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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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2
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Goldstein SA, Krasuski RA. Complex Congenital Heart Disease in the Adult. Annu Rev Med 2024; 75:493-512. [PMID: 38285514 DOI: 10.1146/annurev-med-050922-052324] [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: 01/31/2024]
Abstract
Congenital heart disease (CHD), a heterogeneous group of structural abnormalities of the cardiovascular system, is the most frequent cause of severe birth defects. Related to improved pediatric outcomes, there are now more adults living with CHD, including complex lesions, than children. Adults with CHD are at high risk for complications related to their underlying anatomy and past surgical palliative interventions. Adults with CHD require close monitoring and proactive management strategies to improve outcomes.
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Affiliation(s)
- Sarah A Goldstein
- Division of Cardiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Richard A Krasuski
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA;
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Sharma B, Sikka P, Chopra S, Bansal R, Suri V, Aggarwal N, Saha SC, Vijayvergiya R, Bhukal I, Kumar P. Pregnancy in Eisenmenger syndrome: a case series from a tertiary care hospital of Northern India. Cardiol Young 2023; 33:2185-2189. [PMID: 36601954 DOI: 10.1017/s1047951122004152] [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] [Indexed: 01/06/2023]
Abstract
BACKGROUND Despite advances in medical care, we still come across pregnancy in Eisenmenger syndrome. Eisenmenger syndrome represents the severe end of the spectrum for disease in pulmonary artery hypertension associated with CHD. Due to very high maternal and perinatal morbidity and mortality, pregnancy is contraindicated among these women. Current guidelines also recommend that the women who become pregnant should opt for early termination of pregnancy. Here, we present a case series of 11 women of Eisenmenger syndrome and their pregnancy outcome. METHODS It was a retrospective analysis of 12 pregnancies among 11 women with Eisenmenger syndrome who were managed in a tertiary care referral centre of Northern India. RESULTS The mean age of these women was 28 ± 4 years (range 22 to 36 years). Almost 80% of them (9/11) were diagnosed with Eisenmenger syndrome during pregnancy. The commonest cardiac lesion was Ventricular Septal defect (54.5%) followed by Atrial Septal defect (27.3%) and Patent Ductus arteriosus (9.1%). Only three women opted for medical termination of pregnancy, rest eight continued the pregnancy or presented late. Pregnancy complications found include pre-eclampsia (50%), abruption (22%), and fetal growth retardation (62.5%). There were three maternal deaths (mortality rate 27%) in postpartum period. CONCLUSION This case series highlights the delay in diagnosis and treatment of CHD despite improvement in medical care. Women with Eisenmenger syndrome require effective contraception, preconceptional counselling, early termination of pregnancy, and multidisciplinary care.
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Affiliation(s)
- Bharti Sharma
- Department of Obstetrics & Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pooja Sikka
- Department of Obstetrics & Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Seema Chopra
- Department of Obstetrics & Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramandeep Bansal
- Department of Obstetrics & Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vanita Suri
- Department of Obstetrics & Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelam Aggarwal
- Department of Obstetrics & Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhas C Saha
- Department of Obstetrics & Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Vijayvergiya
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ishwar Bhukal
- Department of Anesthesiology & Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar
- Department of Pediatrics (Neonatology Unit), Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Liu Y, Li H, Li Y, Zhang J, Gu H, Wang J, Wang Q. Outcomes of pregnancy in women with different types of pulmonary hypertension. BMC Cardiovasc Disord 2023; 23:391. [PMID: 37558980 PMCID: PMC10410774 DOI: 10.1186/s12872-023-03423-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is considered to increase maternal and fetal risk, and we attempt to explore pregnancy outcomes in women with different types of PH. METHODS We retrospectively analyzed the clinical data of pregnant women with PH who were admitted to Anzhen Hospital from January 2010 to December 2019, and followed up on these parturients and their offspring. RESULTS Three hundred and sixty-six pregnant women with PH were collected, including 265 pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD), 65 PH caused by left heart disease, 12 idiopathic PH, and 24 PH associated with other diseases. Maternal mean age was 28.4 ± 4.4 years and 72.1% were nulliparous. The estimated systolic pulmonary artery pressure was < 50 mmHg in 40.2% of patients, 50-70 mmHg in 23.2%, and > 70 mmHg in 36.6%. In more than 94% of women, a diagnosis of PH was made before pregnancy. During pregnancy, heart failure occurred in 15% of patients. Cesarean section was performed in 90.5% (20.4% emergency). Complications included fetal mortality (0.5%), preterm delivery (40.4%), and low birth weight (37.7%). A total of 20 mothers died (5.5%). The highest mortality rate was found in patients with idiopathic PH (4/12, 33.3%). A total of 12 children died (3.3%), 5 (1.4%) of them after discharge from the hospital, and 7 (1.9%) were in hospital. CONCLUSIONS Although most of these women are fertile, PH does increase maternal and fetal risk. Women with idiopathic PH and Eisenmenger syndrome are not recommended to have children.
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Affiliation(s)
- Yang Liu
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital Affiliated to Capital Medical University, Chaoyang District, Beijing, China
| | - Haitao Li
- Department of Adult Cardiac Center, Beijing Anzhen Hospital Affiliated to Capital Medical University, Chaoyang District, Beijing, China
| | - Yanna Li
- Department of Obstetrics and Gynecology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Chaoyang District, Beijing, China
| | - Jun Zhang
- Department of Obstetrics and Gynecology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Chaoyang District, Beijing, China
| | - Hong Gu
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital Affiliated to Capital Medical University, Chaoyang District, Beijing, China
| | - Jiangang Wang
- Department of Adult Cardiac Center, Beijing Anzhen Hospital Affiliated to Capital Medical University, Chaoyang District, Beijing, China.
