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Renaud J, Foroshani S, Frishman WH, Aronow WS. The Influence of Pulmonary Arterial Hypertension In Pregnancy: A Review. Cardiol Rev 2024:00045415-990000000-00322. [PMID: 39254515 DOI: 10.1097/crd.0000000000000777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Pulmonary arterial hypertension (PAH) is a severe condition characterized by increased pulmonary vascular resistance and right ventricular failure. This review examines the intersection of PAH and pregnancy, highlighting the significant physiological, hemodynamic, and hormonal changes that exacerbate PAH during gestation. Pregnancy is contraindicated in PAH patients due to high maternal and fetal morbidity and mortality rates. However, some patients choose to continue their pregnancies, necessitating a comprehensive understanding of the implications and management strategies. Effective management of PAH in pregnant patients involves individualized treatment plans. Prepartum management focuses on optimizing therapy and monitoring hemodynamic status. Prostacyclin analogs and phosphodiesterase inhibitors are commonly used, though their safety profiles require further investigation. Intrapartum management prioritizes preventing right ventricular failure, utilizing therapies such as intravenous epoprostenol, inhaled iloprost, and inhaled nitric oxide. Managing PAH in pregnancy requires careful planning, continuous monitoring, and tailored therapeutic strategies to navigate the complex interplay of physiological changes and mitigate risks. Future research should focus on elucidating the pathophysiology of PAH during pregnancy and developing safer, more effective treatments to improve maternal and fetal outcomes.
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Affiliation(s)
- Jodie Renaud
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - Saam Foroshani
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | | | - Wilbert S Aronow
- Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
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2
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Koziol KJ, Isath A, Aronow WS, Frishman W, Ranjan P. Cyanotic Congenital Heart Disease in Pregnancy: A Review of Pathophysiology and Management. Cardiol Rev 2024; 32:348-355. [PMID: 36716356 DOI: 10.1097/crd.0000000000000512] [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] [Indexed: 02/01/2023]
Abstract
The advancement of medical treatment and surgical technique, along with the invention of cardiopulmonary bypass, has allowed for long-term survival of patients with cyanotic congenital heart disease (CHD)-with many women with CHD now reaching child-bearing age and wishing to become pregnant. Pregnancy in these women is a major concern as the physiologic adaptations of pregnancy, including an increased circulating volume, increased cardiac output, reduced systemic vascular resistance, and decreased blood pressure, place a substantial load on the cardiovascular system. These changes are essential to meet the increased maternal and fetal metabolic demands and allow for sufficient placental circulation during gestation. However, in women with underlying structural heart conditions, they place an additional hemodynamic burden on the maternal body. Overall, with appropriate risk stratification, pre-conception counseling, and management by specialized cardiologists and high-risk obstetricians, most women with surgically corrected CHDs are expected to carry healthy pregnancies to term with optimization of both maternal and fetal risks. In this article, we describe the current understanding of 5 cyanotic CHDs-Tetralogy of Fallot, Transposition of the Great Arteries, Truncus Arteriosus, Ebstein's Anomaly, and Eisenmenger Syndrome-and explore the specific hemodynamic consequences, maternal and fetal risks, current guidelines, and outcomes of pregnancy in women with these conditions.
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Affiliation(s)
- Klaudia J Koziol
- From the New York Medical College, School of Medicine, Valhalla, NY
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the New York Medical College, School of Medicine, Valhalla, NY
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - William Frishman
- From the New York Medical College, School of Medicine, Valhalla, NY
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Pragya Ranjan
- From the New York Medical College, School of Medicine, Valhalla, NY
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
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3
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Anderson J, Grell R, Haines D. Anaesthetic management of a patient with severe pulmonary hypertension, moderate tricuspid regurgitation and moderate right ventricular dysfunction presenting for a dilation and curettage. BMJ Case Rep 2024; 17:e257225. [PMID: 38320819 PMCID: PMC10860014 DOI: 10.1136/bcr-2023-257225] [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] [Indexed: 02/15/2024] Open
Abstract
A primigravida woman in her 30s with severe pulmonary hypertension, tricuspid regurgitation and depressed right ventricular function presented for therapeutic termination of pregnancy at 7 weeks gestation after referral and multidisciplinary recommendation. A slowly titrated lumbar epidural was chosen for the primary anaesthetic. Under standard American Society of Anesthesiologists (ASA) monitoring, invasive blood pressure monitoring and continuous transthoracic echocardiography, the patient's right ventricular systolic function was monitored throughout the case using qualitative and quantitative metrics and was notable for a right ventricular systolic pressure of 102.4 mm Hg. Milrinone, started prior to epidural titration, was used for inotropic support. Vasopressin was used in conjunction to sustain systemic vascular resistance while having little effect on the pulmonary vascular resistance. The patient experienced no complications or exacerbation of her pulmonary hypertension and was discharged home the following day.
