated with significant improvement in the mother's clinical and hemodynamic condition and fetal well-being. CONCLUSION The concomitant use of sildenafil and L-arginine for the management of pulmonary hypertension in pregnancy, combined with multidisciplinary care, permitted a good outcome for the mother and her infant.
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Metzler E, Ginsburg E, Tsen LC. Use of assisted reproductive technologies and anesthesia in a patient with primary pulmonary hypertension. Fertil Steril 2004; 81:1684-7. [PMID: 15193496 DOI: 10.1016/j.fertnstert.2003.12.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2003] [Revised: 12/11/2003] [Accepted: 12/11/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To report the use of assisted reproductive technologies (ART) in a patient with primary pulmonary hypertension. DESIGN Case report. SETTING University medical center. PATIENT(S) A 28-year-old nulliparous woman with primary pulmonary hypertension (PPH) treated with continuous intravenous epoprostenol. INTERVENTION(S) Ovarian stimulation, egg retrieval, general anesthesia, and pregnancy by surrogate carrier. MAIN OUTCOME MEASURE(S) Successful ART cycle(s) in patient with PPH and successful gestational carrier pregnancy. RESULT(S) Successful pregnancy by surrogate gestational carrier. CONCLUSION(S) Assisted reproductive technologies and a surrogate gestational carrier were a successful reproductive option for a patient with primary pulmonary hypertension. Ovarian stimulation, oocyte retrieval, and general anesthesia are not without risk but were well tolerated in this case. Multidisciplinary involvement in the planning and administration of such procedures is necessary for optimal outcomes in these patients.
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Affiliation(s)
- Elise Metzler
- Department of Anesthesiology, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Bildirici I, Shumway JB. Intravenous and Inhaled Epoprostenol for Primary Pulmonary Hypertension During Pregnancy and Delivery. Obstet Gynecol 2004; 103:1102-5. [PMID: 15121623 DOI: 10.1097/01.aog.0000121826.75294.39] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary pulmonary hypertension carries a significant mortality risk during pregnancy and delivery. CASE A 36-year-old pregnant woman with primary pulmonary hypertension was transferred to us with severe dyspnea. Intravenous epoprostenol was started, titrated, and maintained until labor augmentation. Because systemic epoprostenol treatment can interfere with platelet aggregation, we switched to inhaled epoprostenol, administered under a U.S. Food and Drug Administration-approved investigational new drug license, before epidural catheter placement. The inhaled drug was continued because it achieved better control of pulmonary hypertension. An uneventful forceps-assisted vaginal delivery was performed, and intravenous epoprostenol was restarted after the delivery. Mother and baby were well 6 months postpartum. CONCLUSION Intravenous epoprostenol treatment is effective in management of pregnant and postpartum women with primary pulmonary hypertension. Inhaled epoprostenol was effective during the intrapartum and immediate postpartum period.
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Affiliation(s)
- I Bildirici
- Department of Obstetrics and Gynecology, Washington University School of Medicine, Barnes Jewish Hospital, St Louis, Missouri 63110, USA.
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Avdalovic M, Sandrock C, Hoso A, Allen R, Albertson TE. Epoprostenol in Pregnant Patients with Secondary Pulmonary Hypertension. ACTA ACUST UNITED AC 2004; 3:29-34. [PMID: 15174891 DOI: 10.2165/00151829-200403010-00004] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Women who present with pulmonary hypertension during gestation have traditionally been persuaded to terminate their pregnancy. Historically, the mortality associated with this group is very high. Certain patients with a secondary cause of pulmonary hypertension are believed to share similar pathophysiology with primary pulmonary hypertension patients. Recently, new treatments have become available that have slowed disease progression. We present the successful treatment of two patients who presented during late gestation with moderate pulmonary hypertension. Both patients were managed with intravenous vasodilators and anticoagulants without complication. Each patient successfully delivered a healthy child via spontaneous vaginal delivery. The review of the historical management of similar patients including new insights into the etiology of pulmonary arterial hypertension is also included. It highlights the complexity involved in managing such patients and the requirement of a multidisiplinary team approach.
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Affiliation(s)
- Mark Avdalovic
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, California 95817, USA.
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Gandhimathi K, Atkinson S, Gibson FM. Pulmonary hypertension complicating twin pregnancy: continuous spinal anaesthesia for caesarean section. Int J Obstet Anesth 2002; 11:301-5. [PMID: 15321534 DOI: 10.1054/ijoa.2002.0975] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A case of secondary pulmonary hypertension complicating twin pregnancy and necessitating caesarean section is presented. A planned team approach involving senior consultants in obstetrics, cardiology, neonatology and cardiac and obstetric anaesthesia resulted in successful perioperative management. Continuous spinal anaesthesia was the chosen technique to give adequate operating conditions with least haemodynamic disturbance. This is the first report of continuous spinal anaesthesia in such a condition.
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Affiliation(s)
- K Gandhimathi
- Department of Anaesthetics, Royal Group of Hospitals, Belfast, UK.
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