- Capital Medical University, Beijing Anzhen Hospital, No.2 An Zhen Road, Chaoyang District, Beijing, 100029, China.
| | - Qiang Wang
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital Affiliated to Capital Medical University, Chaoyang District, Beijing, China.
- Capital Medical University, Beijing Anzhen Hospital, No.2 An Zhen Road, Chaoyang District, Beijing, 100029, China.
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Barańska-Pawełczak K, Wojciechowska C, Jacheć W. Pregnancy in Patients with Pulmonary Arterial Hypertension in Light of New ESC Guidelines on Pulmonary Hypertension. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4625. [PMID: 36901635 PMCID: PMC10001459 DOI: 10.3390/ijerph20054625] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/23/2023] [Accepted: 03/01/2023] [Indexed: 06/18/2023]
Abstract
Pulmonary arterial hypertension (PAH) is defined as an elevated mean pulmonary artery pressure (mPAP) of >20 mmHg together with a pulmonary arterial wedge pressure (PAWP) of ≤15 mmHg and pulmonary vascular resistance (PVR) of>2 Wood units (WU). Although the total mortality of pregnant women with PAH has decreased significantly in recent years and is reported to be around 12% in some databases, total mortality is still at an unacceptably high percentage. Moreover, some subgroups, such as patients with Eisenmenger's syndrome, have a particularly high mortality rate of up to 36%. Pregnancy in patients with PAH is contraindicated; its appearance is an indication for a planned termination. Education of patients with PAH, including counseling on effective contraception, is essential. During pregnancy, blood volume, heart rate, and cardiac output increase, while PVR and systemic vascular resistance decrease. The hemostatic balance is shifted towards hypercoagulability. Among PAH-specific drugs, the use of inhaled or intravenous prostacyclins, phosphodiesterase inhibitors, and calcium channel blockers (in patients with preserved vasoreactivity) is acceptable. Endothelin receptor antagonists and riociguat are contraindicated. Childbirth can take place through either vaginal delivery or caesarean section; similarly, neuraxial and general anesthesia have proven indications. In a situation where all pharmacological options have been used in pregnant or postpartum patients in a serious condition, veno-arterial ECMO is a useful therapeutic option. For PAH patients who want to become mothers, an option that does not endanger their lives is adoption.
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Affiliation(s)
| | - Celina Wojciechowska
- Second Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
| | - Wojciech Jacheć
- Second Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
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Liu Y, Li Y, Zhang J, Zhao Y, Liu K, Li J, Zhao M, Gu H, Fan X, Wang J. Pregnancy outcomes of women with Eisenmenger syndrome: A single-center study. Int J Cardiol 2023; 374:35-41. [PMID: 36526021 DOI: 10.1016/j.ijcard.2022.12.014] [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: 04/24/2022] [Revised: 11/26/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND To explore the outcomes of mothers with Eisenmenger syndrome (ES) and their offspring. METHODS Pregnant women with ES admitted to the Beijing Anzhen Hospital between 2010 and 2019 were retrospectively analyzed and followed up. RESULTS Forty-two parturient women with ES were recruited, with an average age of 26.7 years (standard deviation [SD], ±4.0 years). The average gestational age was 33.7 weeks (SD, ±2.5 weeks). The average percutaneous oxygen saturation was 84.1 (±9.2), and 40 (95.2%) had caesarean delivery. The average pulmonary artery systolic pressure was 107.5 mmHg (SD, ±20.3 mmHg). Twelve (28.6%) women experienced pulmonary hypertensive crisis; 11 (26.2%) of these women died. Regarding the offspring, the average fetal weight was 1778.1 g (SD, ±555.3 g), six (14.3%) died, and congenital heart disease was diagnosed in three (7.1%). There were significant differences in age, gestational age, percutaneous oxygen saturation, Apgar score, and heart failure between the maternal death and non-death groups (P < 0.05). Death was mainly related to pulmonary hypertensive crisis and heart failure. CONCLUSIONS We recommend pregnancy termination if ES occurs during early pregnancy; however, patients should be informed of the risks if it occurs during late pregnancy. Multidisciplinary cooperation should be strengthened to improve the prognosis of the mothers and their offspring.
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Affiliation(s)
- Yang Liu
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital affiliated to Capital Medical University, No. 2 Anzhen Road, Chaoyang District, 100029 Beijing, China
| | - Yanna Li
- Department of Obstetrics and Gynecology, Beijing Anzhen Hospital affiliated to Capital Medical University, No. 2 Anzhen Road, Chaoyang District, 100029 Beijing, China
| | - Jun Zhang
- Department of Obstetrics and Gynecology, Beijing Anzhen Hospital affiliated to Capital Medical University, No. 2 Anzhen Road, Chaoyang District, 100029 Beijing, China
| | - Yichen Zhao
- Department of Valvular Cardiac Surgery Center, Beijing Anzhen Hospital affiliated to Capital Medical University, No. 2 Anzhen Road, Chaoyang District, 100029 Beijing, China
| | - Kemin Liu
- Department of Valvular Cardiac Surgery Center, Beijing Anzhen Hospital affiliated to Capital Medical University, No. 2 Anzhen Road, Chaoyang District, 100029 Beijing, China
| | - Jiachen Li
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital affiliated to Capital Medical University, No. 2 Anzhen Road, Chaoyang District, 100029 Beijing, China
| | - Mingming Zhao
- Department of Surgery, Hebei General Hospital, No. 348 Heping West Road, Xinhua District, 050055 Shijiazhuang City, Hebei Province, China
| | - Hong Gu
- Department of Pediatric Cardiac Center, Beijing Anzhen Hospital affiliated to Capital Medical University, No. 2 Anzhen Road, Chaoyang District, 100029 Beijing, China
| | - Xiangming Fan
- Department of Pediatric Cardiac Surgery, Zhejiang Children's Hospital, Hangzhou City, Zhejiang Province, China
| | - Jiangang Wang
- Department of Valvular Cardiac Surgery Center, Beijing Anzhen Hospital affiliated to Capital Medical University, No. 2 Anzhen Road, Chaoyang District, 100029 Beijing, China.
