Pregnancy feasibility in women with mild pulmonary arterial hypertension: a systematic review and meta-analysis

Abstract

Background The aim of this study was to evaluate the pregnancy feasibility of women with mild pulmonary hypertension according to pregnancy outcomes. Methods This systematic review and meta-analysis compared the differences in maternal and fetal outcomes between mild and moderate-to-severe pulmonary hypertension. Relevant English and Chinese literature were searched in the PubMed, Embase, Cochrane Central Register of Controlled Trials (COCHRANE), CNKI, WanFang Data, and VIP databases between January 1st, 1990 and April 18th, 2023, and the references of the included articles and relevant systematic reviews were reviewed to determine whether studies were missed. The inclusion criteria were randomized controlled and observational studies (including case-control studies and cohort studies) examining maternal and fetal pregnancy outcomes with pulmonary hypertension. Conference abstracts, case reports, case series reports, non-comparative studies, and review articles were excluded. Results This meta-analysis included 32 studies. In this study, maternal and fetal outcomes were better in the mild pulmonary hypertension group than in the moderate-to-severe group. Regarding maternal mortality, the mild group was much lower than the moderate to severe group. We found a significant decrease in maternal mortality in the mild group after 2010. However, no significant difference in maternal mortality before and after 2010 was observed in the moderate to severe group. Cardiac complications, ICU admission, neonatal preterm birth, small for gestational age infants, low birth weight infants, neonatal asphyxia, and neonatal mortality were significantly lower in the mild pulmonary hypertension group than in the moderate to severe pulmonary hypertension group. The cesarean section rates of the two groups were similar. However, the vaginal delivery rate in the mild pulmonary hypertension group was significantly higher than that in the moderate to severe pulmonary hypertension group. Conclusions This meta-analysis confirmed that pregnancies with mild pulmonary hypertension had significantly better maternal and fetal outcomes than those with moderate to severe pulmonary hypertension. For patients with mild pulmonary hypertension and good cardiac function, continued pregnancy or even delivery should be considered under multidisciplinary monitoring. However, maternal and fetal complications with moderate to severe pulmonary hypertension significantly increase. Hence, it is essential to evaluate pregnancy risk and terminate it in time.

Management of pulmonary arterial hypertension：before, during and after pregnancy

“…2 ). Fetal outcomes include low birth weight, week of delivery, neonatal preterm birth, and small for gestational age infants, low birth weight infants, neonatal asphyxia, and higher neonatal mortality [ 39 ]. According to the etiology, idiopathic pulmonary arterial hypertension (iPAH), pulmonary arterial hypertension associated with congenital heart disease (CHD-PAH), pulmonary hypertension associated with left heart disease (LDH-PH), and pulmonary arterial hypertension caused by other diseases (oPAH) constitute the majority of fetal complications.…”

Pulmonary Hypertension in Women

“…32,33 In PAH patients, compensatory mechanisms to accommodate vasodilation of the pulmonary vasculature are decreased or absent, leading to increased pulmonary vascular resistance. 32,34 These changes lead to worsening RV strain and ultimately failure. Pregnancy also increases hypercoagulability and risk of thromboembolic events due to increases in coagulation factors and fibrinogen, decreased protein S, and more protein C resistance.…”

“…Progesterone-only pills could be used, and permanent contraception should be considered, although some patients understandably may not comply. 32,34,36 Intrauterine devices can be considered but can cause vasovagal reactions during insertion and lead to RV strain. Two methods of contraception are recommended in general but are considered necessary when an endothelin receptor antagonist is used.…”

“…37 An MDT consisting of a high-risk obstetrician/gynecologist, cardiologist, critical care specialist, cardiovascular anesthesia specialist, and pulmonologist can help guide different aspects of a pregnant PAH patient's care to help improve outcomes. 34,36,37 The goal of treatment during pregnancy is to optimize RV function. 38 Patients with severely depressed RV function should be started on IV epoprostenol during pregnancy, delivery, and postpartum; those with more preserved RV function may be carefully monitored and continued on oral therapies and/or considered for inhaled prostacyclins.…”

“…39 During delivery, IV prostaglandin should be administered to most patients. 34,36 Close monitoring of hemodynamics should be performed, with current guidelines recommending the use of a central venous catheter and arterial line; however, routine use of a Swan-Ganz catheter is not recommended. 34,36 As medicine continues to advance, noninvasive methods may be used in the future.…”