Pregnancies in women with mild pulmonary arterial hypertension (PAH) who have good cardiac function are feasible and should be considered with the use of multidisciplinary monitoring.
A systematic review and meta-analysis on the topic were conducted, with the findings published in the journal BMC Pregnancy and Childbirth.
In patients with PAH, elevated pulmonary artery pressure, which results in pulmonary artery remodeling/overload, eventually leading to right ventricular hypertrophy, remodeling, and right heart failure, is observed. During pregnancy, it is well known that maternal hemodynamics are altered, with increased blood volume and cardiac output, decreased systemic vascular resistance, heightened oxygen consumption, and a hypercoagulable blood state exacerbating a woman’s risk for pulmonary embolism, deep venous thrombosis, and hypoxemia. Thus, pregnant women with PAH and their fetuses face myriad challenges.
Based on the 2018 European Society of Cardiology guidelines for the Management of Cardiovascular Diseases during pregnancy, “Women with pulmonary hypertension [PH] should avoid pregnancy.” Advancements in medical treatment have been associated with a higher number of women with PH being eager to become pregnant, continue their pregnancy, and deliver a healthy newborn.
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The researchers sought to conduct a systematic review and meta-analysis to assess the feasibility of pregnancy among women with mild PAH, according to pregnancy outcomes. They used recent data to compare the differences in maternal and fetal outcomes between pregnancies in women with mild PAH and pregnancies in women with moderate to severe PAH.
Relevant databases were searched between January 1, 1990, and April 18, 2023. The studies included were randomized controlled and observational in design, which included cohort studies and case-control studies that evaluated maternal and fetal pregnancy outcomes in women with PAH.
Ultimately, 32 studies fulfilled the inclusion criteria of the meta-analysis. Based on the National Institutes of Health-Quality Assessment Tool, 11 of the articles were rated as “good” and 21 were rated as “fair.” Overall, 2520 pregnant women were enrolled in the study, the majority of whom were Chinese. In the study population, most of the causes of PH were from congenital heart disease; a few were associated with idiopathic PH.
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Results of the study demonstrated that maternal and fetal outcomes were better in the mild PAH arm than in the moderate to severe PAH arm. In terms of maternal mortality, rates were much lower in the mild group compared with the moderate to severe group. After 2010, a significant decrease in mortality was observed in the mild PAH group; no significant difference in maternal mortality either prior to or after 2010, however, was reported in the moderate to severe PAH group.
The following were all significantly lower in the mild PAH arm than in the moderate to severe PAH arm:
- Cardiac complications
- Intensive care unit admissions
- Neonatal preterm births
- Small-for-gestational-age infants
- Low birth weight infants
- Neonatal asphyxia
- Neonatal mortality
In addition, the rate of vaginal delivery was significantly higher in the mild PAH arm than in the moderate to severe PAH arm (P <.00001); rates of cesarean section were similar in the 2 groups.
“The findings of this study provide a basis for pre-pregnancy counseling and risk assessment for obstetricians among women with PAH,” the researchers concluded.
Ma R, Gao H, Cui J, et al. Pregnancy feasibility in women with mild pulmonary arterial hypertension: a systematic review and meta-analysis. BMC Pregnancy Childbirth. Published online June 8, 2023. doi:10.1186/s12884-023-05752-w