Severe PAH Sharply Increases Maternal, Fetal Mortality in Pregnant Women

November 18, 2020
Laura Joszt, MA
Laura Joszt, MA

Laura is the editorial director of The American Journal of Managed Care® (AJMC®) and all its brands, including The American Journal of Accountable Care®, Evidence-Based Oncology™, and The Center for Biosimilars®. She has been working on AJMC® since 2014 and has been with AJMC®'s parent company, MJH Life Sciences, since 2011. She has an MA in business and economic reporting from New York University.

Severe pulmonary arterial hypertension (PAH) was associated with a significantly higher rate of maternal and fetal mortality.

The mortality rate is high for pregnant women with severe pulmonary arterial hypertension (PAH), indicating a need for improved nursing care for pregnant women with PAH. A study published in Annals of Palliative Care indicated that women with severe PAH should be under extensive and intensive monitoring and attention for 2 days after delivery to reduce mortality.

PAH is a category of progressive disorders categorized by hypertension in the pulmonary artery. In pregnant women, PAH is accompanied by “sudden onset of syncope, chest pain, or dyspnea.” The most common recommendation for women with PAH during pregnancy is abortion, the authors noted.

“The mortality rate of PAH during pregnancy has been declined dramatically due to medical developments and advancements,” they explained. “However, PAH remains to be a severe issue in the postpartum period.”

The researchers analyzed 59 pregnant women with PAH admitted to the Peking Union Medical College Hospital in Beijing, China, between January 2000 and December 2018. They investigated a number of parameters: age, gestational week, New York Heart Association (NYHA) cardiac functional classification, ultrasonic cardiogram (UCG), blood test, pregnancy complications, pulmonary arterial systolic pressure, and maternal and fetal outcomes.

The women included in the analysis had PAH of at least 25 mm Hg on average, a complete medical record, and had received ultrasonic cardiogram monitoring. UCG monitoring was used to assess pulmonary arterial systolic pressure. Patients with PAH 30 to 39 mm Hg were considered to have mild PAH; 50 to 79 mm Hg, moderate; and greater than 79 mmHg, severe.

The pregnant women enrolled in the study analysis were between the ages of 18 and 41 (mean [SD], 27.7 [1.3] years) with gestational ages between 10 and 40 weeks (mean [SD], 32.5 [2.2] weeks). Eighteen women (32.2%) were placed in the mild PAH group, 17 (28.8%) into the moderate PAH group, and 24 (39%) into the severe PAH group. Based on NYHA classification, 1 patient was grade I, 27 were grade II, 24 were grade III, and 5 were grade IV.

Nearly all of the women (55 of 59, 93.2%) underwent cesarean section. The remaining women had an abortion. Ultimately, 5 mothers and their infants died of multiple organ failure and severe asphyxia. Another 10 infants died from various causes, including severe asphyxia and premature delivery.

The mortality rate for women with severe PAH was 20.8% compared with 0% for women in the mild and moderate groups. The infant mortality rate in the severe PAH group was 33.3% compared with 5.9% in the moderate PAH group and 5.3% in the mild PAH group.

There is no consensus on the optimal delivery for pregnant women with PAH, the authors noted. Vaginal delivery may reduce the risk of general anesthesia; however, vaginal delivery requires intensive care. Cesarean delivery can avoid some of the challenges of vaginal delivery (eg, uncontrolled risk of vaginal hemorrhage, hemodynamic disturbances caused by pushing down and contractions), and the results of the study suggest that cesarean delivery is much safer for women with mild and moderate PAH.

The authors suggested that using a multidisciplinary team to carry out the postoperative follow-up may be beneficial. The majority of women who died postoperatively died within 24 hours after delivery.

“These outcomes suggest that extensive and intensive monitoring and attentions should be paid to those with severe PAH within 48 [hours] after the delivery, and effective measures and interventions should be carried out to reduce the postoperative mortality rate as possible,” they wrote.

The researchers noted that the small sample size is a limitation of the study and the findings should be validated by an investigation with a larger sample size.

“We found that the severity of PAH was a major factor of maternal and fetal outcomes,” they concluded. “Strengthening the nursing care for pregnant women with PAH is of great clinical significance.”

Reference

Zhou Q, Peng P, Liu X, Liu J, Gao J, Chen W. Evaluation of maternal and fetal outcomes in pregnancy complicated with pulmonary arterial hypertension. Ann Palliat Med. Published online October 29, 2020. doi:10.21037/apm-20-551