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Maligireddy A, Jabri A, Zghouzi M, Rojulpote C, VanAken G, Janga C, Radjef R, Aronow H, Awdish R, Kelly B, Grafton G, Paul TK, Lin CJ, Mikhalkova D, Alaswad K, Franco-Palacios D, Villablanca P, Aggarwal V. Maternal and Fetal Outcomes in Pulmonary Hypertension During Pregnancy: A Contemporary Nationwide Analysis. Am J Cardiol 2024; 221:113-119. [PMID: 38663575 DOI: 10.1016/j.amjcard.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 03/25/2024] [Accepted: 04/15/2024] [Indexed: 05/07/2024]
Abstract
Pulmonary hypertension (PH) disproportionately affects women, presenting challenges during pregnancy. Historically, patients with PH are advised to avoid pregnancy; however, recent reports have indicated that the incidence of adverse events in pregnant patients with PH may be lower than previously reported. We conducted a retrospective cohort study in pregnant patients with PH using the National Readmission Database from January 1, 2016, to December 31, 2020. PH was categorized according to the World Health Organization classification. Primary end points include maternal mortality and 30-day nonelective readmission rate. Other adverse short-term maternal (cardiovascular and obstetric) and fetal outcomes were also analyzed. Of 9,922,142 pregnant women, 3,532 (0.04%) had PH, with Group 1 PH noted in 1,833 (51.9%), Group 2 PH in 676 (19.1%), Group 3 PH in 604 (17.1%), Group 4 PH in 23 (0.7%), Group 5 PH in 98 (2.8%), and multifactorial PH in 298 (8.4%). PH patients exhibited higher rates of adverse cardiovascular events (15.7% vs 0.3% without PH, p <0.001) and mortality (0.9% vs 0.01% without PH, p <0.001). Mixed PH and Group 2 PH had the highest prevalence of adverse cardiovascular events in the World Health Organization PH groups. Patients with PH had a significantly higher nonelective 30-day readmission rate (10.4% vs 2.3%) and maternal adverse obstetric events (24.2% vs 9.1%) compared with those without PH (p <0.001) (Figure 1). In conclusion, pregnant women with PH had significantly higher adverse event rates, including in-hospital maternal mortality (85-fold), compared with those without PH.
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Affiliation(s)
- Anand Maligireddy
- Department of Internal Medicine, the Wright Center for Graduate Medical Education, Scranton, Pennsylvania
| | - Ahmad Jabri
- Division of Cardiovascular Medicine, Department of Internal Medicine
| | - Mohammad Zghouzi
- Department of Cardiovascular Sciences, Ascension St. Thomas Hospital, University of Tennessee, Nashville, Tennessee
| | - Chaitanya Rojulpote
- Division of Cardiovascular Medicine, St Louis University College of Medicine, St Louis, Missouri
| | | | - Chaitra Janga
- Department of Internal Medicine, Abington University Hospital of Jefferson Health, Philadelphia, Pennsylvania
| | - Ryhm Radjef
- Division of Cardiovascular Medicine, Department of Internal Medicine
| | - Herbert Aronow
- Division of Cardiovascular Medicine, Department of Internal Medicine; Department of Internal Medicine, Michigan State College of Human Medicine, Detroit, Michigan
| | - Rana Awdish
- Department of Internal Medicine, Michigan State College of Human Medicine, Detroit, Michigan; Division of Pulmonary Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Bryan Kelly
- Division of Pulmonary Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan; Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan
| | - Gillian Grafton
- Division of Cardiovascular Medicine, Department of Internal Medicine
| | - Timir K Paul
- Department of Cardiovascular Sciences, Ascension St. Thomas Hospital, University of Tennessee, Nashville, Tennessee
| | - Chien-Jung Lin
- Division of Cardiovascular Medicine, St Louis University College of Medicine, St Louis, Missouri
| | - Deana Mikhalkova
- Division of Cardiovascular Medicine, St Louis University College of Medicine, St Louis, Missouri
| | - Khaldoon Alaswad
- Division of Cardiovascular Medicine, Department of Internal Medicine; Department of Internal Medicine, Michigan State College of Human Medicine, Detroit, Michigan
| | - Domingo Franco-Palacios
- Division of Pulmonary Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Pedro Villablanca
- Division of Cardiovascular Medicine, Department of Internal Medicine
| | - Vikas Aggarwal
- Division of Cardiovascular Medicine, Department of Internal Medicine.
