Management of pregnant patients with pulmonary arterial hypertension

Abstract

Pregnant individuals with pulmonary arterial hypertension (PAH) have significantly high risks of maternal and perinatal mortality. Profound changes in plasma volume, cardiac output and systemic vascular resistance can all increase the strain being placed on the right ventricle, leading to heart failure and cardiovascular collapse. Given the complex network of opposing physiological changes, strict contraception and reduction of hemodynamic fluctuations during pregnancy are important methods of minimizing the risk of maternal mortality and improving the outcomes following pregnancy. In this review, we discuss the recent research progress into pre-conception management and the various therapeutic strategies for pregnant individuals with PAH.

Classification, Diagnosis, and Medical Treatment of Pulmonary Hypertension

“…Ongoing pregnancy may necessitate adjustments in disease treatment protocols [24]. Drugs such as ERAs, riociguat, and selexipag are typically discontinued due to their potential or unknown risks to fetal development [24,45]. Conversely, treatments like CCBs, PDE-5 inhibitors, and prostacyclin analogs administered via inhalation, IV, or SC routes are generally deemed safe during pregnancy [24,45].…”

“…To manage right heart failure decompensation symptoms, diuretics such as torsemide or furosemide may be utilized [24,45]. However, the use of spironolactone is not recommended during the first trimester due to its antiandrogenic properties [24,45].…”

“…To manage right heart failure decompensation symptoms, diuretics such as torsemide or furosemide may be utilized [24,45]. However, the use of spironolactone is not recommended during the first trimester due to its antiandrogenic properties [24,45]. When administering diuretics, it is crucial to regularly monitor renal function and serum electrolytes to prevent complications like volume depletion, which could further reduce cardiac output and systemic blood pressure [45].…”

“…Heparins are the first-line anticoagulants recommended-particularly low molecular weight heparin (LMWH)-due to their reduced fetal impact and osteoporosis risk. They are recommended for those with cardiopulmonary dysfunction and PH to mitigate thrombosis risks [45]. However, the effectiveness of LMWH in preventing valve thrombosis is limited.…”

“…However, the effectiveness of LMWH in preventing valve thrombosis is limited. Warfarin, though used in specific dosages during the second and third trimesters, poses teratogenic risks and its use remains controversial during pregnancy [45]. Novel oral anticoagulants like dabigatran and rivaroxaban lack robust evidence for safety and efficacy in pregnant women and are associated with higher risks of miscarriage and birth defects; as a result, their use is generally not recommended [45].…”