Intravenous and Inhaled Epoprostenol for Primary Pulmonary Hypertension During Pregnancy and Delivery

Epoprostenol Exposure During Pregnancy

Institutional policies restricting pregnant providers from caring for patients receiving inhaled epoprostenol exist across the nation based on little to no data to substantiate this practice. Over the last 2 decades, the use of inhaled pulmonary vasodilators has expanded in patients with cardiac and respiratory disease providing more evidence for the safety of these medications in obstetrical patients. We propose a thoughtful consideration and review of the literature to remove this restriction to reduce the need to reveal early pregnancy status to employers, to alleviate undue stress for pregnant caregivers who are exposed to patients receiving epoprostenol, and to ensure safe, equal employment, and learning opportunities for pregnant providers.

Management of pregnant patients with pulmonary arterial hypertension

Pregnant individuals with pulmonary arterial hypertension (PAH) have significantly high risks of maternal and perinatal mortality. Profound changes in plasma volume, cardiac output and systemic vascular resistance can all increase the strain being placed on the right ventricle, leading to heart failure and cardiovascular collapse. Given the complex network of opposing physiological changes, strict contraception and reduction of hemodynamic fluctuations during pregnancy are important methods of minimizing the risk of maternal mortality and improving the outcomes following pregnancy. In this review, we discuss the recent research progress into pre-conception management and the various therapeutic strategies for pregnant individuals with PAH.

Pulmonary Hypertension in Pregnancy: Challenges and Solutions

Pulmonary hypertension (PH) is a heterogeneous disease characterized by an elevated mean pulmonary artery pressure of 20 mm Hg or above. PH is a prevalent condition among women of reproductive age and is linked with poor prognosis during pregnancy. Pregnancy is a stressful event and complicates the management and prognosis in patients with PH. In this review, we discuss the pathogenesis, clinical presentation as well as therapeutic options for PH during pregnancy. We also highlight knowledge gaps to guide future research.

Pregnancy and pulmonary arterial hypertension: a case series and literature review

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.

Pregnancy in pulmonary arterial hypertension associated with congenital heart disease: an illustrative case study

Background

Pregnancy in patients with pulmonary arterial hypertension associated with congenital heart disease is associated with a high risk of maternal mortality.

Case presentation

An illustrative case study based on experience gained from management of patients through pregnancy is discussed. A 22-year-old female with a history of a closed patent ductus arteriosus in childhood had been diagnosed with significant pulmonary arterial hypertension at the age of 19. Her clinical condition had improved following the commencement of oral combination therapy with sildenafil 25 mg three times daily and macitentan 10 mg once daily. How should she be counselled regarding the risks of pregnancy and what are the most appropriate forms of contraception? What should the approach be if, despite adequate counselling, she subsequently becomes pregnant? Data to help guide decision-making are reviewed and a clinical approach is suggested.

Conclusions

Patients with pulmonary arterial hypertension should be advised against pregnancy and be given good contraceptive advice. If a patient with pulmonary arterial hypertension becomes pregnant and, after being fully counselled, chooses to proceed with their pregnancy, then they should be managed by an experienced multidisciplinary team.

Management of reproductive health in patients with pulmonary hypertension

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.

[Pregnancy and pulmonary arterial hypertension]

Pulmonary hypertension in pregnant women is associated with high mortality and morbidity despite significant improvement in prognosis. Women with pulmonary arterial hypertension (PAH) should be still advised against pregnancy and advised on effective contraceptive methods. Pregnancy may be manageable in women with well controlled PAH or mild pulmonary hypertension (sPAP<50mmHg). When women with PAH choose to continue their pregnancy, they need: management by a multidisciplinary team in an expert centre; continuation or early introduction of targeted PAH therapy; early planned delivery.

Pregnancy in pulmonary arterial hypertension

Despite advanced therapies, maternal mortality in women with pulmonary arterial hypertension (PAH) remains high in pregnancy and is especially high during the post-partum period. However, recent data indicates that morbidity and mortality during pregnancy and after birth have improved for PAH patients. The current European Society of Cardiology/European Respiratory Society guidelines recommend that women with PAH should not become pregnant. Therefore, the risks associated with pregnancy must be emphasised and counselling offered to women at the time of PAH diagnosis and to women with PAH who become pregnant. Early termination should be discussed. Women who choose to continue with their pregnancy should be treated at specialised pulmonary hypertension centres with experience in managing PAH during and after pregnancy.

Intravenous Epoprostenol for Management of Pulmonary Arterial Hypertension during Pregnancy

Background Pulmonary arterial hypertension carries a high risk of mortality in pregnancy. Recent advances in treatment may improve disease course and allow for successful management of the pregnancy. Case Report We present the case of a 20-year-old gravida 1, para 0 with diagnosis of severe primary pulmonary hypertension. The patient was managed with epoprostenol (prostacyclin) infusion via an indwelling catheter, which was initiated at 23 weeks' gestation. The dose was adjusted to the patient's symptoms and a successful vaginal delivery was achieved at 36 weeks' gestation. Although maternal postpartum course was uncomplicated, unexplained neonatal demise occurred at 11 days of life. Conclusion Successful management of pulmonary hypertension in pregnancy can be accomplished with a multidisciplinary approach and intensive therapy. Long-term effects of epoprostenol on fetal or neonatal well-being are unknown.

