Pregnant women with pulmonary hypertension (PHT) have better postpartum outcomes with vaginal delivery, a new study suggests.
There is a high risk for mortality during pregnancy among women with PHT, and the incidence of most cardiovascular disease is increasing among women of childbearing age, according to researchers from Columbia University, in New York City. They conducted a retrospective cohort study to examine whether there are differences in the management and outcomes of patients with PHT, which affects the arteries in the lungs and the right side of the heart, based on the etiology and classification of PHT.
“Pulmonary hypertension is not a good disease to get, and it’s particularly worrisome in pregnancy,” said Richard M. Smiley, MD, PhD, study author and chief of obstetric anesthesiology at NewYork-Presbyterian/Columbia University Medical Center, in New York City.
The researchers analyzed electronic medical record data for all pregnancies with PHT at Columbia University Medical Center from 1997 to 2013. They identified 20 cases (eight vaginal deliveries, nine cesarean deliveries and three terminated pregnancies). The cases were then divided based on categories from the World Health Organization: congenital heart disease or Eisenmenger syndrome (n=6), rheumatic or valvular disease (n=6), and other (n=8; women who got the disease due to medication, thromboembolic disease, acquired nonrheumatic cardiomyopathy, systemic illness or unknown reasons).
The one-year mortality rate in the cohort was 25% compared with 20% reported in the medical literature. Three women who had a cesarean delivery died within 90 days of delivery and one patient died within 30 days after a terminated pregnancy. There were no deaths in the vaginal delivery group in the first year—one patient from this group died more than two years after delivery. The researchers also found that the congenital heart disease group used more advanced therapies for PHT such as extracorporeal membrane oxygenation.
“If you can get the women to deliver vaginally, and that does take some effort … those women do better. Most of the deaths were in women who had cesarean sections,” Dr. Smiley said. “It does appear that the postoperative period after a cesarean is significantly more risky than the postpartum period after vaginal delivery.”
There was a maternal/obstetric or fetal indication for each cesarean delivery. Neuraxial anesthesia was given to all the women in this group except for one patient who received general anesthesia for urgent cesarean delivery due to acute respiratory failure. The researchers wrote that emergency cesarean deliveries have comparable outcomes to planned cesarean deliveries, and that clinicians may no longer need to plan elective cesareans deliveries to avoid “hypothetical risks” of emergency cesarean deliveries.
The findings suggest that vaginal delivery is the preferred method for patients with cardiac disease, and the use of neuraxial analgesia with early initiation of advanced therapies such as extracorporeal membrane oxygenation, according to the researchers.
“This confirms statements in the cardiology and anesthesia literature over the last 15 or 20 years that suggests a vaginal delivery—if you can get it—is a better way to go,” Dr. Smiley said. The findings were presented at the 2015 annual meeting of the American Society of Anesthesiologists (poster A1140).