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Single Site Experience with Pulmonary Hypertension in Pregnancy
Abstract Number: T1D-351
Abstract Type: Original Research
Background: Pulmonary hypertension (PHTN) in pregnancy is associated with a high maternal mortality and morbidity. The World Health Organization classifies PHTN as Class IV indicating that pregnancy is contraindicated. These patients present multiple challenges for anesthetic management during delivery. We describe a case series of 7 patients with PHTN delivering at our institution over a 5 year period.
Methods: Following Institutional Review Board approval we performed retrospective chart reviews of patients with PHTN from any cause who received pregnancy care at our institution. Demographic data, pulmonary pathology, pre-pregnancy and peripartum pulmonary status, pregnancy course, mode of delivery, method of anesthesia/analgesia and postoperative complications were described.
Results: Data from 7 parturients was collected from 2011 to 2016 with varying etiologies of PHTN. There were 6 cesarean deliveries (CD) and one vaginal delivery (VD). Four of the CD were done emergently for maternal decompensation. The VD and 2 CD were done as scheduled procedures following medical optimization. General anesthesia was performed in 3 CD and Neuraxial anesthesia (NA) was performed for the VD and 3 CD. Specifically, 1 had a single shot spinal, 1 had a combined spinal-epidural, and 1 had an intrathecal catheter. Complications occurred in 5 patients and included cardiogenic shock requiring pulmonary vasodilator or inotropic support (n=2), postpartum hemorrhage (n=3), and maternal death (n=1). Five patients were admitted to the surgical ICU following delivery, 1 to the medical ICU and 1 remained on labor and delivery. For birth control 5 patients had bilateral tubal ligations prior to hospital discharge, 1 had a Depo-Provera shot and 1 had an Essure tubal ligation 2 months postpartum. For neonatal outcomes, there was 1 neonatal death in the setting of emergency CD and maternal cardiac arrest. The gestational age for the emergency deliveries ranged from 26w3d to 33w6d and for the scheduled deliveries was between 34w4d to 38w5d.
Discussion: Caring for these complex patients requires multidisciplinary management early in their pregnancy. At the beginning of this review our institution did not have a method in place to care for these patients. In 2015, a multidisciplinary clinic for cardiac patients was started which helped capture these patients and plan for their delivery. With improved care coordination, patients were able to be optimized, their deliveries were more likely to be scheduled and we were able to minimize the number of emergent deliveries required. As pregnancy is contraindicated in patients with PHTN contraception planning is crucial; 6 of our patients had long term contraception within 2 months of delivery. By optimizing predelivery medical condition and minimizing emergent deliveries patients were more likely to be candidates for NA anesthesia, had greater potential for delivering closer to term and had fewer cardiopulmonary complications.