///2017 Abstract Details
2017 Abstract Details2019-08-02T15:54:53-05:00

A parturient with Pulmonary Hypertension: Multi-disciplinary Team Approach

Abstract Number: SUN-15
Abstract Type: Case Report/Case Series

Asma Asif MD and MBA1 ; Michael Isley MD2; Ami Attali DO3

Introduction: Pulmonary hypertension is defined as a syndrome with elevated pulmonary artery pressures by a mean pulmonary arterial pressure higher than 25 mmHg at rest, diagnosed by right heart catheterization(1). The increased blood pressure in the pulmonary vessels ultimately leads to hypertrophy and failure of the right ventricle (1,2). During pregnancy, physiologic cardiovascular and pulmonary changes worsen pulmonary hypertension and right ventricular dysfunction. Additional hemodynamic changes occur with labor, therefore, physiologic changes during pregnancy but also during delivery and postpartum period are critical for patients with severe pulmonary hypertension (3,4).

Case Presentation: 27 y.o. female, G1P0 at 31 weeks with past medical history of pulmonary hypertension (on CPAP/4L home oxygen – diagnosed 01/2015 post ECHO showing severely enlarged right ventricle with severely reduced global right ventricular systolic function and elevated systolic PA pressure of 74 mmHg), Chronic right-sided heart failure, diastolic CHF, Obesity, Hypertension and Asthma presented in October 2015 with shortness of breath and epigastric pain.

She was also found to be hypertensive with urine dipstick positive for 3+ protein and elevated liver enzymes. She received 2 doses of Betamethasone for fetal lung maturity and started on labetalol and MgSO4 for seizure prophylaxis severe preeclampsia. ABG showed evidence of respiratory acidosis, therefore intubated for hypercapneic respiratory failure. Aretiral Line and Mac Cordis with Swan were placed in preparation for preoperative optimization and for evaluation of pulmonary pressures monitoring. Cardiology was consulted and repeat ECHO and right heart cauterization were performed, which showed severely elevated RA, and moderately elevated RV and PA pressure with Pulmonary hypertension.

Given patient's significant morbidity, decision was made to proceed with delivery. A multidisciplinary meeting was held and elective Caesarean section was planned under general anesthesia. She received a TAP block prior to her incision for post-surgical pain management. Procedure was uncomplicated. Patient was transferred to the MICU postoperatively for continued monitoring.

Discussion: PPH complicating pregnancy remains a fatal condition with deaths reported to occur usually from right heart failure. Epidural and nitric oxide therapies may have a role in controlling PAP during labor but there is no evidence of improved survival (5). In addition, recent case reports describing good maternal and neonatal outcomes from advances in the multidisciplinary approach decreasing the high mortality rate previously reported (4). It is therefore important to provide counseling to patients with pulmonary hypertension before they become pregnant and also give new insights into cardiopulmonary, obstetric, and anesthetic management during pregnancy, delivery, and the postpartum period (1, 3, 4, 7).

References: will be provided

SOAP 2017