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Liu Y, Li Y, Zhang J, Zhang D, Li J, Zhao Y, Liu K, Ma X, Bai C, Gu H, Fan X, Wang J. Maternal and fetal outcomes of pregnant women with pulmonary arterial hypertension associated with congenital heart disease in Beijing, China: a retrospective study. Pulm Circ 2022; 12:e12079. [PMID: 35514772 PMCID: PMC9063973 DOI: 10.1002/pul2.12079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 11/11/2022] Open
Abstract
As pulmonary arterial hypertension associated with congenital heart disease (PAH‐CHD) may increase maternal and fetal risk, this study explored the pregnancy outcomes of Chinese women with PAH‐CHD. The clinical data of pregnant women with PAH‐CHD admitted to the Beijing Anzhen Hospital from 2010 to 2019 were retrospectively analyzed; these patients and their offspring were followed up, with a mean period of 5.9 ± 2.7 years. Overall, 260 patients with PAH‐CHD were included. The mean maternal age was 27.7 ± 4.1 years, and 205 (78.8%) patients were nulliparous. The estimated systolic pulmonary artery pressure was 40–50 mmHg in 34.6% of the patients, 50–70 mmHg in 23.1%, and >70 mmHg in 42.3%. More than 96% of patients were diagnosed with PAH‐CHD before pregnancy. During pregnancy, heart failure occurred in 19.2% of the patients. Cesarean delivery was performed in 88.1% (15.0% emergency) of the patients. Complications included fetal distress (5.8%), preterm delivery (34.2%), and low birth weight (33.8%). A total of 15 mothers (5.8%) died, with the highest mortality rate in those with Eisenmenger syndrome (10/43, 23.3%), and 10 offspring died (3.8%), two (0.8%) following hospital discharge and eight (3.1%) while in hospital. Although most pregnant women with PAH‐CHD were able to have children, PAH increased the maternal and fetal risk. Thus, an individualized risk‐based approach with shared decision‐making may be more appropriate in pregnant women with PAH‐CHD.
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Affiliation(s)
- Yang Liu
- Department of Pediatric Cardiac Center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Yanna Li
- Department of Obstetrics and Gynecology Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Jun Zhang
- Department of Obstetrics and Gynecology Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Dawei Zhang
- Department of Obstetrics and Gynecology Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Jiachen Li
- Department of Pediatric Cardiac Center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Yichen Zhao
- Department of Valvular Cardiac surgery center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Kemin Liu
- Department of Valvular Cardiac surgery center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Xiaolong Ma
- Department of Valvular Cardiac surgery center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Chen Bai
- Department of Valvular Cardiac surgery center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Hong Gu
- Department of Pediatric Cardiac Center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Xiangming Fan
- Department of Pediatric Cardiac Center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
| | - Jiangang Wang
- Department of Valvular Cardiac surgery center Beijing Anzhen Hospital affiliated to Capital Medical University No 2 Anzhen Road Chaoyang District, Beijing China
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Pregnancy in Congenital Heart Disease, Complicated by Pulmonary Arterial Hypertension—A Challenging Issue for the Pregnant Woman, the Foetus, and Healthcare Professionals. Medicina (B Aires) 2022; 58:medicina58040476. [PMID: 35454315 PMCID: PMC9033133 DOI: 10.3390/medicina58040476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Pregnancy and delivery in patients with congenital heart disease (CHD) and pulmonary arterial hypertension (PAH) carry a very high risk for maternal and foetal complications and are contraindicated according to the guidelines. In the last decades, when an available modern PAH-targeted medication therapy and a new management concept improved patients’ well-being and survival, some PAH-CHD females decided to conceive. Of note, despite advanced treatment and modern healthcare system possibilities, dealing with pregnancy in a diverse PAH-CHD population is still challenging. The study aimed to share our experience with PAH-CHD pregnancies and discuss the risk assessment and current management of these patients with the combination of two rare diseases. Materials and Methods: The retrospective search of pulmonary hypertension and adult CHD registries in our hospital was performed, selecting all patients with CHD and PAH who conceived pregnancy from 2013 to 2021. Baseline demographic, clinical, and functional characteristics and clinical outcomes were collected. Results: Thirteen pregnancies in eight patients with PAH-CHD resulted in seven live births, three miscarriages, and three terminations. Five women were diagnosed with Eisenmenger syndrome (ES) and three with residual PAH after CHD repair. Before pregnancy, half of them were in WHO functional class III. Seven (87.5%) patients received targeted PAH treatment with sildenafil during pregnancy. In addition, the two most severe cases were administered with iloprost during peripartum. Three ES patients delivered preterm by Caesarean section under general anaesthesia. No neonatal mortality was reported. Maternal complications were observed in half of our cases. One patient died 12 days after the delivery in another hospital due to deterioration of heart failure. Conclusions: On the basis of our clinical experience, we conclude that pregnancy and delivery carry a high risk for maternal complications and should be avoided in women with PAH-CHD. The individualised approach of multidisciplinary care and appropriate monitoring are mandatory in reducing the risk of adverse outcomes.