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2
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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 DOI: 10.1016/j.ijoa.2024.104210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [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
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.
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Mocumbi A, Humbert M, Saxena A, Jing ZC, Sliwa K, Thienemann F, Archer SL, Stewart S. Pulmonary hypertension. Nat Rev Dis Primers 2024; 10:1. [PMID: 38177157 DOI: 10.1038/s41572-023-00486-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/06/2024]
Abstract
Pulmonary hypertension encompasses a range of conditions directly or indirectly leading to elevated pressures within the pulmonary arteries. Five main groups of pulmonary hypertension are recognized, all defined by a mean pulmonary artery pressure of >20 mmHg: pulmonary arterial hypertension (rare), pulmonary hypertension associated with left-sided heart disease (very common), pulmonary hypertension associated with lung disease (common), pulmonary hypertension associated with pulmonary artery obstructions, usually related to thromboembolic disease (rare), and pulmonary hypertension with unclear and/or multifactorial mechanisms (rare). At least 1% of the world's population is affected, with a greater burden more likely in low-income and middle-income countries. Across all its forms, pulmonary hypertension is associated with adverse vascular remodelling with obstruction, stiffening and vasoconstriction of the pulmonary vasculature. Without proactive management this leads to hypertrophy and ultimately failure of the right ventricle, the main cause of death. In older individuals, dyspnoea is the most common symptom. Stepwise investigation precedes definitive diagnosis with right heart catheterization. Medical and surgical treatments are approved for pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. There are emerging treatments for other forms of pulmonary hypertension; but current therapy primarily targets the underlying cause. There are still major gaps in basic, clinical and translational knowledge; thus, further research, with a focus on vulnerable populations, is needed to better characterize, detect and effectively treat all forms of pulmonary hypertension.
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Affiliation(s)
- Ana Mocumbi
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Moçambique.
- Instituto Nacional de Saúde, EN 1, Marracuene, Moçambique.
| | - Marc Humbert
- Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre (Assistance Publique Hôpitaux de Paris), Université Paris-Saclay, INSERM UMR_S 999, Paris, France
- ERN-LUNG, Le Kremlin Bicêtre, Paris, France
| | - Anita Saxena
- Sharma University of Health Sciences, Haryana, New Delhi, India
| | - Zhi-Cheng Jing
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Karen Sliwa
- Cape Heart Institute, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Friedrich Thienemann
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
- Department of Internal Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Simon Stewart
- Institute of Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
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4
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Xing YY, Ruan Y, Qin H, Zhao L, Zhao Q, Wei Y, Chen J, Ma X. Effects of maternal pulmonary arterial hypertension on fetal hemodynamics and maternal-fetal outcome in late pregnancy. Echocardiography 2023; 40:1339-1349. [PMID: 37922228 DOI: 10.1111/echo.15708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 09/15/2023] [Accepted: 10/19/2023] [Indexed: 11/05/2023] Open
Abstract
