Clinical Characteristics Of Perinatal Pregnancy With Pulmonary Arterial Hypertension

Objective:By analyzing the perinatal clinical characteristics of the 52 pregnant patients with pulmonary arterial hypertension(PAH),who was admitted to the obstetrics department of the First Affiliated Hospital of Kunming Medical University,to discuss the pathogenesis characteristics,the management and monitoring during pregnancy,the choice of termination time and method,and the mother and child prognosis of the pregnant patients,so as to provide reference for clinical work.Methods:Clinical data of 52 pregnant patients with pulmonary hypertension who were delivered in the First Affiliated Hospital of Kunming Medical University from January 1,2015 to February 1,2019 were collected,and the clinical data of these patients were retrospectively analyzed,In this study the data were divided into three groups on the basis of PAH level:mild PAH group have 36 cases,moderate PAH have 8 cases,severe PAH group have 8 cases.the Clinical data as follows were compared and analyzed between the three group:(1)General information:age,body mass idex(BMI),gestational age,number of pregnancies,number of births,length of hospital stay,cardiac function,unplanned pregnancy,and routine prenatal examinations;(2)Clinical manifestations:symptoms(palpitation,chest tightness,dyspnea,cough and sputum)and signs(cyanosis,finger clubbing,edema);(3)Past medical history:whether previous history of cardiopulmonary related diseases,and whether cardiopulmonary related surgery was performed before pregnancy;(4)Termination pregnancy:induced labor,vaginal delivery,cesarean section;(5)Anesthesia methods:general anesthesia and spinal anesthesia(lumbar epidural combined anesthesia and epidural anesthesia);(6)Outcomes:maternal deaths,maternal transferred to ICU ward,pulmonary hypertension crisis(PHC),heart failure,hypoxemia,acute respiratory distress syndrome(ARDS),pulmonary edema,right heart morphology change,loss of fetal,newborn transferred to pediatric ward,preterm birth,low birth weight,fetal distress.These information was analyzed to explore the pathogenesis characteristics of the patients with pulmonary hypertension in pregnancy and the effects on pregnancy outcome and delivery mode of different PAH degrees.Results:(1)Comparison of general conditions:there was no statistical difference among the three groups(the mild PAH group,moderate PAH group and severe PAH group)in the proportion of multipara women and the average total hospital stay(P>0.05);There was no significant difference in the proportion of parturients who had received cardiac related surgery before pregnancy among the three groups(P>0.05).The mean BMI of the mild PAH group was lower than that of the severe PAH group(P<0.05).The mean age of the severe PAH group was lower than that of the mild PAH group or the moderate PAH group(P<0.05).The mean weeks of gestation of the mild PAH group were greater than those of the moderate PAH group or the severe PAH group(P>0.05).There were significant differences among the three groups in the incidence of irregular prenatal examination,unintentional pregnancy,grade ???cardiac function,and eysencemag syndrome,with higher incidence in the severe PAH group than in the moderate or mild PAH group,and higher incidence in the moderate PAH group than in the mild PAH group(P<0.05);(2)There was a significant positive correlation between pulmonary artery pressure level and cardiac function level(rs=0.594,P?0.001);(3)Clinical manifestations:the most common admission symptoms were palpitation(30.8%),dyspnea(28.8%),chest tightness(23.1%),cough and sputum(15.4%),and the incidence of dyspnea was higher in sever PAH group than that of mild PAH group(P<0.05).The most common signs were cyanosis(13.5%),edema(11.5%),and finger clubbing(5.8%),the incidence of cyanosis and finger that indicate pregnant women's anaerobic condition in the severe group was higher than that in the mild PAH group(P<0.05),and there was no significant difference in edema signs among the three groups(P>0.05);(4)Mode of delivery:among PAH pregnant women less-than-28-weeks of gestation,1 case of inevitable abortion,1 case of induced labor for intrauterine death,3 cases terminate pregnancy due to decreased heart