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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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Alsomali F, Mushtaq S, Bakir M, Almustanyir S. Fruitful Pregnancy Outcome in a Case of Eisenmenger Syndrome With Severe Pulmonary Hypertension: A Rare Case Report. Cureus 2022; 14:e21068. [PMID: 35155027 PMCID: PMC8825312 DOI: 10.7759/cureus.21068] [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] [Accepted: 01/10/2022] [Indexed: 11/05/2022] Open
Abstract
Eisenmenger syndrome (ES) is considered an absolute contraindication for pregnancy. ES is characterized by a congenital heart abnormality that results in a significant anatomical shunt. Hemodynamic forces generate a left-right shunt, leading to severe pulmonary arterial hypertension (PAH). Eventually, the shunt will become a right-to-left shunt due to increased pulmonary vascular resistance, leading to significant hypoxemia and cyanosis. Pregnant women with ES experience volume overload as a result of the syndrome and the physiological response of pregnancy. The decrease in systemic vascular resistance that occurs during pregnancy also increases the right-to-left shunt, resulting in left ventricular failure. Due to the significant risk to both the mother and the fetus, women are advised to terminate their pregnancy during the first trimester. However, with all the odds, very few cases show positive neonatal and maternal outcomes. Appropriate management of ES includes a multidisciplinary team assembled to monitor and manage the patient carefully and thoroughly. In this paper, we present a case of ES secondary to an atrial septal defect with severe PAH in a 32-year-old woman who underwent a cesarean section at 33 weeks of gestation. She delivered a healthy baby girl. On the seventh postoperative day, she was discharged with no complications.
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11
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Souabni SA, Belhaddad EH. Successful delivery in a woman with ventricular septal defect complicated with Eisenmenger syndrome: case report. Pan Afr Med J 2022; 43:188. [PMID: 36915419 PMCID: PMC10007704 DOI: 10.11604/pamj.2022.43.188.32982] [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: 12/26/2021] [Accepted: 03/04/2022] [Indexed: 12/13/2022] Open
Abstract
Eisenmenger syndrome is a dramatic complication of certain heart diseases. It is an absolute contra-indication to pregnancy because it holds a high risk of maternal-fetal mortality. Nowadays, we don´t see much of this condition, because congenital heart defects are diagnosed during childhood, infancy, or prenatally; and even if a pregnancy occurs, it is usually terminated as soon as it is diagnosed. Nevertheless, some women are willing to carry the risks that come with their condition. We report the case of a 26-year-old woman with an undiagnosed interventricular septal wall defect that evolved into Eisenmenger syndrome during her pregnancy. A successful elective C-section was done under epidural anesthesia and close monitoring. When facing this challenging situation, there are no clear guidelines, however, premature and elective delivery is paramount.
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Affiliation(s)
- Sara Ait Souabni
- Cadi Ayyad University, Faculty of Medicine and Pharmacy of Marrakesh, Marrakesh, Morrocco
| | - El Habib Belhaddad
- Cadi Ayyad University, Faculty of Medicine and Pharmacy of Marrakesh, Marrakesh, Morrocco
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12
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Abstract
Pulmonary arterial hypertension related to congenital heart disease (PAH-CHD) affects 5% to 10% of adults with CHD and is associated with significant morbidity and mortality. PAH-CHD develops as a consequence of intracardiac or extracardiac systemic-to-pulmonary shunts that lead to pulmonary vascular remodeling through a pathologic process that is similar to other causes of PAH. Eisenmenger syndrome is the most severe phenotype of PAH-CHD and is characterized by severe elevation in pulmonary vascular resistance, with shunt reversal causing hypoxemia and central cyanosis. The primary management strategy for most patients with PAH-CHD is medical therapy, although defect closure is considered in select cases.
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Affiliation(s)
- Sarah A Goldstein
- Section of Adult Congenital Heart Disease, Division of Cardiology, Duke University Medical Center, Box 3331, Durham, NC 27710, USA
| | - Richard A Krasuski
- Section of Adult Congenital Heart Disease, Division of Cardiology, Duke University Medical Center, Box 3331, Durham, NC 27710, USA.
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13
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Low TT, Guron N, Ducas R, Yamamura K, Charla P, Granton J, Silversides CK. Pulmonary arterial hypertension in pregnancy-a systematic review of outcomes in the modern era. Pulm Circ 2021; 11:20458940211013671. [PMID: 34104423 PMCID: PMC8172332 DOI: 10.1177/20458940211013671] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/09/2021] [Indexed: 11/15/2022] Open
Abstract
Pregnancy is hazardous with pulmonary arterial hypertension, but maternal
mortality may have fallen in recent years. We sought to systematically evaluate
pulmonary arterial hypertension and pregnancy-related outcomes in the last
decade. We searched for articles describing outcomes in pregnancy cohorts
published between 2008 and 2018. A total of 3658 titles were screened and 13
studies included for analysis. Pooled incidences and percentages of maternal and
perinatal outcomes were calculated. Results showed that out of 272 pregnancies,
214 pregnancies advanced beyond 20 gestational weeks. The mean maternal age was
28 ± 2 years, mean pulmonary artery systolic pressure on echocardiogram was
76 ± 19 mmHg. Etiologies include idiopathic pulmonary arterial hypertension
(22%), congenital heart disease (64%), and others (15%). Majority (74%) had good
functional class I/II. Only 48% of women received pulmonary arterial
hypertension-specific therapy. Premature deliveries occur in 58% of pregnancies
at mean of 34 ± 1 weeks, most (76%) had Cesarean section. Maternal mortality
rate was 12% overall (n = 26); even higher for idiopathic
pulmonary arterial hypertension etiology alone (20%). Reported causes of death
included right heart failure, cardiac arrest, pulmonary arterial hypertension
crises, pre-eclampsia, and sepsis; 61% of maternal deaths occur at 0–4 days
postpartum. Stillbirth rate was 3% and neonatal mortality rate was 1%. In
conclusion, pulmonary arterial hypertension in pregnancy continues to be
perilous with high maternal mortality rate. Continued prospective studies are
needed.
