Pregnancy and Pulmonary Hypertension
Section snippets
Physiology
The physiologic changes of pregnancy are poorly tolerated by women with PAH. During pregnancy, cardiac output increases by 50% from baseline. This is accomplished by several mechanisms. Blood volume increases in the early stages, leading to an increase in stroke volume. This is further enhanced by a reduction in afterload secondary to decreased peripheral vascular resistance.2 Later in pregnancy, cardiac output is augmented by an increase in heart rate. Under normal conditions, there is a
Classification of PH
According to the latest World Health Organization criteria, PAH is defined by a mean pulmonary artery (PA) pressure greater than 25 mm Hg at rest, a normal PA occlusion pressure (≤15 mm Hg), and increased PVR.5 Current categorization of PAH includes patients with idiopathic or heritable PH, PH associated with congenital heart disease, as well as PH in the setting of connective tissue disease, human immunodeficiency virus (HIV), portal hypertension, anorexigen use, or pulmonary venoocclusive
Diagnosis and screening
The availability and improved technique of transthoracic echocardiography (TTE) has led to its widespread use as a screening tool for PH. Good correlation has been demonstrated between PA pressures measured by right heart catheterization (RHC) and the right ventricular systolic pressure measured by TTE, but many factors, such as advanced lung disease, premature ventricular contractions, and inaccurate estimates of right atrial pressure in the modified Bernoulli equation, can lead to
Pregnancy outcomes and mortality
PH complicates a relatively small number of pregnancies. The true incidence of PH in pregnancy has not been reported, but studies have attempted to estimate the effect of PH on maternal outcomes. Between 2002 and 2004, there were an estimated 14 million hospitalizations related to pregnancy, based on extrapolations from the Nationwide Inpatient Sample database.10 Of these, 407 (0.003%) were to the result of a diagnosis of idiopathic pulmonary arterial hypertension (IPAH). In this study, PAH was
PH developing during pregnancy
The onset of PH during pregnancy can be a first manifestation of previously undiagnosed or asymptomatic PH, which becomes unmasked under the stress of pregnancy. PH can also develop acutely during the course of pregnancy. The presence of severe dyspnea, syncope, or chest pain during pregnancy should prompt immediate investigation. The diagnosis of acute pulmonary embolism should always be suspected in such patients. If excluded, a TTE should be done to look for cardiac disease, including PH. If
Conception counseling
Despite possible improvements in pregnancy outcomes in woman with PH, the risk of death is still high enough to warrant a recommendation to avoid pregnancy. Contraception is indicated in women of child-bearing age with PH, but the modality must be chosen carefully. Combined hormonal contraceptives (oral, implanted, or transdermal) increase the risk of thrombosis, and are therefore contraindicated in woman with PH in whom this could represent a life-threatening complication. In patients with
Management of PH during pregnancy
For many different reasons, neither contraception nor termination of pregnancy is an option for some patients. Although it is unclear to what extent current strategies used to manage PH in pregnancy have had an effect on mortality, successful outcomes have been described with a variety of medical and surgical approaches. When a woman with known PH becomes pregnant, or if PH is newly discovered during pregnancy, the patient should be referred to a center that has expertise in managing PH.
Summary and recommendations
The diagnosis of PH by TTE is not uncommon in pregnancy. Because of the high output state of pregnancy, PH on a TTE should never be misconstrued as diagnostic of PAH. In approximately one-third of cases, the TTE finding represents a false-positive. Those with true arteriopathy and PAH are at increased risk for mortality as a result of the physiologic stresses of pregnancy, labor, and delivery. Recently published data that take newer therapies into account suggest that the mortality of PH in
References (67)
Pulmonary hypertension and pregnancy
Int J Obstet Anesth
(2009)Pregnancy and pulmonary hypertension
Int J Cardiol
(2004)- et al.
Pulmonary arterial hypertension: baseline characteristics from the REVEAL Registry
Chest
(2010) - et al.
Updated clinical classification of pulmonary hypertension
J Am Coll Cardiol
(2009) - et al.
