Outcomes of Pulmonary Arterial Hypertension in Pregnancy: A Tertiary Care Retrospective Study

Pulmonary arterial hypertension (PAH) is a rare disease affecting mainly women of childbearing age. It is associated with high maternal mortality. Hence, obstetricians and cardiologists recommend against pregnancy, thereby stressing the need for effective contraception such as an intrauterine contraceptive device (IUD), and in case pregnancy occurs, early termination of pregnancy should be considered. The present study aims to retrospectively analyse 12 cases presenting with PAH in pregnancy and their maternal and fetal outcomes.

Retrospective analysis of 12 cases of PAH in pregnancy who reported to the emergency or in the cardio-obstetric clinic of Postgraduate Institution of Medical Education and Research (PGIMER), Chandigarh, India, in the last 24 years was conducted in terms of obstetric, cardiology, and neonatal parameters. PAH was diagnosed on the basis of high systolic pulmonary artery pressure (sPAP) > 20 mmHg on echocardiography. Secondary causes of pulmonary hypertension were ruled out in all patients whenever possible, depending on maternal condition.

Out of the total 12 patients, 10 (83.33%) presented in the antepartum period, and two (16.66%) in the postpartum period. Moreover, 50% were New York Heart Association (NYHA) class 3-4 at admission. There was increased PAP, ranging from 42 to 140 mmHg. As regards obstetrical outcome in 10 patients who delivered in our institution, one (10%) delivered vaginally, five (50%) had a cesarean section, one (10%) underwent medical termination of pregnancy (MTP), one (10%) patient was lost to follow-up, and two (20%) died undelivered. Maternal mortality was 36.36% (4/11), which included two antenatal and two delivered patients. Out of seven patients who delivered, five (71.42%) had fetal growth retardation, and one (14.28%) had stillbirth.

PAH has high maternal mortality despite modern treatment modalities. Patients presenting with higher NYHA class had poorer outcomes and a higher incidence of fetal growth retardation. Hence, MTP should be offered to patients with PAH who present in early pregnancy. A multidisciplinary (cardiology, anaesthesiology, neonatology, cardiac anaesthetist, along with an obstetrician experienced in managing high-risk pregnancy) team approach should be adopted while managing such patients. However, considering a very high risk in continuing the pregnancy, an ethical dilemma for continuing the pregnancy in women desirous of the same remains.