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Affiliation(s)
- Ting-Ting Low
- Department of Cardiology, National University Heart Centre Singapore, Singapore.,Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Nita Guron
- Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.,Department of Cardiology, Libin Cardiovascular Institute of Alberta, Calgary, Canada
| | - Robin Ducas
- Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.,Section of Cardiology, University of Manitoba, Winnipeg, Canada
| | - Kenichiro Yamamura
- Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.,Department of Paediatrics, Kyushu University, Fukuoka, Japan
| | - Pradeepkumar Charla
- Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.,Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH, USA
| | - John Granton
- Division of Respirology, Department of Medicine, University Health Network, Sinai Health System, University of Toronto, Toronto, Canada
| | - Candice K Silversides
- Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.,Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai Hospital and Univeristy Health Network, Toronto, Canada
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14
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Congenital heart disease in the ESC EORP Registry of Pregnancy and Cardiac disease (ROPAC). INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100107] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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15
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Miao H, Chen Y, Wang C, Huang T, Lin J. Pregnancies in women with moderate and severe pulmonary hypertension remain challenging: A single-center experience in East China. Int J Gynaecol Obstet 2021; 157:140-148. [PMID: 33864679 DOI: 10.1002/ijgo.13708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 04/13/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine the outcomes in women with pulmonary hypertension (PH) and determine the factors related to adverse outcomes. METHODS Data from 684 women with PH admitted to the Affiliated Renji Hospital from January 2001 to December 2020 were collected. Outcomes were compared based on the causes and severity of PH. RESULTS The overall mortality was 2.8%, decreasing from 6.6% in 2001-2005 to 1.7% in 2016-2020 (P = 0.10). Idiopathic PH had the highest mortality (35.3%) and the lowest live birth rate (82.4%). Mortality was similar between moderate and severe PH (5.3% versus 9.7%), but the live birth rate was much lower in severe PH (78.6% versus 89.9%). Hypoxemia and vaginal birth were risk factors of maternal death (odds ratio [OR] 35.28, 95% confidence interval [CI] 1.42-878.75; OR 850.86, 95% CI 5.67-127 606.74, respectively). General anesthesia was a risk factor in the univariate analysis (OR 12.07, 95% CI 3.72-39.15) but was not significant in the multivariate analysis (P = 0.16). CONCLUSION The mortality rate in this retrospective study was lower than that previously reported. Pregnancy is safe in mild PH but still has a high risk of complications in moderate and severe PH. Hypoxemia is a risk factor for maternal death, but cesarean section may be a protective factor.
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Affiliation(s)
- Huixian Miao
- Department of Obstetrics and Gynecology, Affiliated Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yunyan Chen
- Department of Obstetrics and Gynecology, Affiliated Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chuan Wang
- Department of Obstetrics and Gynecology, Affiliated Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Taotao Huang
- Department of Obstetrics and Gynecology, Affiliated Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianhua Lin
- Department of Obstetrics and Gynecology, Affiliated Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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16
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Hardee I, Wright L, McCracken C, Lawson E, Oster ME. Maternal and Neonatal Outcomes of Pregnancies in Women With Congenital Heart Disease: A Meta-Analysis. J Am Heart Assoc 2021; 10:e017834. [PMID: 33821681 PMCID: PMC8174159 DOI: 10.1161/jaha.120.017834] [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] [Indexed: 02/07/2023]
Abstract
Background With advances in the treatment of congenital heart disease (CHD), more women with CHD survive childhood to reach reproductive age. The objective of this study was to evaluate the maternal and neonatal outcomes of pregnancies among women with CHD in the modern era. Methods and Results We conducted a meta‐analysis of peer‐reviewed literature published January 2007 through June 2019. Studies were included if they reported on maternal or fetal mortality and provided data by CHD lesion. Meta‐analysis was performed using random effect regression modeling using Comprehensive Meta‐Analysis (v3). CHD lesions were categorized as mild, moderate, and severe to allow for pooling of data across studies. Of 2200 articles returned by our search, 32 met inclusion criteria for this study. Overall, the rate of neonatal mortality was 1%, 3.1%, and 3.5% in mild, moderate, and severe lesions, respectively. There were too few maternal deaths in any group to pool data. The rates of maternal and neonatal morbidity among women with CHD increase with severity of lesion. Specifically, rates of maternal arrhythmia and heart failure, cesarean section, preterm birth, and small for gestational age neonate are all markedly increased as severity of maternal CHD increases. Conclusions In the modern era, pregnancy in women with CHD typically has a successful outcome in both mother and child. However, as maternal CHD severity increases, so too does the risk of numerous morbidities and neonatal mortality. These findings may help in counseling women with CHD who plan to become pregnant, especially women with severe lesions.