The pregnant patient with congenital heart disease

Advances in the surgical palliation and correction of congenital heart lesions have improved survival and increased the number of patients living into adulthood. Although pregnancy outcomes will be favorable for most patients with congenital heart disease, the cardiovascular challenges associated with pregnancy and delivery are best managed with a multidisciplinary approach during the puerperium. This review addresses the prevalence, physiology, risk assessment, peripartum complications, and anesthetic management of the pregnant patient with underlying congenital heart disease.

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.

Dramatic response of a patient with pregnancy induced idiopathic pulmonary arterial hypertension to sildenafil treatment

Idiopathic pulmonary arterial hypertension (IPAH) is characterized by a progressive increase in pulmonary vascular resistance, which may lead to right ventricular failure and death. Major cardiovascular and pulmonary alterations occur during pregnancy and therefore worsen or increase the complications of pulmonary arterial hypertension (PAH). A patient diagnosed with IPAH after a successful full-term pregnancy and cesarean section with epidural anesthesia is presented. The postoperative course was complicated by progressive dyspnea, and lower limb edema. The outcome of treatment with sildenafil during puerperium was favorable in this patient. The clinical course was complicated by an unexpected spontaneous pregnancy after primary infertility.

Treatment of pulmonary arterial hypertension in pregnancy

PURPOSE

The treatment of pulmonary arterial hypertension (PAH) in pregnancy is reviewed.

SUMMARY

PAH is a disease characterized by narrowing of the pulmonary arteries and increased vascular resistance. Women with PAH should avoid becoming pregnant, as the physiological, cardiovascular, and pulmonary changes that occur during pregnancy can exacerbate the condition. However, several viable treatment options are available to improve the outcomes in this patient population, including inhaled nitric oxide, calcium-channel blockers, targeted pulmonary vasodilators, and sildenafil. Epoprostenol, a naturally occurring prostaglandin and vasodilator, is a pregnancy category B drug. Reproductive studies in rats and rabbits have found no impaired fertility or fetal harm at 2.5-4.8 times the recommended human dosage of epoprostenol. Most of the published case reports describe initiating epoprostenol 2-4 ng/kg/min i.v. several weeks before or near the time of delivery. Iloprost is a pregnancy category C drug but has demonstrated benefit in pregnant patients with PAH, with no congenital abnormalities and no postpartum maternal or infant mortality reported. Sildenafil causes vasodilation of the pulmonary vascular bed and vasodilation in the systemic circulation. Two case reports have described the successful treatment with sildenafil, a pregnancy category B drug, of pregnant patients with PAH. Patients with idiopathic PAH or chronic thromboembolic PAH should receive full-dose subcutaneous low-molecular-weight heparin therapy instead of warfarin for bleeding prophylaxis during pregnancy.

CONCLUSION

Targeted pulmonary vasodilators are viable treatment options for pregnant patients with PAH. Early recognition and management of worsening symptoms are essential to improve outcomes for both the mother and infant.

Serial Hemodynamics and Complications of Pregnancy in Severe Pulmonary Arterial Hypertension

We report a case of a woman who became pregnant after the diagnosis of moderate to severe pulmonary hypertension and underwent successful full-term pregnancy. Pulmonary hemodynamics were monitored before pregnancy and in the peripartum period. The patient was followed closely by the cardiology and high-risk obstetric specialists in the outpatient setting until she underwent c-section with epidural anesthesia. Outpatient medical management included twice daily subcutaneous enoxaparin and once daily amlodipine. Immediately prior to cesarian section, and for several days postoperatively, invasive hemodynamic monitoring was employed to titrate medical therapy. During delivery, strict attention focused on limiting intravenous fluids in order to avoid right ventricular volume overload. The postoperative course was complicated by a spontaneous, acute rise in pulmonary vascular resistance, which was managed with intravenous epoprostenol. In addition, abdominal bleeding, likely related to postoperative anticoagulation and platelet dysfunction, was controlled with transfusion and spontaneously resolved after discontinuing the anticoagulation. This case presents a favorable outcome in a pregnant patient undergoing cesarian section despite several complications related to pulmonary hypertension and right ventricular dysfunction, which are often fatal.

[Pregnancy and lungs]

Respiratory pathology can be relatively frequent during pregnancy. One third of pregnant woman may experience worsening of their asthma condition. Pulmonary tromboembolism is 5 times more frequent in pregnancy. Bacterial, viral and fungal pneumonias are badly tolerated during pregnancy, provoking mother-foetal morbidity, respiratory insufficiency, low born-weight or prematurity. Non-treated tuberculosis may increase maternal mortality and preterm birth by 4 and 9 times respectively. Pregnancy is counter-indicated in women with cystic fibrosis and severe pulmonary function. Despite therapeutic progresses already made, pulmonary hypertension is associated to over 30% of mother-foetal morbidity and mortality. Approximately 1 in 1,000-1,500 pregnancies is affected by mother cancer. High rates of lung cancer morbility in women bring new and important challenges to therapy.

Exacerbation of underlying pulmonary disease in pregnancy

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.