PURPOSE The aim of this study was to investigate the effects of maternal pulmonary arterial hypertension (PAH) on fetal hemodynamics in the third trimester and to identify hemodynamic indicators associated with adverse maternal and fetal outcomes. METHODS We recruited 48 pregnant women with PAH in the third trimester and 32 women with normal pregnancies as controls matched for age and gestational week. Fetal growth and hemodynamic parameters were assessed by two-dimensional and color Doppler. All cases were followed up until delivery and maternal and fetal outcomes were collected. High throughput sequencing method was used to determine differential miRNA patterns in plasma exposed to pulmonary arterial hypertension (PAH) in pregnant women. We then performed the validated of key differentially expressed miRNAs by real-time PCR. RESULTS Compared with the normal and mild PAH groups, resistance index (RI), pulsatility index (PI) of the fetal umbilical artery (UA) and quantitative ductus venosus (QDV) blood flow were increased in subjects with moderate to severe PAH, while PI and the ratio of peak systolic velocity (PSV) to end-diastolic velocity (EDV) (S/D) of the middle cerebral artery (MCA) were decreased. Compared with the normal group, subjects in the mild and moderate PAH groups had lower neonatal weight, shorter neonatal height, and higher preterm birth rates. In addition, miRNA sequencing data showed that PAH affected the levels of 23 miRNAs in plasma. At the same time, we showed that PAH significantly decreased the level of miR-1255a and increased the level of miR-548ar-3p by real-time PCR. CONCLUSION In the group of pregnant women with moderate to severe pulmonary hypertension, there was a higher proportion of preterm births and low birth weight babies. Hemodynamic changes in the fetal UA, MCA, and ductus venosus (DV) during late pregnancy were associated with adverse fetal outcomes. At the same time, miRNA sequencing results showed that miR-1255a and miR-548ar-3p may play an important role in the development of PAH.
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Affiliation(s)
- Yuan Yuan Xing
- Department of Ultrasound, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yanping Ruan
- Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Huai Qin
- Department of Ultrasound, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Lei Zhao
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Qing Zhao
- Department of Ultrasound, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yun Wei
- Department of Ultrasound, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jie Chen
- Department of Ultrasound, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Xiaohai Ma
- Department of Interventional Diagnosis and Treatment, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
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5
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Weatherald J, Varughese RA, Liu J, Humbert M. Management of Pulmonary Arterial Hypertension. Semin Respir Crit Care Med 2023; 44:746-761. [PMID: 37369218 DOI: 10.1055/s-0043-1770118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a rare pulmonary vascular disease characterized by progressive pulmonary arterial remodeling, increased pulmonary vascular resistance, right ventricular dysfunction, and reduced survival. Effective therapies have been developed that target three pathobiologic pathways in PAH: nitric oxide, endothelin-1, and prostacyclin. Approved therapies for PAH include phosphodiesterase type-5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, prostacyclin analogs, and prostacyclin receptor agonists. Management of PAH in the modern era incorporates multidimensional risk assessment to guide the use of these medications. For patients with PAH and without significant comorbidities, current guidelines recommend two oral medications (phosphodiesterase type-5 inhibitor and endothelin receptor antagonist) for low- and intermediate-risk patients, with triple therapy including a parenteral prostacyclin to be considered in those at high or intermediate-high risk. Combination therapy may be poorly tolerated and less effective in patients with PAH and cardiopulmonary comorbidities. Thus, a single-agent approach with individualized decisions to add-on other PAH therapies is recommended in older patients and those with significant comorbid conditions. Management of PAH is best performed in multidisciplinary teams located in experienced centers. Other core pillars of PAH management include supportive and adjunctive treatments including oxygen, diuretics, rehabilitation, and anticoagulation in certain patients. Patients with PAH who progress despite optimal treatment or who are refractory to best medical care should be referred for lung transplantation, if eligible. Despite considerable progress, PAH is often fatal and new therapies that reverse the disease and improve outcomes are desperately needed.