function during mid-pregnancy;Among PAH pregnant women over-28-weeks of gestation,,All severe groups were performed cesarean section to terminate pregnancy(100%),and one patient in the moderate group chose vaginal delivery,fifteen patients in the mild group chose vaginal delivery.Although the cesarean section rate in the three groups showed the following trends:severe PAH group(100%)>PAH moderate group(83.3%)>PAH mild group(57.1%),the statistical test was not statistically significant(P>0.05);The worse the cardiac function was,the higher the cesarean section rate was,and the difference was statistically significant(P<0.05);(5)Caesarean section anesthesia:There was a statistically significant difference in the anesthesia mode among the three groups of mild,moderate and severe cesarean section(P<0.05),the proportion of intraspinal anesthesia in the mild PAH group(85.0%).>moderate PAH group(80.0%)>severe PAH group(33.3%),the rate of general anesthesia in the severe PAH group(66.7%)was higher than that in intraspinal anesthesia(33.3%);The incidence of PHC in prengent with PAH performed General anesthesia intubation was higher than that of PAH women who underwent spinal anesthesia(0.0%),and the difference was statistically significant(P<0.05),The incidence of death,pulmonary infection,heart failure,and ARDS in General anesthesia intubation was higher than that underwent spinal anesthesia,but the difference was not statistically significant(P>0.05);(6)Outcomes:maternal outcomes:1 case of maternal death in the middle and severe groups,the incidence of PAH maternal transfer to ICU,PHC,heart failure,hypoxemia,pulmonary edema,hemodynamic instability and right heart morphological was highest in severe PAH group than moderate PAH group and mild PAH group,and the difference was statistically significant(P<0.05);There was no significant difference in the preterm birth rate among the three groups(P>0.05).Conclusion(s):(1)The risk of perinatal death was high in pregnant patients with moderate and severe PAH,and the rate of death in the moderate and severe PAH group was 1/8;Pregnancy with pulmonary hypertension and PHC have a very high risk of death,and the perinatal death rate of PAH pregnant women with PHC is 1/2;(2)The incidence of PAH original disease from high to low is congenital heart disease(CHD),idiopathic pulmonary hypertension(IPAH),rheumatic heart disease(RHD);There was a significant correlation between pulmonary artery pressure level and cardiac function level;(3)The higher the PAH was,the higher the incidence of irregular prenatal examination,unplanned pregnancy,poor cardiac function,and eisenman syndrome was;(4)The most common admission symptoms for pregnancy with PHA are palpitations,dyspnea,chest tightness and cough.The higher the PAH was,the higher the incidence of dyspnea was.;(5)Cyanosis,clubbing fingers and edema are the most common signs of pregnancy complicated with PHA.The higher the PAH was,the higher the incidence of cyanosis and clubbing of fingers was.Edema has no direction in the severity of PAH;(6)In the selection of delivery mode,except obstetric operation indications,patients with higher pulmonary artery pressure have higher cesarean section rate.Cesarean section was safer in patients with moderate or severe pulmonary artery pressure or cardiac function of II or above.the success rate of vaginal delivery in patients with mild PAH was 42.9%;(7)The higher the PAH was,the higher the incidence of general anesthesia rate in cesarean section was.general anesthesia is a risk factor for PHC in pregnant women with PHA,general anesthesia may be a risk factor for adverse outcomes(death,pulmonary infection,heart failure,ARDS)in pregnant with PHA.Epidural anesthesia and combined spinal may be the safe anesthetic method for parturients with PAH;(8)High dose use of oxytocin may be a risk factor for PHC and death in parturients with PAH,and high dose use of oxytocin should avoid in Parturients with PHA;(9)Maternal and fetal outcomes:The higher the PAH was,the higher the incidence of maternal deaths,admission to ICU,complications of cardiopulmonary diseases,irreversible changes in cardiac structure,fetal loss(including iatrogenic termination),neonatal conversion to pediatrics ward,dysplasia and fetal distress was.