Pulmonary hypertension in pregnancy
DOI:
https://doi.org/10.18203/2320-1770.ijrcog20210777Keywords:
Pregnancy, Pulmonary hypertension, Blood investigationsAbstract
Pulmonary hypertension is defined as an increase in mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest as assessed by right heart catheterisation. Pulmonary hypertension in pregnancy is known to be associated with significantly high morbidity and mortality rate which ranges between 30% and 56%. So during pregnancy, efforts to be made to diagnose common medical ailments that can be complicated by pulmonary hypertension. Bedside 2D Echo and thoracic ultrasound are the strongly recommended in these patients to diagnose early and prevent the devastating complications. Relevant blood investigations need to be sent to diagnose the underlying etiology and to assess the prognosis. Cardiac catheterization is the gold standard investigation of choice for pulmonary hypertension. But it is 1 performed in very few cardiac centres in developing countries. In India diagnosis largely depends on echocardiography. It should be made clear to women at the time of their PAH diagnosis that pregnancy is not recommended due to the high maternal and fetal risks. If a woman with known PHT become pregnant, counselling should be given for therapeutic abortion. If they are willing for therapeutic abortion, it should be done before 22 weeks of gestation. All women with PHT should be initiated on PAH specific therapies (prostanoids, ccbs, phosphodiesterase inhibitors) except endothelin receptor blockers as it is teratogenic. Pregnancy in PAH is difficult to manage and needs mutidisciplanary team. Pregnancy is not recommended in women with PAH and appropriate counselling to be done to the mother and their relatives.
References
Galiè N, Hoeper MM, Humbert M. Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2009;30:2493-537.
Bassily-Marcus AM, Yuan C, Oropello J, Manasia A, Kohli-Seth R, Benjamin E. Pulmonary hypertension in pregnancy: Critical care management. Pulm Med. 2012;2012:709407
Weiss BM, Zemp L, Seifert B, Hess OM. Outcome of pulmonary vascular disease in pregnancy: A systematic overview from 1978 through 1996. J Am Coll Cardiol. 1998;31:1650-7.
Smith JS, Mueller J, Daniels CJ. Pulmonary arterial hypertension in the setting of pregnancy: A case series and standard treatment approach. Lung. 2012;190:155-60.
La Vecchia L, Ottani F, Favero L, Spadaro GL, Rubboli A, Boanno C, et al. Increased cardiac troponin i on admission predicts in-hospital mortality in acute pulmonary embolism. Heart. 2004;90:633-7.
Ghofrani HA, Wilkins MW, Rich S. Uncertainties in the diagnosis and treatment of pulmonary arterial hypertension. Circulation. 2008;118:1195-201.
Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med. 2008;359: 2025-33.
Burgazli KM, Bilgin M, Kavukcu E, Altay MM, Ozkan HT, Coskun U, et al. Diagnosis and treatment of deep-vein thrombosis and approach to venous thromboembolism in obstetrics and gynecology. J Turk Ger Gynecol Assoc. 2011;12:168-75.
Stone SE, Morris TA. Pulmonary embolism during and after pregnancy. Crit Care Med. 2005;33:S294-300.
Stone SE, Morris TA. Pulmonary embolism and pregnancy. Crit Care Clin. 2004;20:661-77.
Kajimoto K, Madeen K, Nakayama T, Tsudo H, Kuroda T, Abe T. Rapid evaluation by lung-cardiac-inferior vena cava (lci) integrated ultrasound for differentiating heart failure from pulmonary disease as the cause of acute dyspnea in the emergency setting. Cardiovasc Ultrasound. 2012;10:49.
Cardinale L, Volpicelli G, Binello F, Garofalo G, Priola SM, Veltri A, et al. Clinical application of lung ultrasound in patients with acute dyspnea: Differential diagnosis between cardiogenic and pulmonary causes. Radiol Med. 2009;114:1053-64.
McMillan E, Martin WL, Waugh J, Rushton I, Lewis M, Clutton-Brock T, et al. Management of pregnancy in women with pulmonary hypertension secondary to sle and anti-phospholipid syndrome. Lupus. 2002; 11:392-8.
Bedard E, Dimopoulos K, Gatzoulis MA. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension? Eur Heart J. 2009;30:256-65.
Kiely DG, Condliffe R, Webster V, Mills GH, Wrench I, Gandhi SV, et al. Improved survival in pregnancy and pulmonary hypertension using a multiprofessional approach. BJOG. 2010;117:565-74.
Galiè N, Humbert M, Vachiery JL. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2016;37:67-119.
