Severe Pulmonary Hypertension during Pregnancy: Mode of Delivery and Anesthetic Management of 15 Consecutive Cases
(Anesthesiology, 102:1133-1137, 2005)
Department of Anesthesiology and Intensive Care, Antoine Beclere Hospital-APHP, Clamart, France.
Existing literature on pregnant women with severe pulmonary hypertension (PH) is based mainly on anecdotal case reports and on only 2 case series. The charts of all pregnant women with severe PH who were followed up at their institutions during the past 10 years were reviewed to assess the multidisciplinary treatment and outcome of these patients. Fifteen pregnancies in 14 women with severe PH were managed during this period. There were 4 cases of idiopathic pulmonary hypertension (PAH), 6 cases of congenital heart disease-associated PAH, 1 case of fenfluramine-associated PAH, 1 case of human immunodeficiency virus-associated PAH, and 2 cases of chronic thromboembolic PH. PH presented during pregnancy in 3 patients. Two patients died before delivery at 12 and 23 weeks of gestation. Four patients had vaginal deliveries with regional anesthesia. One died 3 months postpartum, 1 worsened, and 2 remained stable. Four had cesarean deliveries during general anesthesia: 1 died 3 weeks postpartum, 1 worsened, and 2 remained stable. Five had cesarean deliveries during low-dose combined spinal-epidural anesthesia: 1 died 1 week postpartum, and 4 remained stable. There were 2 fetal deaths: 1 related to therapeutic abortion at 21 weeks of gestation and 1 stillbirth at 36 weeks of gestation followed by the death of the mother 1 week later. Despite the most modern efforts at treatment, the maternal mortality was 36%. Scheduled cesarean delivery during combined spinal-epidural anesthesia appeared to be an attractive approach, but there was no evidence of actual benefit. Therefore, pregnancy must still be discouraged in patients with severe PH. For patients whose conditions worsen during the pregnancy and wish to continue with the pregnancy, the use of prostanoids should be considered early in the course.