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Affiliation(s)
- Joshua Anderson
- Anesthesiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Ryan Grell
- Anesthesiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel Haines
- Anesthesiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Condliffe R, Durrington C, Hameed A, Lewis RA, Venkateswaran R, Gopalan D, Dorfmüller P. Clinical-radiological-pathological correlation in pulmonary arterial hypertension. Eur Respir Rev 2023; 32:230138. [PMID: 38123231 PMCID: PMC10731450 DOI: 10.1183/16000617.0138-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 08/21/2023] [Indexed: 12/23/2023] Open
Abstract
Pulmonary hypertension (PH) is defined by the presence of a mean pulmonary arterial pressure >20 mmHg. Current guidelines describe five groups of PH with shared pathophysiological and clinical features. In this paper, the first of a series covering all five PH classification groups, the clinical, radiological and pathological features of pulmonary arterial hypertension (PAH) will be reviewed. PAH may develop in the presence of associated medical conditions or a family history, following exposure to certain medications or drugs, or may be idiopathic in nature. Although all forms of PAH share common histopathological features, the presence of certain pulmonary arterial abnormalities, such as plexiform lesions, and extent of co-existing pulmonary venous involvement differs between the different subgroups. Radiological investigations are key to diagnosing the correct form of PH and a systematic approach to interpretation, especially of computed tomography, is essential.
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Affiliation(s)
- Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
- These authors contributed equally to this work
| | - Charlotte Durrington
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, UK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, UK
| | - Robert A Lewis
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Rajamiyer Venkateswaran
- Department of Heart and Lung Transplantation, Manchester University NHS Foundation Trust, Manchester, UK
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London, UK
- These authors contributed equally to this work
| | - Peter Dorfmüller
- Department of Pathology, University Hospital of Giessen and Marburg, Giessen, Germany
- Institute for Lung Health, Giessen, Germany
- These authors contributed equally to this work
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Pusianawati D, Suryawan AZ, Tjandraprawira KD, Cool CJ. Dilemmas in pregnancies with pulmonary hypertension: Case report from a low-resource setting. SAGE Open Med Case Rep 2023; 11:2050313X231201737. [PMID: 37771651 PMCID: PMC10524062 DOI: 10.1177/2050313x231201737] [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: 02/15/2023] [Accepted: 08/30/2023] [Indexed: 09/30/2023] Open
Abstract
Little awareness persists of how pregnancy worsens cardiac diseases. We wish to highlight the challenges in managing pulmonary hypertension (PH) in pregnancy, within low socioeconomic environments. A 31-year-old G3P1A1 of 5 months gestation presented with worsening dyspnea and extremital edema. She had a history of heart disease with no cardiologist follow-up. She was diagnosed with type I/II PH at 4 months gestation. Her ultrasound revealed intrauterine fetal death (IUFD). She was referred for pregnancy termination. At presentation, she was tachypneic with SaO2 at 68%. After labor, she was transferred to a cardiac intensive care unit with SaO2 at 60%. Bedside echocardiography revealed a high probability of PH (pulmonary artery systolic pressure value: 109 mmHg). Unfortunately, she deteriorated and passed away a day later. Cardiac diseases in pregnancy contribute significantly to maternal mortality in Indonesia and other low socioeconomic countries. Traditional views on pregnancy and family and human rights advocate pregnancy as one of the rights, pregnancy complicated with cardiac diseases is detrimental and potentially lethal. Disparities in healthcare practices and low socioeconomic environments also contribute to such outcomes. Lack of awareness and improperly held beliefs on conception and family have led women to conceive amidst severe underlying cardiac diseases with dire outcomes.