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Affiliation(s)
- Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Rhea A Varughese
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Jonathan Liu
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Hôpital Marie Lannelongue, Le Plessis Robinson, INSERM UMR_S 999, France
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6
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Tian X, Zhao J, Song Y, Wang Q, Li M, Liu J, Zeng X. 2022 Chinese guideline for the management of pregnancy and reproduction in systemic lupus erythematosus. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2023; 4:115-138. [PMID: 37781682 PMCID: PMC10538620 DOI: 10.2478/rir-2023-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/19/2023] [Indexed: 10/03/2023]
Abstract
Systemic lupus erythematosus (SLE), a prevalent autoimmune disease predominantly affecting women of childbearing age, presents ongoing challenges despite notable advances in diagnosis and treatment. Although survival rates for SLE patients have significantly improved, pregnancy continues to pose a considerable obstacle. Addressing this critical need for enhanced reproductive and prenatal care, there is a pressing imperative to establish standardized protocols for peri-gestational monitoring and treatment in SLE patients. This guideline is jointly sponsored by the National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), the Chinese Systemic Lupus Erythematosus Treatment and Research Group (CSTAR), and the Chinese Research Committee of Pregnancy and Reproduction in Autoimmune Rheumatic Diseases (CHOPARD). Thirteen pertinent clinical questions have been generated through several rounds of rigorous clinical and methodological expert discussions and selections for a comprehensive understanding of key aspects in this domain. Guided by thorough examination of research evidence and expert perspectives, the formulated recommendations aim to optimize pregnancy success rates, reduce maternal and infant mortality rates, and ultimately enhance the overall well-being of SLE patients.
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Affiliation(s)
- Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Yijun Song
- Department of Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Juntao Liu
- Department of Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
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7
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Jha AK, Jha N, Malik V. Perioperative Decision-Making in Pulmonary Hypertension. Heart Lung Circ 2023; 32:454-466. [PMID: 36841637 DOI: 10.1016/j.hlc.2023.01.013] [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: 09/21/2021] [Revised: 11/03/2022] [Accepted: 01/03/2023] [Indexed: 02/27/2023]
Abstract
Pulmonary hypertension (PH) is a haemodynamic manifestation of cardiorespiratory and non-cardiorespiratory pathologies. Cardiorespiratory pathologies account for nearly three-fourths of patients with PH. It is now increasingly being recognised due to routine requests for transthoracic echocardiographic examination in the perioperative setting in patients undergoing intermediate- to high-risk non-cardiac surgery. The increased risks of perioperative morbidity and mortality attributed to PH have been widely acknowledged in the literature. The importance of PH in perioperative decision-making and postoperative outcomes has had little mention in all the guidelines. Understanding the complexity of the pathophysiology of PH may help in anaesthetic and surgical decision-making. Preoperative evaluation and risk assessment are guided by the nature, extent, invasiveness, and duration of surgery. Surgical decision-making and anaesthetic management involve preoperative risk stratification, understanding the interactions between surgical procedures and PH, and understanding the interactions between anaesthetic procedures, PH, and cardiopulmonary interactions. Intraoperative and postoperative monitoring is crucial for maintaining the haemodynamic parameters and helps titrate anaesthetic agents and medication. This narrative review focusses on all issues related to anaesthetic and surgical challenges in patients with PH. This review aimed to suggest a preoperative evaluation plan, surgical decision-making, anaesthetic plan, and anaesthetic management based on the evidence available in the literature.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.
