Pulmonary hypertension, cardiac disease and pregnancy

How severity and classification of pulmonary hypertension affect pregnancy outcomes: a systematic review and timeline

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.

Pregnancy and pulmonary hypertension

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.

Maternal and perinatal outcome in rheumatic heart disease

OBJECTIVES

To study the maternal and perinatal outcome of pregnancies complicated by rheumatic heart disease.

METHODS

A retrospective study was carried out in the cardio-obstetric clinic of the Postgraduate Institute of Medical Education and Research, Chandigarh (India) over a period of 13 years (1987-1999) involving 486 pregnant patients with rheumatic heart disease. Maternal and perinatal outcome was reviewed.

RESULTS

Three hundred and four patients (63.3%) had single valve involvement and mitral stenosis was the most predominant lesion (89.2%). One hundred and seventy one (38.6%) patients had undergone surgical correction prior to the onset of pregnancy. One hundred and thirteen patients (22.6%) were identified as NYHA class III-IV. Mitral valvotomy was performed during pregnancy in 48 patients. The incidence of preterm birth and small for gestational age newborns was 12% and 18.2%, respectively. There were 10 maternal deaths, of which eight patients were NYHA III and IV.

CONCLUSIONS

Rheumatic heart disease in pregnancy is associated with significant maternal and perinatal morbidity in NYHA class III-IV patients.

Cardiac disease and pregnancy

The pregnant state imposes a supraphysiologic strain on the pregnant woman's cardiac performance through complex biochemical, electric, and physiologic changes affecting the blood volume, myocardial contractility, and resistance of the vascular bed. In the presence of underlying heart disease, these changes can compromise the woman's hemodynamic balance, her life, and that of her unborn child. Cardiac pathology represents a heterogeneous group of disorders, each with its own hemodynamic, genetic, obstetric, and social implications. Physicians caring for these women should actively address the issue of reproduction. Ideally, pregnancy should be planned to occur after optimization of cardiac performance by medical or surgical means. Once pregnancy is achieved, the concerted effort of a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, nursing, social, and other services provides the best opportunity to carry the pregnancy to a successful outcome.

Human immunodeficiency virus (HIV)-related pulmonary complications in pregnancy

With changes in the demographics of human immunodeficiency virus (HIV) infection, women and children are becoming the fastest growing group of newly infected patients. With longer survival after HIV infection, more women infected with HIV are becoming pregnant. Pulmonary disease is one of the most common presenting conditions in an AIDS-defining illness. Pneumocystis carini pneumonia and tuberculosis are the most common disorders that herald the onset of AIDS. They are also the most frequently encountered HIV-related pulmonary complications during pregnancy. Others have been rarely reported during pregnancy and include fungal infections (Cryptococcus neoformans, Histoplasma capsulatum, and Coccidioides immitus), bacterial infections (Haemophilus influenzae and Streptococcus pneumoniae along with Pseudomona aeruginosa), viral infections (CMV), opportunistic neoplasms (Kaposi's sarcoma, lymphoma) and miscellaneous conditions peculiar to HIV-infected individuals (nonspecific interstitial pneumonitis, lymphoid interstitial pneumonitis, isolated pulmonary hypertension, and pulmonary edema secondary to cardiac disease or drug abuse). Most of the data regarding the pulmonary complications of HIV infection come from studies in nonpregnant patients. The extent to which pregnancy affects the course of respiratory disease in HIV infection and vice versa is not well documented. Clinical presentation is usually not altered by pregnancy. Except for minor modifications mainly related to potential fetal effects, the diagnostic work-up and management are similar to those in the nonpregnant patient. The most important effect of pregnancy on these conditions remains the delay in diagnosis and treatment. A high index of suspicion should, therefore, be maintained. In addition, most prophylactic measures recommended in nonpregnant HIV-infected individuals also apply to pregnant women.