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Affiliation(s)
- Dini Pusianawati
- Department of Obstetrics and Gynecology, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Alfonsus Zeus Suryawan
- Department of Obstetrics and Gynecology, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Kevin Dominique Tjandraprawira
- Department of Obstetrics and Gynecology, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Charlotte J Cool
- Department of Cardiology, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
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Pulmonary arterial hypertension in pregnancy. Curr Opin Cardiol 2023; 38:250-256. [PMID: 36811622 PMCID: PMC10090373 DOI: 10.1097/hco.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Although pregnancy in pulmonary arterial hypertension (PAH) is considered high risk and contraindicated, the incidence is rising. It is paramount to understand the pathophysiology and effective management strategies to ensure optimal outcomes for maternal and fetal survival. RECENT FINDINGS In this review, we highlight the outcomes of recent case series of PAH patients in pregnancy, with a focus on proper risk assessment and target goals of PAH therapy. These findings support the notion that the pillars of PAH management, including pulmonary vascular resistance reduction resulting in right heart functional improvement, and widening of the cardiopulmonary reserve, should serve as a blueprint for PAH management in pregnancy. SUMMARY Multidisciplinary and tailored management of PAH in pregnancy, with emphasis on optimizing right heart function prior to delivery, can result in excellent clinical outcomes in a referral pulmonary hypertension center.
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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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Pregnancy in Pulmonary Arterial Hypertension: A Multidisciplinary Approach. J Cardiovasc Dev Dis 2022; 9:jcdd9060196. [PMID: 35735825 PMCID: PMC9225127 DOI: 10.3390/jcdd9060196] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/07/2022] [Accepted: 06/15/2022] [Indexed: 02/04/2023] Open
Abstract
Pulmonary arterial hypertension (PAH), a female predominant disease, carries a high maternal and fetal mortality in pregnancy despite improved insight and the development of novel therapies. The high risk is attributed to the adaptive changes that take place to promote healthy fetal development during pregnancy, which can adversely affect the already compromised right ventricle in patients with PAH. While in the prior era emphasis was placed on termination of pregnancy, here we will illustrate through a multidisciplinary approach and meticulous planning at an expert center, these high-risk women can undergo successful childbirth.
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Vaidya A, Oliveros E, Mulla W, Feinstein D, Hart L, Forfia P. Management of Pulmonary Arterial Hypertension in Pregnancy: Experience from a Nationally Accredited Center. J Cardiovasc Dev Dis 2022; 9:jcdd9060195. [PMID: 35735823 PMCID: PMC9224797 DOI: 10.3390/jcdd9060195] [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: 05/14/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
(1) Background: In pulmonary arterial hypertension (PAH), pregnancy is regarded a contraindication due to high maternal and fetal morbidity and mortality. We report our experience in the management of pregnancies in PAH. (2) Methods: retrospective observational study in a nationally accredited pulmonary hypertension (PH) center from 2013 to 2021. (3) Results: seven pregnancies in six women with PAH, ranging from low to high risk and 21 to 37 years old. Half had known pre-existing PAH before pregnancy. One had a multifetal gestation, and one was pregnant twice under our care. PH medical therapy and serial clinical assessment throughout pregnancy were implemented with focused attention on optimizing right heart function. Delivery was planned by a multidisciplinary team involving PH cardiology, maternal fetal medicine, and obstetric anesthesiology. Patients delivered between 31 and 40 weeks of gestation; five of the seven were via cesarean section. All received regional anesthesia and were monitored in the PH intermediate step-down unit after delivery until discharge. In all cases, delivery was without complications with excellent outcomes for the mother and child. (4) Conclusions: Multidisciplinary and tailored management of PAH in pregnancy, emphasizing optimized right heart function prior to delivery, can result in excellent clinical outcomes in a referral PH center.
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Affiliation(s)
- Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Temple Heart and Vascular Institute, Department of Medicine, Temple University Hospital, Philadelphia, PA 19197, USA; (E.O.); (P.F.)
- Correspondence: ; Tel.: +1-215-707-7636
| | - Estefania Oliveros
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Temple Heart and Vascular Institute, Department of Medicine, Temple University Hospital, Philadelphia, PA 19197, USA; (E.O.); (P.F.)
| | - Wadia Mulla
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA 19197, USA; (W.M.); (L.H.)
| | - Diana Feinstein
- Obstetric Anesthesiology, Department of Anesthesiology, Temple University Hospital, Philadelphia, PA 19197, USA;
| | - Laura Hart
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA 19197, USA; (W.M.); (L.H.)
| | - Paul Forfia
- Pulmonary Hypertension, Right Heart Failure, CTEPH Program, Temple Heart and Vascular Institute, Department of Medicine, Temple University Hospital, Philadelphia, PA 19197, USA; (E.O.); (P.F.)
