Multidisciplinary Approach Key to Management of Pregnant Pulmonary Hypertension Patients
Findings from a recent study published in the Annals of Cardiac Anaesthesia determined that a multidisciplinary approach is key to the successful management of pregnant patients with Pulmonary Hypertension (PH). According to the study, secondary PH results in higher morbidity and mortality, and in particular the older the age, the higher the maternal morbidity and mortality.
Pulmonary hypertension is a rare and serious condition in pregnancy with a tendency toward rapid deterioration in severe cases. Early recognition and medical management is helpful and can direct obstetric and anesthetic management.
To review the management of such patients in a tertiary center over a 15 year period, in the study titled “Pulmonary hypertension and pregnancy: The experience of a tertiary institution over 15 years,” John Monagle from the Department of Anaesthesia and Perioperative Medicine at Monash Medical Centre in Australia and colleagues identified cases meeting the criteria from the high-risk pregnancy database within the department of anesthesia and from the hospital medical records.
Severity of PH were based on systolic pulmonary artery pressure (sPAP) estimation on transthoracic echocardiogram (TTE) and classified as mild (30-40 mmHg), moderate (40-70 mmHg) or severe (>70 mmHg).
The researchers also assessed the type of PH (primary or secondary), New York Heart Association (NYHA) functional status at presentation, NYHA at delivery, timing of delivery (weeks), mode of delivery, peripartum monitoring used for anesthetic management, oxytocin dose given, APGAR scores at 1 and 5 min and birth weight.
The researchers identified 19 eligible patients. Of these, two were second pregnancies and considered as separate events, six had severe, 11 had moderate, and two had mild PH at presentation.
Patients experiencing more severe symptoms due to their PH were aggressively managed during pregnancy. Overall, there was an improvement in NYHA functional status at the time of delivery. Epidural analgesia and anesthesia for labor and operative delivery seem to be the ideal choice.
Based on the results, the researchers suggested that multidisciplinary management and planning are essential. TTE was found to be a reliable diagnostic and provides information for risk stratification and to monitor right heart function. The use of exercise testing may have some outcome predictive value as well.
The study findings also revealed that although mild PH appears to be low-risk, monitoring with TTE is essential should the disease progress or if patients become symptomatic. Moreover, this investigation was particularly relevant in showing that secondary PH results in higher morbidity and mortality, in particular, older the age higher the maternal morbidity and mortality.