| | - Nivedita Jha
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Vishwas Malik
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
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8
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Chin KM, Santiago-Munoz P. Pregnancy and Congenital Heart Disease-Associated Pulmonary Hypertension: Are Outcomes Improving? Circulation 2023; 147:562-564. [PMID: 36780392 DOI: 10.1161/circulationaha.122.063191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Affiliation(s)
- Kelly M Chin
- Department of Internal Medicine, Pulmonary and Critical Care Medicine (K.M.C.), University of Texas Southwestern Medical Center, Dallas
| | - Patricia Santiago-Munoz
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine (P.S.-M.), University of Texas Southwestern Medical Center, Dallas
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9
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Zhang L, Qie G, Yin X, Zhao H, Zhang F, Wang T, Meng M, Sha J, Chu Y. Pregnant outcomes of critically ill pregnant patients with pulmonary hypertension: A multicenter retrospective study. Front Cardiovasc Med 2022; 9:872833. [PMID: 36158823 PMCID: PMC9489930 DOI: 10.3389/fcvm.2022.872833] [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: 02/10/2022] [Accepted: 08/11/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To identify the pregnancy outcomes and risk factors of critically ill pulmonary hypertension (PH) patients with intensive care unit (ICU) admission. Methods The multicenter, retrospective cohort study was performed on 60,306 parturients from January 2013 to December 2018 in China. Diagnosis of PH was based on the estimation of systolic pulmonary arterial pressure (sPAP) via echocardiography. Patients were stratified by sPAP into three groups, mild (30–50 mmHg), moderate (51–70 mmHg), and severe (>70 mmHg). The primary outcome was major adverse cardiovascular events (MACE), defined as a composite of in-hospital death, heart failure, and sustained arrhythmias requiring treatment. The secondary outcome was fetal adverse clinical events (FACE), a composite of fetal/neonatal death, prematurity, small birth weight, and fetal distress. Results A total of 181 pregnant patients were enrolled, including 101 patients with mild PH, 31 with moderate PH, and 49 with severe PH. The maternal median age was 32 (27, 35) years and 37% were nulliparous. The MACE occurred in 59 (59/181, 32.6%) women, including in-hospital death in 13 (13/181, 7.2%), heart failure in 53 (53/181, 29.3%), and sustained arrhythmias in 7 (7/181, 3.9%). The incidence of FACE was as high as 66.3% (120/181). Compared with mild and moderate PH patients, patients with severe PH had a significantly higher mortality rate (22.4 vs. 1.51%, P < 0.001) and MACE incidence (51.0 vs. 25.8%, P = 0.001). Although the incidence of FACE in severe PH was slightly higher than that in mild to moderate PH, there was no significant difference (69.4 vs. 65.1%, P = 0.724). PH complicated with left heart disease (OR = 4.365, CI: 1.306–14.591), elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) level (OR = 1.051, CI:1.015–1.088), and sPAP level estimated by echocardiography (OR = 1.021; CI: 1.003–1.040) were independently associated with MACE in multivariable regression (P < 0.05). Increased risk of FACE was noted for PH patients combined with eclampsia/preeclampsia (OR = 6.713; CI: 1.806–24.959). Conclusion The incidence of MACE and FACE remained high in critically ill pregnant patients with PH, particularly moderate and severe PH in China. Further studies are warranted to identify subsets of women with PH at lower pregnant risks and seek more effective therapy to improve pregnancy outcomes.
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Affiliation(s)
- Lin Zhang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Guoqiang Qie
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xiaoyu Yin
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Hongyan Zhao
- Department of Critical Care Medicine, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Fusen Zhang
- Department of Intensive Care Unit, Taian Central Hospital, Taian, China
| | - Tao Wang
- Department of Intensive Care Unit, Binzhou Medical University Hospital, Binzhou, China
| | - Mei Meng
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Sha
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yufeng Chu
- Department of Critical Care Medicine, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- *Correspondence: Yufeng Chu
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10
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Pulmonary hypertension in pregnancy and its effects on the fetus. Semin Fetal Neonatal Med 2022; 27:101348. [PMID: 35568671 DOI: 10.1016/j.siny.2022.101348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pulmonary hypertension (PH) is an important and potentially lethal diagnosis for pregnant patients. Although pregnancy is usually contraindicated in this condition and there is no standard algorithm for the treatment of pregnant patients with PH, studies in recent years have shown improvement in maternal outcomes for those with PH. Many factors have likely contributed to the improved outcomes, including earlier treatment by multidisciplinary teams. Pregnant patients with PH require specialized management throughout pregnancy, especially in the early post-partum period. Echocardiography is an important diagnostic tool to follow cardiac function in these patients. PH and its treatment during pregnancy has significant implications on maternal as well as fetal outcomes. In this review, PH management during pregnancy and the fetal implications are summarized.