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Afify H, Kong A, Bernal J, Elgendy IY. Pulmonary Hypertension in Pregnancy: Challenges and Solutions. Integr Blood Press Control 2022; 15:33-41. [PMID: 35401013 PMCID: PMC8985908 DOI: 10.2147/ibpc.s242242] [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: 01/03/2022] [Accepted: 03/25/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Hesham Afify
- Department of Internal Medicine, University of Central Florida HCA Healthcare GME, Greater Orlando, FL, USA
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Alexander Kong
- Department of Internal Medicine, University of Central Florida HCA Healthcare GME, Greater Orlando, FL, USA
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Jopher Bernal
- Department of Internal Medicine, University of Central Florida HCA Healthcare GME, Greater Orlando, FL, USA
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
- Correspondence: Islam Y Elgendy, Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA, Email
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Westphal JG, Oehler M, Schulze PC, Kretzschmar D. A case report of a 37-year-old woman with pulmonary arterial hypertension first presented during her 3rd pregnancy and favourable long-term vasoreactive response. Eur Heart J Case Rep 2022; 6:ytac031. [PMID: 35233488 PMCID: PMC8874844 DOI: 10.1093/ehjcr/ytac031] [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: 06/08/2021] [Revised: 07/20/2021] [Accepted: 12/13/2021] [Indexed: 11/16/2022]
Abstract
Background Pulmonary arterial hypertension is a rare disease associated with high rates of mortality and can significantly complicate pregnancy posing health risks for the mother and child alike. Case summary We present the case of a 37-year-old female patient with World Health Organisation functional Class IV symptoms during the 34th week of her 3rd pregnancy. Initial echocardiography showed a significantly elevated estimated systolic pulmonary artery pressure of 86 mmHg + central vein pressure as well as signs of chronic pulmonary hypertension. After a successful emergent caesarean section, pulmonary hypertension was confirmed via right heart catheterization. After exclusion of secondary aetiologies of pulmonary hypertension, the diagnosis of Class 1 pulmonary artery hypertension was made. We initially treated the patient with the phosphodiesterase-5 inhibitor sildenafil (20 mg oral bid trice daily) and later extended the medication with the dual endothelin receptor antagonist Macicentan (10 mg daily). Since the patient remained symptomatic vasodilator testing was performed and showed a significant response to intravenous Epoprostenol. We initiated a high-dose calcium channel blocker (CCB) therapy with amlodipine (20 mg daily) which led to symptomatic relief, increased exercise capacity as well as reduction in mean pulmonary artery pressure and pulmonary vascular resistance as confirmed by another right heart catheterization after therapy initiation. Discussion Since the presentation is usually non-specific, the diagnosis of pulmonary artery hypertension can be challenging and cause a delay in treatment initiation. Even though rare vasodilator testing and invasive haemodynamic measurements should be performed to identify patients with favourable long-term response to high-dose CCB.
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Affiliation(s)
- Julian Georg Westphal
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, Friedrich‐Schiller‐University Jena, Am Klinikum 1, 07747 Jena, Germany
- Corresponding author. Tel: +49 3641 9324598,
| | - Matthias Oehler
- Division of Cardiology, Department of Internal Medicine, Hufeland Klinikum Bad Langensalza, Rudolph-Weiss-Straße 1-5, 99947 Bad Langensalza, Germany
| | - Paul Christian Schulze
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, Friedrich‐Schiller‐University Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Daniel Kretzschmar
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, Friedrich‐Schiller‐University Jena, Am Klinikum 1, 07747 Jena, Germany
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12
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Radvansky BM, Shah R, Feinman J, Augoustides JG, Kiers A, Younger J, Sanders J, Knott VH, Fernando RJ. Pulmonary Hypertension in Pregnancy: A Positive Outcome with a Multidisciplinary Team and Individualized Treatment Plan. J Cardiothorac Vasc Anesth 2022; 36:3403-3413. [DOI: 10.1053/j.jvca.2021.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 11/11/2022]
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13
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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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14
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Lai W, Ding Y, Wen L. Long-term outcomes of pregnant women with pulmonary hypertension diagnosed by echocardiography: a retrospective cohort study in a single center from China. Pulm Circ 2021; 11:2045894020966876. [PMID: 33614014 PMCID: PMC7869154 DOI: 10.1177/2045894020966876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/27/2020] [Indexed: 11/18/2022] Open
Abstract
Recent studies suggest that pregnancy may not be absolutely contraindicated in
women with moderate pulmonary hypertension. We aimed to evaluate the long-term
outcomes of pregnant women with pulmonary hypertension diagnosed by
echocardiography in our clinical department. Pregnant women with pulmonary
hypertension, diagnosed by a pulmonary systolic arterial pressure > 30 mmHg
via echocardiography, who were admitted in our department for termination of
pregnancy or delivery between 2004 and 2016 were included in this retrospective
cohort study. Demographic characteristics, clinical histories, perinatal
outcomes, and follow-up outcomes after discharge were reported. The primary
outcome was survival of the pregnant women after discharge. A total of 88
pregnant women with pulmonary hypertension were included in this cohort study.
