Pregnancy, With Care Team, Possible if PH Moderate, Study Suggests

Although pregnancy should be avoided by women with severe pulmonary hypertension (PH), close monitoring by a multidisciplinary team may make it possible in those with moderate PH, a study from China suggests.

The study “Long-term outcomes of pregnant women with pulmonary hypertension diagnosed by echocardiography: a retrospective cohort study in a single center from China,” was published in the journal Pulmonary Circulation.

During pregnancy, a woman’s heart is forced to pump up to 50% more blood, in order to nourish the developing fetus. This extra effort increases the stress on the heart and circulatory system. Because acute pulmonary and cardiac failure is possible in women with PH as a pregnancy progresses, pregnancy is not advised under current guidelines

However, emerging evidence suggests that pregnancy outcomes have improved in women with moderate PH who are using targeted therapies, indicating that pregnancy may be possible for these patients.

Still, data reporting long-run pregnancy outcomes are scarce, as very few PH patients risk pregnancy.

To address this knowledge gap, a team at Second Xiangya Hospital assessed outcomes of pregnant women with severe or moderate PH during a median follow-up of 26 months (slightly over two years).

Their study involved 88 pregnant women diagnosed with PH by echocardiography, who either terminated a pregnancy or gave birth at their hospital between 2004 and 2016.

PH was classified as moderate if pulmonary systolic arterial pressure (PSAP) was diagnosed as less than 50 mmHg, and as severe when PSAP was set at 50 mmHg or higher.

Researchers analyzed clinical characteristics that included the heart rate at rest, systolic and diastolic blood pressure, and levels of the cardiac biomarker NT-proBNP.

Their study’s primary goal was survival after discharge. Other reported outcomes covered the perinatal period, or the period immediately before and after birth, and follow-up outcomes after discharge. These outcomes included changes in cardiac function before pregnancy and at follow-up compared to the moment after delivery. Cardiac function was assessed based on New York Heart Association (NYHA) functional class.

Complications concerning the child’s birth, including premature delivery, fetal distress or malformation, and stillbirth were also recorded.

Women with severe PH were found to have higher NYHA scores, indicating worse cardiac function, during the perinatal period than during the follow-up months (75.5% vs. 61.2%).

Neonatal or fetal complications were higher in women with severe PH (of 49 patients, 18 had complications), relative to 39 women with moderate PH (three had such complications). Yet, the incidence of obstetrical complications, as well as lengths of hospitalization and intensive care unit stay, were comparable between women with moderate or severe disease. Examples of obstetrical complications included preterm birth and gestational diabetes mellitus.

Women with severe PH, however, had poorer survival rates at five years after discharge (35%) than did those with moderate PH (90%).

“Long-term survival for pregnant women with moderate PH diagnosed by echocardiography seemed to be acceptable in this study cohort [group]. As such, results of our study suggest that pregnancy might not be absolutely contraindicated in women with moderate PH,” the researchers wrote.

They also found that poorer cardiac function prior to pregnancy to be a risk factor for mortality.

“Evaluation of baseline [initial] cardiac function is significant for risk stratification in these women; pregnancy should be strictly avoided in women with PH with poor baseline cardiac classification,” the study noted.

Insufficient care during pregnancy and hyperuricemia (high levels of uric acid in the blood) were other risk factors for early death after hospital discharge following a pregnancy. Hyperuricemia is a marker of PH severity.

“Taken together, these results suggest that pregnancy should be contraindicated for women with severe PH diagnosed by echocardiography as they have significantly poor maternal and neonatal outcomes,” the researchers wrote.

Careful monitoring and pregnancy management by a comprehensive multidisciplinary team for those with moderate disease is crucial.

“Collaborative care, including expert cardiologists, obstetrics, and emergent medicine care may lead to effective treatment and intensive monitoring of this patient population, leading to improved outcomes,” the team concluded.