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11
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Li M, Tian Z, Qian J, Huang C, Zhao J, Wang Q, Song Y, Tian X, Li M, Liu J, Zeng X. Impact of pregnancy in patients with systemic lupus erythematosus-associated pulmonary arterial hypertension: case series and literature review. Lupus Sci Med 2022; 9:9/1/e000636. [PMID: 35256456 PMCID: PMC8905977 DOI: 10.1136/lupus-2021-000636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/17/2022] [Indexed: 11/22/2022]
Abstract
Objective This study aimed to investigate the clinical characteristics and outcomes of pregnancy complicated by SLE-associated pulmonary arterial hypertension (SLE-PAH) in a case series and literature review. Methods This single-centre retrospective study included 10 consecutive pregnancies complicated by SLE-PAH confirmed by right heart catheterisation (RHC) at Peking Union Medical College Hospital between 2009 and 2020. A literature search was conducted and 14 pregnancy cases complicated by SLE-PAH were reviewed. Results At the time of 10 patients’ initial visits, the average age was 30.00±5.72 years and the median disease duration of SLE and PAH was 34.5 (range 1–164) months and 2 (1–51) months. Two patients carried planned pregnancy, seven patients developed PAH during pregnancy and one pregnancy was unplanned. Further, nine patients had low disease activity, with Systemic Lupus Erythematosus Disease Activity Index between 0 and 4, and 30%, 30% and 40% of patients were of WHO functional class II, III and IV, respectively. All patients were evaluated by RHC and echocardiography. N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were elevated in 70% of patients, with a median level of 776 (56–18 023) pg/mL. The median time of completed pregnancies in all patients was 31 (15–38) weeks and six patients delivered live infants. SLE activity and PAH severity improved in 70% of patients within 6 months after delivery. One patient died on the 15th day after induction of labour. In the remaining patients, all achieved a lupus low disease activity state; according to the European Society of Cardiology/European Respiratory Society risk stratification, seven were categorised at a lower risk state compared with their risk stratification during pregnancy, and two remained at intermediate risk. Additionally, 80% of patients exhibited mild impairments with WHO functional class I or II. The median NT-proBNP level was 184 (32–4003) pg/mL within 6 months after delivery. In the reviewed literature, the average age of patients was 30.09±5.37 years. The median time of completed pregnancies was 36 (28–40) weeks. More cases were planned and successful, and the survival rates of mothers and neonates were 85.71% and 92.86%, respectively. Conclusions Successful pregnancy could be possible in women with SLE-PAH if SLE-PAH treatment goals are achieved under proper therapies, careful monitoring and thorough evaluations.
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Affiliation(s)
- Mucong Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Junyan Qian
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Can Huang
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yijun Song
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR), State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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12
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Wang J, Zhang Z, Liang C, Lv T, Yu H, Ren S, Lin P, Du G, Sun L. Targeting Myadm to Intervene Pulmonary Hypertension on Rats Before Pregnancy Alleviates the Effect on Their Offspring's Cardiac-Cerebral Systems. Front Pharmacol 2022; 12:791370. [PMID: 35115938 PMCID: PMC8804385 DOI: 10.3389/fphar.2021.791370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/08/2021] [Indexed: 11/26/2022] Open
Abstract
Pregnancy with pulmonary hypertension (PH) seriously threatens the life and safety of mothers and infants. Here, the long-term effect of maternal PH on the postpartum growth of rat offspring was focused for the first time, as well as explored the role of Myadm in PH rats before pregnancy based upon the previous findings. Patients with PH are prone to hypoxemia, leading to insufficient placental structure and function, which affects the organ function of fetuses, followed by evidence that differently expressed genes (DEGs) existed in the heart of maternal PH newborn rats and enriched in pathways related to cardiac and nerve development on human infants with similar birth outcome: low birth weight (LBW). LBW was one of the possible birth outcomes of pregnancy with PH, especially severe PH, accompanied by evidence that offspring derived from mothers with PH presented lower birth weights and slower growth rates than those derived from normal control mothers in a rat model. Besides, maternal PH rat offspring showed cardiac remodeling and a significant elevation of the expression levels of hypoxia- and inflammation-related markers in the cerebral cortex at both 10 and 14 weeks of age, respectively. What is more, the previous studies found that the overexpression of Myadm could result in the remodeling of the pulmonary artery. And targeting Myadm to intervene PH before pregnancy could alleviate sustained low weight growth in maternal PH rat offspring, and the pathological changes of the cardiac–cerebral system caused by maternal PH, including enlarged right heart cavity, loss of cardiomyocytes, abnormal heart index, as well as cerebral cortex hypoxia and the inflammatory state as they grew up to a certain extent. The findings show the pathological significance of maternal PH on offspring growth and the cardiac–cerebral development in a rat model, as well as point out the potential treatment target, which may provide a further reference for pregnancy outcomes in women with PH and healthy development of offspring to some extent.