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Affiliation(s)
- Isabel Hardee
- Department of Pediatrics University of Colorado School of Medicine Denver CO
| | - Lydia Wright
- Department of Pediatrics Emory University School of Medicine, Children's Healthcare of Atlanta Atlanta GA
| | - Courtney McCracken
- Department of Pediatrics Emory University School of Medicine, Children's Healthcare of Atlanta Atlanta GA
| | - Emily Lawson
- Woodruff Health Sciences Center Library Emory University Atlanta GA
| | - Matthew E Oster
- Department of Pediatrics Emory University School of Medicine, Children's Healthcare of Atlanta Atlanta GA
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17
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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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18
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Avila WS, Alexandre ERG, Castro MLD, Lucena AJGD, Marques-Santos C, Freire CMV, Rossi EG, Campanharo FF, Rivera IR, Costa MENC, Rivera MAM, Carvalho RCMD, Abzaid A, Moron AF, Ramos AIDO, Albuquerque CJDM, Feio CMA, Born D, Silva FBD, Nani FS, Tarasoutchi F, Costa Junior JDR, Melo Filho JXD, Katz L, Almeida MCC, Grinberg M, Amorim MMRD, Melo NRD, Medeiros OOD, Pomerantzeff PMA, Braga SLN, Cristino SC, Martinez TLDR, Leal TDCAT. Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease - 2020. Arq Bras Cardiol 2020; 114:849-942. [PMID: 32491078 PMCID: PMC8386991 DOI: 10.36660/abc.20200406] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Walkiria Samuel Avila
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Marildes Luiza de Castro
- Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas gerais (UFMG),Belo Horizonte, MG - Brasil
| | | | - Celi Marques-Santos
- Universidade Tiradentes,Aracaju, SE - Brasil.,Hospital São Lucas, Rede D'Or Aracaju,Aracaju, SE - Brasil
| | | | - Eduardo Giusti Rossi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Felipe Favorette Campanharo
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil.,Hospital Israelita Albert Einstein,São Paulo, SP - Brasil
| | | | - Maria Elizabeth Navegantes Caetano Costa
- Cardio Diagnóstico,Belém, PA - Brasil.,Centro Universitário Metropolitano da Amazônia (UNIFAMAZ),Belém, PA - Brasil.,Centro Universitário do Estado Pará (CESUPA),Belém, PA - Brasil
| | | | | | - Alexandre Abzaid
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Antonio Fernandes Moron
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Carlos Japhet da Mata Albuquerque
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil,Hospital Barão de Lucena, Recife, PE – Brazil,Hospital EMCOR, Recife, PE – Brazil,Diagnósticos do Coração LTDA, Recife, PE – Brazil
| | | | - Daniel Born
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Fernando Souza Nani
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Flavio Tarasoutchi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - José de Ribamar Costa Junior
- Hospital do Coração (HCor),São Paulo, SP - Brasil.,Instituto Dante Pazzanese de Cardiologia,São Paulo, SP - Brasil
| | | | - Leila Katz
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil
| | | | - Max Grinberg
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Nilson Roberto de Melo
- Departamento de Obstetrícia e Ginecologia da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP – Brazil
| | | | - Pablo Maria Alberto Pomerantzeff
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
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19
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Pulmonary hypertension and pregnancy outcomes: Systematic Review and Meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 253:108-116. [PMID: 32862030 DOI: 10.1016/j.ejogrb.2020.08.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/19/2020] [Accepted: 08/21/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Traditionally, pulmonary hypertension during pregnancy has been associated with increased risk of adverse maternal and fetal outcomes. The aim of this study to systematically analyze the published literature mentioning pregnancy outcomes in pregnant women with pulmonary hypertension in recent decades. STUDY METHODS A Comprehensive electronic literature search of MEDLINE, EMBASE and Cochrane library was done to find studies published in English literature from 1 Jan 1990 to 31st May 2018. Prospective and retrospective observational studies describing pregnancy outcomes in at least 4 women with pulmonary hypertension were included in this study. Meta-analysis was performed using the random-effects model. Risk of bias was assessed by the Newcastle-Ottawa Scale. The primary outcomes included maternal mortality and any pregnancy loss. The analysis included absolute risks and 95% confidence intervals (CI) for adverse outcomes using the DerSimonian-Laird random effects model. Heterogeneity was assessed by I2 statistic and visual plot. RESULTS Twenty studies captured data from 589 parturient describing 610 pregnancies. The pooled unadjusted data yielded maternal mortality of 11.5 (95% CI; 7.6-17.2) and the total pregnancy loss was 22.8 (95% CI; 16.2-31.1). Prematurity and IUGR/SGA were reported by 7 and 8 studies and had pooled estimates of 51.7 (95% CI; 37.6-65.7) and 29.3 (95% CI; 20.9-39.5), respectively. The pooled estimates of cesarean delivery and general anesthesia were 72.1 (95% CI; 60.6-81.93) and 40.1 (95% CI; 26.4-55.5), respectively. CONCLUSIONS Fetomaternal outcomes have improved in recent decades in parturient with moderate to severe pulmonary hypertension. These findings have implications for preconceptional counselling and risk stratifications.
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20
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Abstract
The mortality of pregnant women with pulmonary arterial hypertension (PAH) remains high. The aim of this study was to evaluate and analyze perinatal and postpartum outcomes in patients with PAH.A total of 79 pregnant patients with PAH who underwent abortion or parturition were reviewed retrospectively. Preoperative characteristics, anesthesia method, intensive care management, PAH-specific therapy, and maternal and neonatal outcomes were analyzed in this case series study.This study was a retrospective analysis of 79 pregnant women with PAH. We collected data on maternal, obstetrical, and neonatal outcomes. The mean age of the parturient women with mild and severe PAH was 26.6 ± 5.7 and 26.0 ± 4.9 years, respectively, and the mean systolic pulmonary arterial pressure of the 2 groups was 43.8 ± 4.2 mmHg and 76.7 ± 15.6 mmHg, respectively. Of the 79 patients, 43 (54.4%) had severe PAH and 36 (45.6%) had mild PAH. The gestational weeks were significantly shorter and the rate of fetal death was higher in the severe PAH group than in the mild PAH group (36.0 vs 37.3 weeks and 6/24 vs 1/30, respectively; P < .05). Fifty-seven patients received PAH-specific therapy during pregnancy, including sildenafil, iloprost, and treprostinil. Overall, 22 PAH patients underwent therapeutic abortion and 57 continued their pregnancy. A total of 9 women, all of whom had severe PAH, died within 3 months of labor, giving a mortality rate of 15.8% (9/57). Of the 57 parturients, 21 (35.6%) gave birth prematurely and 36 (64.4%) delivered at term. Overall, 55 (96.5%) patients delivered by cesarean section and 2 (3.5%) delivered vaginally. There were 7 fetal deaths - 6 in the severe PAH group and one in the mild PAH group (6/24 vs 1/30).Although the mortality rate of this group of women with PAH was lower than that previously reported, patients with PAH should still be advised against pregnancy.