A comparison of echocardiography and pulmonary artery catheterization for evaluation of pulmonary artery pressures in pregnant patients with suspected pulmonary hypertension
Am J Obstet Gynecol
(2001) - et al.
Outcome of pulmonary vascular disease in pregnancy: a systematic overview from 1978 through 1996
J Am Coll Cardiol
(1998) Pulmonary hypertension, cardiac disease and pregnancy
Int J Gynaecol Obstet
(1995)- et al.
Diagnosis of pulmonary arterial hypertension
Clin Chest Med
(2007) - et al.
2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
J Am Coll Cardiol
(2008) - et al.
Percutaneous balloon mitral valvuloplasty in comparison with open mitral valve commissurotomy for mitral stenosis during pregnancy
J Am Coll Cardiol
(2001)
Long-term outcome of patients undergoing balloon mitral valvotomy in pregnancy
Am J Cardiol
Respiratory failure due to choriocarcinoma: a study of 103 dyspneic patients
Gynecol Oncol
Pulmonary embolism, pulmonary hypertension, and choriocarcinoma
Lancet
Rapid reversal of critical haemodynamic compromise with nitric oxide in a parturient with amniotic fluid embolism
Int J Obstet Anesth
Inhaled nitric oxide therapy in pregnancy complicated by pulmonary hypertension
Am J Obstet Gynecol
Cesarean section and primary pulmonary hypertension: the role of intravenous dexmedetomidine
Int J Obstet Anesth
Safety of regional anesthesia in Eisenmenger’s syndrome
Reg Anesth Pain Med
Use of vasopressin after Caesarean section in idiopathic pulmonary arterial hypertension
Br J Anaesth
Pregnancy and primary pulmonary hypertension: successful outcome with epoprostenol therapy
Chest
Pulmonary hypertension in pregnancy: treatment with pulmonary vasodilators
Obstet Gynecol
Inhaled nitric oxide for primary pulmonary hypertension in pregnancy
Obstet Gynecol
Management of labor in Eisenmenger syndrome with inhaled nitric oxide
Am J Obstet Gynecol
Fetal vascular responses to prostacyclin
Am J Obstet Gynecol
Updated evidence-based treatment algorithm in pulmonary arterial hypertension
J Am Coll Cardiol
The effect of anticoagulant therapy in primary and anorectic drug-induced pulmonary hypertension
Chest
Eisenmenger’s syndrome in pregnancy: does heparin prophylaxis improve the maternal mortality rate?
Am Heart J
Low-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy
Blood
Fondaparinux is a safe alternative in case of heparin intolerance during pregnancy
Blood
Primary pulmonary hypertension in pregnancy
Obstet Gynecol Surv
Venous thromboembolic disease and pregnancy
N Engl J Med
Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease
Am J Respir Crit Care Med
Correlation of transthoracic echocardiography and right heart catheterization in pregnancy
J Perinat Med
Pregnancy outcomes in systemic sclerosis, primary pulmonary hypertension, and sickle cell disease
Obstet Gynecol
Cited by (22)
Pulmonary hypertension and pregnancy
2012, CardiocoreContraception, Pregnancy and Rare Respiratory Diseases
2012, Archivos de BronconeumologiaCitation Excerpt :Patients in functional class III/IV should receive continuous IV epoprostenol. If drug treatment does not control the symptoms or the patient was already in functional class III–IV before pregnancy, percutaneous valvuloplasty could be considered.17 In the case of patients with RLD, childbirth is considered high risk and should be monitored by an experienced multidisciplinary team as it requires detailed planning and generally requires scheduled birth or cesarean section (Table 5).
Maternal and Neonatal Outcomes in Pregnant Patients with Pre-Existing Cardiac Diseases
2022, Pakistan Armed Forces Medical JournalAnalgesia, anaesthesia and pregnancy: A practical guide: Fourth edition
2019, Analgesia, Anaesthesia and Pregnancy: A Practical Guide: Fourth EditionPulmonary hypertension in pregnancy
2018, Critical Care Obstetrics