The women were categorized into severe and moderate pulmonary hypertension
groups according to their pulmonary systolic arterial pressure at admission.
Women with severe pulmonary hypertension were significantly more likely to have
deteriorated cardiac function and higher incidence of neonatal complications
during the perinatal periods (p < 0.05). During a median follow-up of 26
months, the mortality rate was significantly higher in women with severe
pulmonary hypertension (p < 0.05). However, the accumulated survival rate was
>90% for women with moderate pulmonary hypertension within the follow-up
period. Multivariate Cox regression analyses showed that poor cardiac function
before pregnancy, irregular antenatal care, and hyperuricemia were independent
mortality risk factors for women with pulmonary hypertension after discharge. In
conclusion, the long-term survival of pregnant women with moderate pulmonary
hypertension diagnosed by echocardiography was considered acceptable in this
cohort. Our findings suggest that pregnancy might not be absolutely
contraindicated in women with moderate pulmonary hypertension.
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Affiliation(s)
- Weisi Lai
- Department of Obstetrics and Gynecology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Yiling Ding
- Department of Obstetrics and Gynecology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Lieming Wen
- Department of Ultrasound Diagnosis, Second Xiangya Hospital, Central South University, Changsha, China
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15
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Gin-Sing W. General management of pulmonary arterial hypertension associated with adult congenital heart disease. JOURNAL OF CONGENITAL CARDIOLOGY 2020. [DOI: 10.1186/s40949-020-00044-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractOver the past 15 years there have been significant improvements in the treatment of pulmonary arterial hypertension due to congenital heart disease. Patients now live for several decades, but morbidity and mortality remain high. This article describes the holistic management of this patient group with an emphasis on both the physical and psychosocial aspects of care, taking into account the consequences of chronic cyanosis, avoiding complications and improving quality of life.
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Abstract
Pulmonary arterial hypertension is a rare disease that predominantly affects women. The pathophysiology of the disease is complex, with both genetic and hormonal influences. Pregnancy causes significant physiologic changes that may not be well tolerated with underlying pulmonary arterial hypertension, in particular leading to volume overload and increased pulmonary pressures. A multidisciplinary approach and careful monitoring are essential for appropriate management of pulmonary arterial hypertension during pregnancy. Nonetheless, outcomes are still poor, and pregnancy is considered a contraindication in patients with pulmonary arterial hypertension.
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17
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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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18
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Stratifying management of rheumatic disease for pregnancy and breastfeeding. Nat Rev Rheumatol 2019; 15:391-402. [DOI: 10.1038/s41584-019-0240-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2019] [Indexed: 12/16/2022]
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19
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Morton A, Laurie J, Hill J. Portal hypertension in pregnancy - Concealed perils. Obstet Med 2018; 13:142-144. [PMID: 33093867 DOI: 10.1177/1753495x18801464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/27/2018] [Indexed: 11/15/2022] Open
Abstract
Pregnancy in women with portal hypertension is high risk due to the danger of variceal haemorrhage, which complicates 15-34% of cases. Variceal bleeding in pregnancy to women with non-cirrhotic portal hypertension is associated with increased risk of abortion (29%) and perinatal death (33%). Pregnancy in women with cirrhosis while less common due to hypogonadism, is associated with additional potential complications of hepatic decompensation and encephalopathy (10%), hepatorenal syndrome, ascites and bacterial peritonitis. Pregnancy in women with cirrhotic portal hypertension is associated with maternal death in 1.6%, and fetal loss in 10-66%. We present a case of non-cirrhotic portal hypertension in pregnancy, discussing two other potential critical complications of portal hypertension in pregnancy, splenic artery aneurysm (SAA) and pulmonary hypertension.
