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Anesthetic Management of a Parturient with Human Immunodeficiency Virus and Associated Pulmonary Arterial Hypertension
Abstract Number: F-68
Abstract Type: Case Report/Case Series
We present a 30 year-old, G3P0 with WHO group 1 severe pulmonary arterial hypertension (PAH) associated with congenital HIV/AIDS. She was found to be pregnant at 12 weeks gestation and was initially counseled to terminate the pregnancy, which she refused. The patient subsequently presented with shortness of breath, hypoxia, and peripheral edema at 25 weeks. On admission, her CD4 count and viral load were 72/μL and 494 copies/mL, respectively. Pro-BNP was 880pg/mL and PA systolic pressure was 82 mmHg by transthoracic echocardiography (TTE). She was diuresed and received treatment for Pneumocystis pneumonia (PCP). Due to outpatient medication nonadherence, she remained hospitalized for 51 days until her scheduled cesarean delivery for monitoring and symptom management. Serial TTE was obtained to assist in medical management and her PAH was managed with tadalafil.
A multidisciplinary team consisting of cardiologists, obstetricians, and obstetric anesthesiologists planned for delivery. Scheduled cesarean was performed successfully at 33 weeks with continuous inhaled epoprostenol, epidural anesthesia, arterial pressure monitoring, and PICC line for vasopressor infusion. After returning to the cardiac intensive care unit immediately postpartum, the patient’s remaining postoperative course was uneventful and she was discharged on postpartum day 7.
As a result of the use of highly active antiretroviral therapy (HAART), survival rates for children with congenital HIV have improved dramatically. Thus, an increasing number of these individuals with chronic HIV infection are nearing reproductive age. HIV-related pulmonary arterial hypertension (HIV-PAH) is a rare complication of HIV infection, occurring in about 1 in 200 HIV-infected individuals. Even during the era of HAART, prevalence of HIV-PAH has remained unchanged. As noted in several studies, severe PAH in pregnancy has a mortality rate as high as 30 to 50%. Death most often occurs following delivery as significant changes in physiology occur rapidly over several hours to days. However, prior to delivery, pregnancy related cardiovascular and pulmonary changes can worsen pulmonary hypertension. Therefore, a multidisciplinary team approach prior to delivery is essential to optimize outcomes.
Bonnin, Martine, et al. "Severe pulmonary hypertension during pregnancy." Anesthesiology 2005;102(6): 1133-7.
Opravil, Milos, et al. "HIV-associated primary pulmonary hypertension. A case control study. Swiss HIV Cohort Study." American journal of respiratory and critical care medicine 1997;155(3): 990-5.
Simonneau, Gérald, et al. "Updated clinical classification of pulmonary hypertension." Journal of the American College of Cardiology 2009;54(1 supp): S43-S54.
Sitbon O, Lascoux-Combe C, Delfraissy JF, et al. “Prevalence of HIV-related pulmonary arterial hypertension in the current antiretroviral therapy era.” Am J Respir Crit Care Med 2008;177(1): 108-13.