The Early Recognition and Management of Pregnancy with Pulmonary Hypertension

doi:10.12280/gjfckx.f20200974

Abstract

Abstract:

Pregnancy with pulmonary hypertension is a life-threatening disease to both maternal and fetal. Pulmonary hypertension is currently listed as a pregnancy contraindication, no matter what the primary causes. Maternal deaths are mostly related to pulmonary hypertension crisis, right heart failure, and embolism. The main impacts on the fetus include intrauterine death, miscarriage, premature delivery, and fetal growth restriction. After pregnancy, women with pulmonary hypertension often have no obvious clinical symptoms in the early stage, and they are easily confused with pregnancy status, which poses challenges for early recognition. Echocardiography, which is convenient, simple, non-invasive and non-radiation, can be used as a screening method for high-risk populations. Once pregnant patients with pulmonary hypertension are diagnosed, they should be transferred to a maternal and fetal medicine center, with relevant management experience. Individualized management and multidisciplinary teamwork should be emphasized, and the timing, method and anesthesia method of delivery should be determined based on the maternal and fetal conditions to reduce the risks and ensure the safety.

Key words: Hypertension,pulmonary, Pregnancy, Prenatal diagnosis, Maternal health

SHI Tian-yi, GONG Ying-ying, QIAN Hui-qin, YU Hong. The Early Recognition and Management of Pregnancy with Pulmonary Hypertension[J]. Journal of International Obstetrics and Gynecology, 2021, 48(4): 367-370.

Figures/Tables 2

References 25

[1]	中华医学会呼吸病学分会肺栓塞与肺血管病学组, 中国医师协会呼吸医师分会肺栓塞与肺血管病工作委员会, 全国肺栓塞与肺血管病防治协作组, 等. 中国肺动脉高压诊断与治疗指南(2021版)[J]. 中华医学杂志, 2021, 101(1):11-51. doi: 10.3760/cma.j.cn112137-20201008-02778. doi: 10.3760/cma.j.cn112137-20201008-02778
[2]	Thomas E, Yang J, Xu J, et al. Pulmonary Hypertension and Pregnancy Outcomes: Insights From the National Inpatient Sample[J]. J Am Heart Assoc, 2017, 6(10):e006144. doi: 10.1161/JAHA.117.006144. doi: 10.1161/JAHA.117.006144
[3]	Zhao H, Zhang H, Xu X, et al. Risk factors for perinatal cardiac complications in pregnancy with pulmonary hypertension[J]. Pregnancy Hypertens, 2018, 12:207-213. doi: 10.1016/j.preghy.2017.09.001. doi: S2210-7789(17)30061-2 pmid: 29113717
[4]	林晓, 王志华. 妊娠合并肺动脉高压的临床分析[J]. 现代妇产科进展, 2020, 29(2):130-133. doi: 10.13283/j.cnki.xdfckjz.2020.02.011. doi: 10.13283/j.cnki.xdfckjz.2020.02.011
[5]	Meng ML, Landau R, Viktorsdottir O, et al. Pulmonary Hypertension in Pregnancy: A Report of 49 Cases at Four Tertiary North American Sites[J]. Obstet Gynecol, 2017, 129(3):511-520. doi: 10.1097/AOG.0000000000001896. doi: 10.1097/AOG.0000000000001896
[6]	Sliwa K, van Hagen IM, Budts W, et al. Pulmonary hypertension and pregnancy outcomes: data from the Registry Of Pregnancy and Cardiac Disease (ROPAC) of the European Society of Cardiology[J]. Eur J Heart Fail, 2016, 18(9):1119-1128. doi: 10.1002/ejhf.594. doi: 10.1002/ejhf.594
[7]	Badesch DB, Raskob GE, Elliott CG, et al. Pulmonary arterial hypertension: baseline characteristics from the REVEAL Registry[J]. Chest, 2010, 137(2):376-387. doi: 10.1378/chest.09-1140. doi: 10.1378/chest.09-1140 pmid: 19837821
[8]	George MG, Schieb LJ, Ayala C, et al. Pulmonary hypertension surveillance: United States, 2001 to 2010[J]. Chest, 2014, 146(2):476-495. doi: 10.1378/chest.14-0527. doi: S0012-3692(15)48835-X pmid: 24700091
[9]	Simonneau G, Montani D, Celermajer DS, et al. Haemodynamic definitions and updated clinical classification of pulmonary hypertension[J]. Eur Respir J, 2019, 53(1):1801913. doi: 10.1183/13993003.01913-2018. doi: 10.1183/13993003.01913-2018
[10]	Galiè N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension[J]. Rev Esp Cardiol(Engl Ed), 2016, 69(2):177. doi: 10.1016/j.rec.2016.01.002. doi: 10.1016/j.rec.2016.01.002
[11]	Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy[J]. Eur Heart J, 2018, 39(34):3165-3241. doi: 10.1093/eurheartj/ehy340. doi: 10.1093/eurheartj/ehy340
[12]	Lima FV, Yang J, Xu J, et al. National Trends and In-Hospital Outcomes in Pregnant Women With Heart Disease in the United States[J]. Am J Cardiol, 2017, 119(10):1694-1700. doi: 10.1016/j.amjcard.2017.02.003. doi: 10.1016/j.amjcard.2017.02.003
[13]	Thomas CA, Anderson RJ, Condon DF, et al. Diagnosis and Management of Pulmonary Hypertension in the Modern Era: Insights from the 6th World Symposium[J]. Pulm Ther, 2020, 6(1):9-22. doi: 10.1007/s41030-019-00105-5. doi: 10.1007/s41030-019-00105-5
[14]	Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography[J]. J Am Soc Echocardiogr, 2010, 23(7):685-713;quiz 786-788. doi: 10.1016/j.echo.2010.05.010. doi: 10.1016/j.echo.2010.05.010
[15]	Cordina RL, Playford D, Lang I, et al. State-of-the-Art Review: Echocardiography in Pulmonary Hypertension[J]. Heart Lung Circ, 2019, 28(9):1351-1364. doi: 10.1016/j.hlc.2019.03.003. doi: 10.1016/j.hlc.2019.03.003
[16]	D′Alto M, Bossone E, Opotowsky AR, et al. Strengths and weaknesses of echocardiography for the diagnosis of pulmonary hypertension[J]. Int J Cardiol, 2018, 263:177-183. doi: 10.1016/j.ijcard.2018.04.024. doi: 10.1016/j.ijcard.2018.04.024
[17]	陈菲菲, 赵谊昶, 郭然, 等. 多普勒超声心动图评估肺动脉压力的临床价值[J]. 心肺血管病杂志, 2019, 38(4):423-428. doi: 10.3969/j.issn.1007-5062.2019.04.024. doi: 10.3969/j.issn.1007-5062.2019.04.024
[18]	Sawada N, Kawata T, Daimon M, et al. Detection of Pulmonary Hypertension with Systolic Pressure Estimated by Doppler Echocardiography[J]. Int Heart J, 2019, 60(4):836-844. doi: 10.1536/ihj.18-453. doi: 10.1536/ihj.18-453 pmid: 31257329
[19]	Diamanti E, Baud D, Aubert JD, et al. Pulmonary hypertension and pregnancy[J]. Rev Med Suisse, 2017, 13(583):1974-1979. pmid: 29143500
[20]	Khan MS, Memon MM, Amin E, et al. Use of Balloon Atrial Septostomy in Patients With Advanced Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis[J]. Chest, 2019, 156(1):53-63. doi: 10.1016/j.chest.2019.03.003. doi: 10.1016/j.chest.2019.03.003
[21]	Martin SR, Edwards A. Pulmonary Hypertension and Pregnancy[J]. Obstet Gynecol, 2019, 134(5):974-987. doi: 10.1097/AOG.000000 doi: 10.1097/AOG.000000
	0000003549.
[22]	Wang J, Lu J. Anesthesia for Pregnant Women with Pulmonary Hypertension[J]. J Cardiothorac Vasc Anesth, 2021, 35(7):2201-2211. doi: 10.1053/j.jvca.2020.06.062. doi: 10.1053/j.jvca.2020.06.062
[23]	中国心胸血管麻醉学会非心脏手术麻醉分会. 妊娠合并心脏病围麻醉期中国专家临床管理共识[J]. 临床麻醉学杂志, 2019, 35(7):703-708. doi: 10.12089/jca.2019.07.018. doi: 10.12089/jca.2019.07.018
[24]	缪慧娴, 冯蜀欢, 汪川, 等. 上海市产科心脏病监护中心26年妊娠合并心血管疾病死亡病例分析[J]. 中华妇产科杂志, 2019, 54(12):826-832. doi: 10.3760/cma.j.issn.0529?567x.2019.12.006. doi: 10.3760/cma.j.issn.0529?567x.2019.12.006
[25]	Franco V, Ryan JJ, McLaughlin VV. Pulmonary Hypertension in Women[J]. Heart Fail Clin, 2019, 15(1):137-145. doi: 10.1016/j.hfc.2018.08.013. doi: 10.1016/j.hfc.2018.08.013

