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New Onset Pulmonary Hypertension (PHTN) Presenting in Pregnancy
Abstract Number: SUN-18
Abstract Type: Case Report/Case Series
PHTN in pregnancy presents a unique challenge to healthcare providers due to the hemodynamic changes that occur during pregnancy and at the time of delivery. Despite advances in the management of these patients, maternal morbidity and mortality remains high and thus pregnancy is generally contraindicated in these patients. We present a case of an urgent cesarean delivery in a patient with no significant cardiac history who presented with new onset RV failure due to PHTN.
A 27 y/o G2P1 with an IUP at 30 EGA presented to the ED with SOB and chest pressure. She reported a cough with associated chest pain for 3 months. She was also tachycardic and tachypneic. Exam was significant for increased work of breathing and JVD. CTA was obtained which was negative for PE. TTE was then performed which showed severely depressed systolic function and PAP of 89mmHg.
Several hours later, pt began having contractions. She also developed a new onset thrombocytopenia with platelets of 108 K/uL. Decision was made to transfer her to the hospital where ECMO is available with plan for cesarean delivery. CVP and swan ganz catheter were placed (PAPs were in the 40s-50s). The patient was induced with etomidate and succinylcholine, followed by successful intubation. TEE showed severely depressed RV function with bowing of the atrial and ventricular septum from R to L. She was then preemptively placed on NO. Following delivery, the patient’s SBP rapidly declined requiring treatment with epinephrine and vasopressin boluses, followed by an epinephrine infusion. At the conclusion of the case, the NO was discontinued and the patient was successfully extubated. She was discharged on POD 5. Repeat echo showed normal PAP and moderately depressed RV.
PHTN presents multiple challenges when present in a parturient. Recent studies report a mortality rate of 12-17%, while older studies show a mortality rate as high as 56%. 2 The poor outcomes in this patient population are the result of the inability of the pulmonary vasculature to respond to the hemodynamic changes of pregnancy. While it is unknown whether our patient actually had PHTN prior to becoming pregnant, her symptoms of worsening dyspnea did not present until the 2nd trimester. In our literature search, data on patients with newly diagnosed pulmonary hypertension first presenting during pregnancy was scarce. Moll et al. published a case report in 2015 on a patient who appeared to develop gestational PHTN in 3 separate pregnancies, which resolved upon termination or delivery. 1 Another article by Limoges et al. questions whether pregnancy may act as a trigger or accelerate idiopathic pulmonary hypertension. 3 In conclusion, PHTN poses a significant risk to the mother and fetus and requires multidisciplinary management during the peripartum period.
1. Moll 2015
2. Rex 2016
3. Limoges 2016