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Affiliation(s)
| | - Huafang Shi
- Department of Obstetrics, The Second Xiangya Hospital of Central South University, Changsha
| | - Li Xu
- Department of The Second Chest Medicine, The Affiliated Cancer Hospital of Xiangya School of medicine, Central South University, Changsha, Hunan
| | - Wei Su
- Department of Cardiology, The Third Affiliated Hospital of Southern Medical University, Guangdong, China
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21
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Lopez BM, Malhamé I, Davies LK, Gonzalez Velez JM, Marelli A, Rabai F. Eisenmenger Syndrome in Pregnancy: A Management Conundrum. J Cardiothorac Vasc Anesth 2020; 34:2813-2822. [PMID: 32381307 DOI: 10.1053/j.jvca.2020.02.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/04/2019] [Accepted: 02/28/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Brandon M Lopez
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL.
| | - Isabelle Malhamé
- Department of Medicine, McGill University, Montreal, Quebec, Canada; Obstetric Medicine, Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Laurie K Davies
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL
| | - Juan M Gonzalez Velez
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA
| | - Ariane Marelli
- Obstetric Medicine, Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada; MAUDE Unit, Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ferenc Rabai
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL
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22
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Wang T, Lu J, Li Q, Chen Y, Ye Q, Gao J, Yang D, Zhao L, Huang J, Zhang J. Rapid Titration of Intravenous Treprostinil to Treat Severe Pulmonary Arterial Hypertension Postpartum: A Retrospective Observational Case Series Study. Anesth Analg 2019; 129:1607-1612. [PMID: 31743181 DOI: 10.1213/ane.0000000000003827] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Pulmonary hypertension during pregnancy carries high mortality rate. The relatively long-acting, specific pulmonary vasodilator treprostinil has been used to improve survival in these parturients. Slow uptitration is performed in most cases, and rapid titration has not been reported in the postpartum period. METHODS We retrospectively reviewed 17 pregnant patients with severe pulmonary arterial hypertension who were treated with intravenous treprostinil in our institution between 2014 and 2016. Patients' demographic characteristics, etiology, functional status, mode of delivery, anesthetic administration, medical therapy, echocardiographic and hemodynamic measurements, subsequent clinical course, and maternal-fetal outcomes were assessed. The a priori primary outcome is maternal mortality in this study. RESULTS Rapid titration of intravenous treprostinil was initiated at 1.25 ng/kg/min and increased to effective dose of 10 ng/kg/min by 1.25-2.5 ng/kg/min every 3 hours. In the next 24 hours, we adjusted the dosage to a median maximum dose of 15 ng/kg/min (interquartile range, 15-20 ng/kg/min) over a median uptitration period of 34 hours (interquartile range, 24-41 hours) for 17 parturients with severe pulmonary hypertension. Treprostinil was weaned off by 0.50-1.25 ng/kg/min every 3 hours in 94.3 ± 42.4 hours. Fifteen patients survived to discharge, and only 2 patients died of pulmonary hypertensive crisis (maternal mortality rate, 11.7%). No treprostinil infusion-related postpartum complication was observed. CONCLUSIONS Our experience suggested that rapid uptitration of intravenous treprostinil combined with oral sildenafil in the postpartum period may be a safe and effective approach for these very sick parturients with severe pulmonary hypertension.
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Affiliation(s)
- Tengke Wang
- From the Departments of Surgical Intensive Care Medicine
| | | | - Qiang Li
- From the Departments of Surgical Intensive Care Medicine
| | - Yao Chen
- From the Departments of Surgical Intensive Care Medicine
| | - Qing Ye
- From the Departments of Surgical Intensive Care Medicine
| | - Jie Gao
- From the Departments of Surgical Intensive Care Medicine
| | - Dong Yang
- Obstetric Medicine, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing AnZhen Hospital, Capital Medical University, Beijing, China
| | | | - Jiapeng Huang
- Department of Anesthesiology, Jewish Hospital, Louisville, Kentucky
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Jinglan Zhang
- From the Departments of Surgical Intensive Care Medicine
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23
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Hartopo AB, Anggrahini DW, Nurdiati DS, Emoto N, Dinarti LK. Severe pulmonary hypertension and reduced right ventricle systolic function associated with maternal mortality in pregnant uncorrected congenital heart diseases. Pulm Circ 2019; 9:2045894019884516. [PMID: 31798834 DOI: 10.1177/2045894019884516] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 10/01/2019] [Indexed: 11/15/2022] Open
Abstract
Background Pregnant uncorrected congenital heart disease patients, especially those who already developed pulmonary hypertension, have increased risk for maternal mortality. The pulmonary hypertension severity and right ventricle function may be associated with higher maternal mortality. The study aimed to investigate the mortality rate of pregnant uncorrected congenital heart disease and the impact of pulmonary hypertension severity on mortality. Methods This is the sub study of COngenital HeARt Disease in adult and Pulmonary Hypertension Registry. The data of pregnant uncorrected congenital heart disease patients were analyzed from registry database. The maternal mortality was recorded. The data of demography, clinics, obstetrics, and transthoracic echocardiography were collected. The factors that influenced maternal mortality were analyzed. A statistical significance was determined when p value < 0.05. Results From 2012 until 2017, there were 78 pregnant congenital heart disease patients. Of them, 56 patients were eligible for analyses. The majority of congenital heart disease was atrial septal defect (91.1%). The maternal mortality rate was 10.7% (6 of 56). Pulmonary hypertension occurred in 48 patients, therefore the maternal mortality rate among congenital heart disease-pulmonary hypertension with majority of atrial septal defect was 12.5% (6 of 48). Among nonsurvivors, 100% suffered from severe pulmonary hypertension as compared to survivors (56.0%), p = 0.041. Most nonsurvivors were Eisenmenger syndrome (83.3%), significantly higher compared to survivors (22.0%), p = 0.006. Nonsurvivors had significantly worsened WHO functional class, reduced right ventricle systolic function, and right heart failure. The modes of maternal death were severe oxygen desaturation (66.7%) and respiratory failure and sepsis (33.3%). Most of the maternal deaths occurred within 24 h postpartum period. Conclusion Maternal mortality rate among pregnant uncorrected congenital heart disease with majority of atrial septal defect was 10.7% and among congenital heart disease-pulmonary hypertension with majority of atrial septal defect was 12.5%. Factors related with maternal mortality were severe pulmonary hypertension, Eisenmenger syndrome, and reduced right ventricle systolic function.