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Affiliation(s)
- Jingrong Wang
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,The State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Beijing, China
| | - Zirui Zhang
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,The State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Beijing, China
| | - Cui Liang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Tingting Lv
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,The State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Beijing, China
| | - Haoying Yu
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,The State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Beijing, China
| | - Shuyue Ren
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,The State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Beijing, China
| | - Peirong Lin
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Guanhua Du
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,The State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Beijing, China
| | - Lan Sun
- Institute of Materia Medica, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,The State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Beijing, China
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13
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Progress continues on the management of pulmonary arterial hypertension in pregnancy. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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14
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Han R, Gao L, Sun H, Li M, Deng C. Effect of Yiqi Buxue Decoction on Hemodynamic Changes of the Uterine Artery and Fetal Umbilical Artery and Pregnancy Outcomes in Pregnant Patients with Pulmonary Arterial Hypertension. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021; 2021:1849114. [PMID: 34457018 PMCID: PMC8387161 DOI: 10.1155/2021/1849114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/09/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To explore the effect of Yiqi Buxue decoction on hemodynamic changes of the uterine artery and fetal umbilical artery and pregnancy outcomes in pregnant patients with pulmonary arterial hypertension (PAH). METHODS 120 pregnant patients with PAH treated in our hospital (January 2019-January 2020) were chosen as the research objects, and randomly split into group A (n = 60) and group B (n = 60). Both groups received routine treatment, and group B was treated with sildenafil citrate, while group A was treated with Yiqi Buxue decoction combined with sildenafil citrate. Both groups received 6 weeks of treatment to analyze the hemodynamic changes of the uterine artery and fetal umbilical artery and compare the cardiopulmonary function indexes and pregnancy outcomes between the two groups. RESULTS The hemodynamic indexes of the uterine artery and fetal umbilical artery, cardiopulmonary function indexes, and pregnancy outcomes in group A after treatment were notably better compared with group B (P < 0.01). CONCLUSION Yiqi Buxue decoction can stabilize the hemodynamics of pregnant patients with PAH, improve their cardiopulmonary function, alleviate hypotension, and thus, reduce the possibility of adverse pregnancy outcomes, which should be popularized in practice.
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Affiliation(s)
- Rendong Han
- Department of Obstetrics, Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Liya Gao
- Department of Gynecology and Obstetrics, Beijing ChuiYangLiu Hospital, Beijing 100022, China
| | - Hongbo Sun
- Department of Gynecology and Obstetrics, Beijing ChuiYangLiu Hospital, Beijing 100022, China
| | - Mei Li
- Department of Gynecology and Obstetrics, Beijing ChuiYangLiu Hospital, Beijing 100022, China
| | - Chunxia Deng
- Department of Gynecology and Obstetrics, Beijing ChuiYangLiu Hospital, Beijing 100022, China
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Mantoo M, Makkar N, Mahidhar J, Karuru U, Kumar D, Seth S. Outcome of pulmonary hypertension in pregnancy in contemporary era: A case-based narrative review. JOURNAL OF THE PRACTICE OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.4103/jpcs.jpcs_49_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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