Critical care management of pulmonary arterial hypertension in pregnancy: the pre-, peri- and post-partum stages

Abstract

The mortality rate of pulmonary hypertension in pregnancy is 25%–56%. Pulmonary arterial hypertension is the highest incidence among this group, especially in young women. Despite clear recommendation of pregnancy avoidance, certain groups of patients are initially diagnosed during the gestational age step into the third trimester. While the presence of right ventricular failure in early gestation is usually trivial, it can be more severe in the late trimester. Current evidence shows no consensus in the management and serious precautions for each stage of the pre-, peri- and post-partum periods of this specific group. Pulmonary hypertension-targeted drugs, mode of delivery, type of anesthesia, and some avoidances should be planned among a multidisciplinary team to enhance maternal and fetal survival opportunities. Sudden circulatory collapse from cardiac decompensation during the peri- and post-partum phases is detrimental, and mechanical support such as extracorporeal membrane oxygenation should be considered for mitigating hemodynamics and extending cardiac recovery time. Our review aims to explain the pathophysiology of pulmonary arterial hypertension and summarize the current evidence for critical management and precautions in each stage of pregnancy.

Effects of maternal pulmonary arterial hypertension on fetal hemodynamics and maternal‐fetal outcome in late pregnancy

“…Among the 32 normal pregnant women, vaginal delivery was the main mode of delivery. There were 22 women with various degrees of PAH and women with normal pregnancies were 8−10 points, and there was no significant difference in Apgar scores between the three groups. Only one pregnant woman died in the moderate-to-severe PAH group.…”

“…Studies have confirmed that pregnant women with PAH are prone to hypoxemia in the third trimester of pregnancy, thus resulting in reduced placental perfusion pressure and intrauterine hypoxia in the fetus. 22,3 The resistance of the umbilical artery increases significantly, and distal disconnection may occur, thus showing that the difference between PSV and EDV, with increase of S/D, RI, and PI. 23,24 In severe cases, brain protection effect may occur, which is manifested a decrease in MCA resistance, evidenced by a reduction in RI, PI, and S/D.…”

Maternal Outcomes Among Pregnant Women With Congenital Heart Disease–Associated Pulmonary Hypertension

“…Last, although most postpartum deaths in pregnant women occur within 1 month of delivery, the effects of pregnancy on the cardiovascular system can persist for several months after delivery; 4,27 thus, the lack of longer-term follow-up could potentially confound our results. 34,35 Therefore future studies should consider a longer follow-up period.…”

Changes of Severe Maternal Clinical Features

“…A study on 151 pregnant women with pulmonary arterial hypertension shows that, despite the mortality decreased to 4.6% (7/151), that of idiopathic pulmonary arterial hypertension is still high 42.9% (3/7) [12];The clinical manifestation of PAH is similar to normal pregnancy-induced physiological symptoms (palpitation, shortness of breath, lower extremity edema, etc.) [13], so it is easy to be ignored by pregnant women and clinicians, and the special physiological changes during pregnancy will sharply increase the right ventricular afterload of PAH pregnant women and threaten their lives; we recommend that the length of ICU stay of PAH pregnant women be extended, it may increase patients' survival probability to pay attention to monitor hemodynamic changes, negative uid balance, properly conduct analgesia and sedation, and formulate individualized treatment solutions of the MDT dominated by the ICU. [10,13,14]…”

“…[13], so it is easy to be ignored by pregnant women and clinicians, and the special physiological changes during pregnancy will sharply increase the right ventricular afterload of PAH pregnant women and threaten their lives; we recommend that the length of ICU stay of PAH pregnant women be extended, it may increase patients' survival probability to pay attention to monitor hemodynamic changes, negative uid balance, properly conduct analgesia and sedation, and formulate individualized treatment solutions of the MDT dominated by the ICU. [10,13,14]…”