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Affiliation(s)
- Anggoro B Hartopo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada and Dr Sardjito Hospital, Jogjakarta, Indonesia
| | - Dyah W Anggrahini
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada and Dr Sardjito Hospital, Jogjakarta, Indonesia
| | - Detty S Nurdiati
- Department of Obstetry and Gynecology, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada and Dr Sardjito Hospital, Jogjakarta, Indonesia
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.,Laboratory of Clinical Pharmaceutical Science, Kobe Pharmaceutical University, Kobe, Japan
| | - Lucia K Dinarti
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada and Dr Sardjito Hospital, Jogjakarta, Indonesia
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24
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Li Q, Dimopoulos K, Liu T, Xu Z, Liu Q, Li Y, Zhang J, Gu H. Peripartum outcomes in a large population of women with pulmonary arterial hypertension associated with congenital heart disease. Eur J Prev Cardiol 2019; 26:1067-1076. [PMID: 30971116 DOI: 10.1177/2047487318821246] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Aims Pulmonary arterial hypertension is a severe complication in patients with congenital heart disease and poses a significant risk to women wishing to become pregnant. This study describes the clinical presentation, maternal outcomes and risk factors for the peripartum period in women with pulmonary arterial hypertension related to congenital heart disease (PAH-CHD). Methods All pregnant women with PAH-CHD who were admitted for delivery in a tertiary center between February 2011–September 2016 were included. Logistic regression analysis was used to identify predictors of the combined endpoint of maternal death, severe heart failure requiring treatment, or pulmonary hypertensive crisis. Results Ninety-three women (94 pregnancies) were included. Average age was 27.5 ± 4.4 years. Thirty (31.9%) patients had Eisenmenger syndrome, 51 (54.3%) had pulmonary arterial hypertension associated with systemic-to-pulmonary shunts, and 13 (13.8%) had pulmonary arterial hypertension with corrected congenital heart disease. Twenty-three (24.5%) women required admission for delivery within two days from presentation. Elective Cesarean section was performed in 95.7% of women, with intravertebral anesthesia in 93.6%. Fifty-one (54.2%) patients received pulmonary arterial hypertension therapies during pregnancy. Six (6.4%) women died, 33 (35.1%) developed heart failure and 10 (10.6%) had a pulmonary hypertensive crisis. Patients who met the combined endpoint ( n = 34, 36.2%) were more likely to have Eisenmenger syndrome or repaired defects ( p < 0.001). Other risk factors in the multivariate model included lower arterial blood oxygen saturation, higher brain natriuretic peptide, and pericardial effusion on echocardiography. Conclusion Maternal mortality and morbidity remain high in PAH-CHD patients, who should be counseled on the risks of pregnancy and managed in a tertiary multidisciplinary environment to improve prognosis.
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Affiliation(s)
- Qiangqiang Li
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, China
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and Imperial College, UK
| | - Tianyang Liu
- Hospital Manager Office, Beijing Anzhen Hospital, China
| | - Zhuoyuan Xu
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, China
| | - Qian Liu
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, China
| | - Yanna Li
- Obstetrics and Gynecology, Beijing Anzhen Hospital, Capital Medical University, China
| | - Jun Zhang
- Obstetrics and Gynecology, Beijing Anzhen Hospital, Capital Medical University, China
| | - Hong Gu
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, China
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25
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Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, Iung B, Johnson MR, Kintscher U, Kranke P, Lang IM, Morais J, Pieper PG, Presbitero P, Price S, Rosano GMC, Seeland U, Simoncini T, Swan L, Warnes CA. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018; 39:3165-3241. [PMID: 30165544 DOI: 10.1093/eurheartj/ehy340] [Citation(s) in RCA: 1084] [Impact Index Per Article: 180.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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26
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Abstract
Parturient with corrected or uncorrected cardiac problem may undergo neuraxial anaesthesia for several reasons and in different trimesters. The altered physiological state in a parturient is further deranged in the presence of a cardiovascular lesion, producing the added risk to the parturient undergoing a neuraxial block. A detailed evaluation, knowledge regarding cardiovascular disease state, more vigilant monitoring, and a team approach can lead to a successful outcome.
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Affiliation(s)
- Minati Choudhury
- Department of Cardiac Anaesthesia Cardiothoracic Sciences Centre, AIIMS, New Delhi, India
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