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A review of high risk OB patients with PAH

Laura Savage

Janet Pinson


Daniel Grinnan


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Conference: 2017 PH Professional Network Symposium

Release Date: 10.06.2017

Presentation Type: Abstracts

File Download: 2017 PHPN Abstract 1030

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Abstract presented at the 2017 PH Professional Network Symposium held in Bethesda, MD on October 5-7, 2017

Purpose

To describe a single center experience in the pregnant patient with pulmonary arterial hypertension. 

Background

Pulmonary hypertension (PH) remains a contraindication to pregnancy. However, with the increased number of proven treatment options, outcomes have improved. Despite these improvements in the pregnant patient, Kiely et al (2013) report maternal mortality between 12% to 33%. It is recognized that the right ventricle(RV) is the Achilles heel in PH. Due to progressive narrowing in the pulmonary arterial vasculature, right ventricular afterload increases leading to right heart failure and even death. In pregnancy, the normal physiology changes significantly in relation to several factors. Oxygen consumption increases by 30% and blood volume can increase by 40-50% by 32-36 weeks’ gestation (Weiss 2000 and Bonica 1995). These changes result in higher cardiac output. Accordingly, this strain on the RV can produce symptoms of failure; shortness of breath and edema. However, it has been shown that fluid shifts in the immediate post-partum period place the patient at the greatest risk of mortality and morbidity (Weiss, 1998). In addition, it has been postulated that hormonal changes during pregnancy can be protective in their "vasodilatory" properties which is reduced immediately after delivery. Lastly, the "procoagulant effect may cause obstruction of the vasculature by thrombosis". (Kiely 2013). This is thought to further compromise the narrowed vasculature in the pulmonary artery.

Methods

Retrospective review of our center's pregnant patients between 2006-2017. The following variables were identified: WHO group, treatment, age, race, management during pregnancy and in the post-partum period, maternal outcomes, and number of pregnancies

Results

This descriptive review from 2006-2017 reveals severity of disease, age at time of pregnancy, management strategies during and after pregnancy using a multi-disciplinary approach. The cohort consists of 8 women with 20 pregnancies among them. All of them were WHO Group 1: {2- idiopathic, 3- Congenital heart disease, 2- mixed connective tissue disease and 1- CTEPH}. Demographics revealed: RACE- 2/8 Caucasians, 5/8 African American. 1/8 Asian. AGE range at time of pregnancy :19-33 years old. There was one maternal death post-partum (5%).
All but one patient had multiple pregnancies. 50% of pts presented to an OSH during their pregnancy. 10/20 (50%) were managed at this center during their entire pregnancy.

Conclusion

PH remains a contraindication to pregnancy. However, it has been demonstrated in one center's experience, that with a multi-disciplinary approach, early treatment, vigilant monitoring during pregnancy and post-partum, successful outcomes can occur. PH patients who became pregnant tended to have multiple pregnancies. For those pts known to our practice prior to pregnancy, they were routinely and repeatedly counseled regarding the risks of pregnancy. Pts with financial and social resources tended to weigh the risk of pregnancy making a more informed decision to become pregnant and follow up with recommended monitoring. Further study is needed to determine if pregnancy is more likely among socially and financially disadvantaged PH patients.