Pulmonary Hypertension in Pregnancy: Critical Care Management

Abstract

Pulmonary hypertension is common in critical care settings and in presence of right ventricular failure is challenging to manage. Pulmonary hypertension in pregnant patients carries a high mortality rates between 30–56%. In the past decade, new treatments for pulmonary hypertension have emerged. Their application in pregnant women with pulmonary hypertension may hold promise in reducing morbidity and mortality. Signs and symptoms of pulmonary hypertension are nonspecific in pregnant women. Imaging workup may have undesirable radiation exposure. Pulmonary artery catheter remains the gold standard for diagnosing pulmonary hypertension, although its use in the intensive care unit for other conditions has slowly fallen out of favor. Goal-directed bedside echocardiogram and lung ultrasonography provide attractive alternatives. Basic principles of managing pulmonary hypertension with right ventricular failure are maintaining right ventricular function and reducing pulmonary vascular resistance. Fluid resuscitation and various vasopressors are used with caution. Pulmonary-hypertension-targeted therapies have been utilized in pregnant women with understanding of their safety profile. Mainstay therapy for pulmonary embolism is anticoagulation, and the treatment for amniotic fluid embolism remains supportive care. Multidisciplinary team approach is crucial to achieving successful outcomes in these difficult cases.

Pulmonary hypertension and its management in patients undergoing non‐cardiac surgery

“…Avoidance of pregnancy is still strongly advocated and early termi- nation is recommended for PAH patients. With regards to the specific medical management of PAH, endothelin receptor antagonists are contraindicated during pregnancy due to their teratogenic effect, but epoprostenol, trepostinil, nebulised iloprost, sildenafil and inhaled nitric oxide can be used [77]. Calcium channel blockers are recommended for responders to the vasodilatory testing.…”

“…Most case reports describing pregnant patients with PH placed patients on thromboprophylaxis during pregnancy and through the postpartum period with only a brief interruption around the time of delivery. Exceptions are for those who had a history of thromboembolic disease and idiopathic PAH where higher levels of anticoagulation may be required [77,79].…”

Multidisciplinary Team Approach is The Key to The Successful Assessment and Management of Complex Obstetric Patients

“…Although pregnancies affected by PH are rare with an incidence of 1.1/100,000 women, severe PH is poorly tolerated in pregnancy, and PH is associated with a high maternal mortality of estimated between 30% and 56% (3,4). Careful preoperative assessment, treatment and planning before delivery provided by an experienced multidisciplinary team is indispensable to optimize the cardiac function of the parturient during the peripartum period and to make decisions on mode of delivery and choice of anesthetic techniques.…”

Contemporary diagnosis and management of pulmonary hypertension

“…These changes are poorly tolerated in patients with PAH and pregnancy is associated with high maternal mortality rates and therefore pregnancy is contraindicated 60. Two forms of contraception are generally recommended including barrier and progesterone-only hormonal methods 1…”