Serial Hemodynamics and Complications of Pregnancy in Severe Pulmonary Arterial Hypertension

Clinical outcomes of pulmonary hypertension in pregnancy among women with congenital heart disease in China

OBJECTIVE

Pulmonary arterial hypertension (PAH) increases the risk for perinatal women and newborns, especially in women with congenital heart disease (CHD). We explored the maternal, perinatal, and postneonatal outcomes of PAH in pregnant women with CHD in China.

METHODS

A total of 95 pregnant women with CHD-PAH in Beijing Anzhen Hospital from 2009 to 2013 were included retrospectively. We described their characteristics and examined the associations between the grade of PAH and maternal, perinatal, and postneonatal outcomes.

RESULTS

The New York Heart Association (NYHA) classification grade, delivery mode, and infant outcomes in CHD-PAH patients were analyzed. Overall 95 patients with CHD-PAH, there were 17 patients in mild group(17.7%), 27 patients in moderate group (28.1%), and 51 patients in severe group (53.1%)。The CHD patients with mild PAH, were mostly NYHA class I-II and CHD patients with severe PAH were NYHA class II-IVs. Cesarean section (67.7%) was the most common method of delivery. The rate of therapeutic abortion in the severe group (76.9%) was obviously higher than that in other groups (11.5% in mild group and moderate group respectively), whereas there was no term delivery in severe group, with 2 cases in mild group and moderated group respectively . The rates of heart failure and therapeutic abortion in pregnant women were positively associated with the severity of PAH. The rate of term delivery was higher in patients whose CHD had been corrected by cardiac surgery (83.3%) before pregnancy.

CONCLUSION

Patients with severe PAH have poor cardiac adaptability, poor maternal and fetal outcomes, and are contraindicated during pregnancy. Patients with mild PAH are not absolutely contraindicated during pregnancy, but their heart burden increases significantly in the third trimester. Patients in mid-gestation should preferentially be delivered by cesarean section. When pregnant patients prefer to continue pregnancy, their close monitoring is essential. We provide useful data for guiding management of pregnancy and delivery in patients with CHD in China.

Pregnancy Considerations in the Multidisciplinary Care of Patients with Pulmonary Arterial Hypertension

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.

Pregnancy as a possible trigger for heritable pulmonary arterial hypertension

It is unclear whether pregnancy is a trigger or accelerant for idiopathic pulmonary arterial hypertension (PAH). Alternatively, its frequency close to the onset of symptoms and diagnosis in the idiopathic PAH population may represent a coincidence in a disease that predominates in young women. We describe a carrier of a BMPR2 gene mutation who had an uneventful first pregnancy but had aggressive PAH during her second pregnancy and now has ongoing heritable PAH. The possible role of pregnancy as a trigger in this vulnerable patient is discussed. Databases of patients with heritable PAH should be explored to see whether pregnancy is related to overt manifestation of the disease.

Management of pulmonary arterial hypertension during pregnancy: a retrospective, multicenter experience

BACKGROUND

Pulmonary arterial hypertension (PAH) is a rare disease with a predilection for young women that is associated with right ventricular failure and premature death. PAH can complicate pregnancy with hemodynamic instability or sudden death during parturition and postpartum. Our aim was to examine the impact of PAH on pregnancy outcomes in the modern era.

METHODS

We conducted a retrospective evaluation of pregnant patients with PAH managed between 1999 and 2009 at five US medical centers. Patient demographics, medical therapies, hemodynamic measurements, manner of delivery, anesthetic administration, and outcomes were assessed.

RESULTS

Among 18 patients with PAH, 12 continued pregnancy and six underwent pregnancy termination. Right ventricular systolic pressure in patients managed to parturition was 82 ± 5 mm Hg and in patients with pregnancy termination was 90 ± 16 mm Hg. Six patients underwent pregnancy termination at mean gestational age of 13 ± 1.0 weeks with no maternal deaths or complications. Twelve patients elected to continue their pregnancy and were hospitalized at 29 ± 1.4 weeks. PAH-specific therapy was administered to nine (75%) at time of delivery consisting of sildenafil, IV prostanoids, or combination therapy. All parturients underwent Cesarean section at 34 weeks with one in-hospital death and one additional death 2 months postpartum for maternal mortality of 16.7%.

CONCLUSIONS

Compared with earlier reports, maternal morbidity and mortality among pregnant women with PAH was reduced, yet maternal complications remain significant and patients should continue to be counseled to avoid pregnancy.

Surgical repair of atrial septal defect with severe pulmonary hypertension during pregnancy: a case report with literature review

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.

Epoprostenol treatment for idiopathic pulmonary arterial hypertension in pregnancy

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.

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.