三尖瓣反流速度	是否有PH超声表现	提示PH可能性
≤2.8 m/s或测不出	否	低级
≤2.8 m/s或测不出	是	中级
2.9~3.4 m/s	否	中级
2.9~3.4 m/s	是	高级
>3.4 m/s	不需要	高级

三尖瓣反流速度	是否有PH超声表现	提示PH可能性
≤2.8 m/s或测不出	否	低级
≤2.8 m/s或测不出	是	中级
2.9~3.4 m/s	否	中级
2.9~3.4 m/s	是	高级
>3.4 m/s	不需要	高级

A：心室	B：肺动脉	C：下腔静脉及右心房
右心室/左心室内径比>1.0	多普勒右心室流出加速时间<105 ms和（或）收缩中期喀喇音	下腔静脉直径>21 mm,吸气时塌陷（深吸气时塌陷率<50%或平静吸气时塌陷率<20%）
室间隔展平[收缩期和（或）舒张期左心室偏心指数>1.1]	舒张早期肺动脉反流速度>2.2 m/s 肺动脉直径>25 mm	右房面积（收缩末期>18 cm²）

A：心室	B：肺动脉	C：下腔静脉及右心房
右心室/左心室内径比>1.0	多普勒右心室流出加速时间<105 ms和（或）收缩中期喀喇音	下腔静脉直径>21 mm,吸气时塌陷（深吸气时塌陷率<50%或平静吸气时塌陷率<20%）
室间隔展平[收缩期和（或）舒张期左心室偏心指数>1.1]	舒张早期肺动脉反流速度>2.2 m/s 肺动脉直径>25 mm	右房面积（收缩末期>18 cm²）