Hemnes AR, Kiely DG, Cockrill BA. Statement on pregnancy in pulmonary hypertension from the pulmonary vascular research institute. Pulm Circ. 2015;5:435-65.
Hsu CH, Gomberg-Maitland M, Glassner C. The management of pregnancy and pregnancy-related medical conditions in pulmonary arterial hypertension patients. Int J Clin Pract Suppl. 2011; 175:6-14.
Olsson KM, Jais X. Birth control and pregnancy management in pulmonary hypertension. Semin Respir Crit Care Med. 2013;34:681-8.
Thorne S, Nelson-Piercy C, MacGregor A. Pregnancy and contraception in heart disease and pulmonary arterial hypertension. J Fam Plann Reprod Health Care. 2006;32:75-81.
Mantha S, Karp R, Raghavan V. Assessing the risk of venous thromboembolic events in women taking progestin-only contraception: a meta-analysis. BMJ. 2012;345:e4944.
Hemnes AR, Kiely DG, Cockrill BA. Statement on pregnancy in pulmonary hypertension from the Pulmonary Vascular Research Institute. Pulm Circ. 2015;5:435-65.
Austin ED, Loyd JE, Phillips JA. Heritable pulmonary arterial hypertension. In: Pagon RA, Adam MP, Ardinger HH, eds. Seattle: University of Washington publication; 2002.
Liu S, Liston RM, Joseph KS. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ. 2007;176: 455-60.
Uebing A, Steer PJ, Yentis SM. Pregnancy and congenital heart disease. BMJ. 2006;332: 401-6.
Warnes CA. Pregnancy and pulmonary hypertension. Int J Cardiol. 2004;97:11-3.
Jais X, Olsson KM, Barbera JA. Pregnancy outcomes in pulmonary arterial hypertension in the modern management era. Eur Respir J. 2012;40:881-5.
Bedard E, Dimopoulos K, Gatzoulis MA. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension?. Eur Heart J. 2009;30:256-65.
Bonnin M, Mercier FJ, Sitbon O. Severe pulmonary hypertension during pregnancy: mode of delivery and anesthetic management of 15 consecutive cases. Anesthesiol. 2005;102:1133-7.
Madden BP. Pulmonary hypertension and pregnancy. Int J Obstet Anesth. 2009;18:156-64.
Louis ED, Mayer SA, Rowland LP. Merrit’s Neurology. 13th Ed. Netherlands: Wolters Kluwer; 2015:1043.
Yamaguchi ET, Cardoso MM, Torres ML. Oxytocin in cesarean sections: what is the best way to use it?. Rev Bras Anestesiol. 2007;57:324-50.
O’Hare R, McLoughlin C, Milligan K. Anaesthesia for caesarean section in the presence of severe primary pulmonary hypertension. Br J Anaesth. 1998;81:790-2.
Albackr HB, Aldakhil LO, Ahamd A. Primary pulmonary hypertension during pregnancy: a case report. J Saudi Heart Assoc. 2013;25:219-23.
Terek D, Kayikcioglu M, Kultursay H, . Pulmonary arterial hypertension and pregnancy. J Res Med Sci. 2013;18:73-6.
Madden BP. Pulmonary hypertension and pregnancy. Int J Obstet Anesth. 2009;18:156-64.
Hilfiker-Kleiner D, Struman I, Hoch M. 16-kDa prolactin and bromocriptine in postpartum cardiomyopathy. Curr Heart Fail Rep. 2012;9:174-82.
Elliot CA, Stewart P, Webster VJ. The use of iloprost in early pregnancy in patients with pulmonary arterial hypertension. Eur Respir J. 2005; 26:168-73.
Kiely DG, Condliffe R, Webster V. Improved survival in pregnancy and pulmonary hypertension using a multiprofessional approach. BJOG. 2010; 117:565-74.
Bildirici I, Shumway JB. Intravenous and inhaled epoprostenol for primary pulmonary hypertension during pregnancy and delivery. Obstet Gynecol. 2004;103:1102-5.
Avdalovic M, Sandrock C, Hoso A. Epoprostenol in pregnant patients with secondary pulmonary hypertension: two case reports and a review of the literature. Treat Respir Med. 2004;3:29-34.
Stewart R, Tuazon D, Olson G. Pregnancy and primary pulmonary hypertension: successful outcome with epoprostenol therapy. Chest. 2001;119:973-5.
Lacassie HJ, Germain AM, Valdes G. Management of Eisenmenger syndrome in pregnancy with sildenafil and L-arginine. Obstet Gyneco.l 2004;103:1118-20.