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Affiliation(s)
- Adam Morton
- Mater Health and University of Queensland, Brisbane, Australia
| | | | - Jessica Hill
- Mater Health and University of Queensland, Brisbane, Australia
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20
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Viaris de Lesegno B, Nelson-Piercy C. Advances in the management of cardiovascular disease during pregnancy. Future Cardiol 2018; 14:269-272. [PMID: 29932743 DOI: 10.2217/fca-2018-0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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21
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Wang Y, Xu H, Li H, Liu Y, Bai Q. Association of hemodynamics during caesarean section, outcomes after caesarean section and hormone changes with different anesthesia in pregnant women with severe pulmonary arterial hypertension. Exp Ther Med 2018; 15:4731-4736. [PMID: 29805492 PMCID: PMC5952086 DOI: 10.3892/etm.2018.5996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/16/2018] [Indexed: 11/15/2022] Open
Abstract
In the present study we aimed to analyze the effects of different anesthesia methods on the hemodynamics of caesarean section, outcomes after caesarean section and hormone changes in pregnancy complicated with severe pulmonary arterial hypertension (PAH). A total of 75 pregnancy complicated with severe PAH that were treated in Jining First People's Hospital from January 2016 to January 2017 were selected. Three groups were set according to the anesthesia methods, including the subarachnoid combined epidural anesthesia group (group I, n=25), the epidural anesthesia group (group II, n=25) and the general anesthesia group (group III, n=25). Effects on the outcomes of caesarean section of pregnancy complicated with PAH were observed. Sex hormone levels before and 24, 48 and 72 h after the operation were measured. There were remarkable changes in the postoperative hemodynamics compared with those before anesthesia, but changes in groups I and II were significantly smaller than those in group III (P<0.05). No significant differences in maternal mortality rate, neonatal mortality rate and neonatal asphyxia rate among the three groups were found (P>0.05). Time of postoperative mechanical ventilation, ICU residence and hospitalization in groups I and II were shorter than those in group III, the differences were statistically significant (P<0.05). Postoperative levels of sex hormones, including estradiol (E2), human chorionic gonadotrophin (HCG), prolactin (PRL) and plasma total testosterone (TT) decreased, while postoperative levels of sex hormones follicle stimulating hormone (FSH), luteinizing hormone (LH) and progestogen increased, and differences in the decreased E2 and TT at each time-point were statistically significant (P<0.05). In conclusion, there is no remarkable difference in the effects of three anesthesia methods on pregnancy outcomes. However, compared with general anesthesia, intravertebral anesthesia achieve shorter time of postoperative mechanical ventilation, ICU residence and hospitalization in pregnancy complicated with severe PAH, which is preferred in pregnancy without contraindication of the anesthesia.
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Affiliation(s)
- Yun Wang
- Department of Obstetrics, Jining First People's Hospital, Jining, Shandong 272000, P.R. China
| | - Haiyan Xu
- Department of Obstetrics, Jining First People's Hospital, Jining, Shandong 272000, P.R. China
| | - Haiyan Li
- Department of Anesthesiology, People's Hospital of Zhangqiu District, Jinan, Shandong 250200, P.R. China
| | - Yan Liu
- Department of Surgery, People's Hospital of Zhangqiu District, Jinan, Shandong 250200, P.R. China
| | - Qingling Bai
- Department of Operation Room, People's Hospital of Zhangqiu District, Jinan, Shandong 250200, P.R. China
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22
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Morton A, Teasdale S. Review article: Investigations and the pregnant woman in the emergency department - part 2: Point-of-care ultrasound, electrocardiography, respiratory function tests and radiology. Emerg Med Australas 2018; 30:749-753. [PMID: 29577627 DOI: 10.1111/1742-6723.12956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 12/13/2022]
Abstract
Accurate assessment of the pregnant patient in the ED depends on knowledge of physiological changes in pregnancy, and how these changes may impact on pathology tests, appearance on point-of-care ultrasound, electrocardiography and respiratory function tests. In addition, the emergency physician needs to be cognisant of disorders that are unique to or more common during pregnancy. Part 2 of this review addresses the role of point-of-care ultrasound in pregnancy, physiological changes that may affect interpretation of point-of-care ultrasound, changes in electrocardiography and respiratory function tests, and the safety of radiological procedures in the pregnant patient. Part 1 addressed potential deviations in laboratory investigation reference intervals resulting from physiological alterations in pregnancy and the important causes of abnormal laboratory results in pregnancy.
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Affiliation(s)
- Adam Morton
- Mater Health and The University of Queensland, Brisbane, Queensland, Australia
| | - Stephanie Teasdale
- Mater Health and The University of Queensland, Brisbane, Queensland, Australia
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23
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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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