Pregnancy complicated with maternal pulmonary hypertension and placenta accreta

Pregnancy is contraindicated in cases of maternal pulmonary hypertension, a highly morbid disease affecting young women of childbearing age. The rate of heart failure increases gradually with the severity of pulmonary hypertension. In certain instances, the severity of maternal pulmonary hypertension in rheumatic heart diseases can be higher than in congenital heart diseases. Placenta accreta is an important cause of bleeding in the second half of pregnancy and in labor. In severe cases, hysterectomy is the only way to manage the bleeding during cesarean section. A 33-year-old gravida, G2P0AA1, suffering from rheumatic heart disease with mitral valve stenosis and pulmonary hypertension, was referred to our high-risk pregnancy center at 10(+3) weeks of gestation due to lower abdominal pain and brownish vaginal bleeding. She had received 2 mitral valve replacements in Shenzhen, China, at the ages of 22 and 26, respectively. Ultrasound scan of the abdomen at 12(+2) gestational weeks showed that the internal cervix was completely covered with the placenta, and a retroplacental hypoechoic space measuring 35 x 13 mm was observed at the upper posterior margin of the placenta. On color Doppler scan, an area of lacunar lake flow was observed in the hypoechoic space of the placenta and a spiral artery with low blood flow resistance was detected. The pulsation of the placental flow was synchronized with the maternal pulse rate. Team specialists, including neonatologists, pulmonary physicians, pediatric cardiologists, hematologists, anesthesiologists, psychiatrists and social workers, as well as high-risk obstetricians were consulted in an effort to minimize fetal and maternal morbidity and mortality. At 29(+2) weeks, the patient developed preeclampsia and delivered a healthy newborn by cesarean section, the uterus being preserved by square compression sutures. The gravida tolerated the procedures and was discharged in stable condition.