Complementary and Alternative Medicines in the Management of Heart Failure: A Scientific Statement From the American Heart Association | Circulation
Managing Pulmonary Hypertension In Pregnancy
Pulmonary arterial hypertension (PAH) can be a challenging complication to manage during pregnancy; women with PAH who are pregnant are considered a high-risk population, and they face higher rates of maternal and fetal complications.
Close monitoring and individualizing treatment plans should be top priorities for the multidisciplinary teams caring for women who are pregnant or are considering pregnancy and exhibiting signs of pulmonary hypertension, according to new research published in International Journal of Cardiology Congenital Heart Disease.1
This patient population is known to have higher risks of maternal morbidity and mortality, in addition to poor fetal outcomes, and newer data indicate that individual prognosis may be dependent on underlying etiology, such as hemodynamic changes—or alterations in blood flow such as from a cardiovascular condition.2
For this analysis, the investigators used these disease classifications of pulmonary hypertension:
Pulmonary hypertension typically is diagnosed when someone exhibits a mean pulmonary arterial pressure (mPAP) above 20 mm Hg at rest, but global guidance on risk stratification does not include much information on pregnancy-related outcomes. Also, women with pulmonary arterial hypertension (PAH) are classified as World Health Organization class IV, a group that has the highest risk of complications and an estimated maternal cardiac event rate of 40% to 100%.
In pregnant women, in particular, who have PAH, prominent cardiac complications include cardiac arrest, pulmonary hypertensive crisis, intrauterine growth restriction, and miscarriage. Those with severe or idiopathic PAH are at the highest risk during pregnancy, according to data from the Registry of Pregnancy And Cardiac disease.
Women with pulmonary arterial hypertension who are pregnant or considering pregnancy are considered a high-risk population, and they face increased rates of maternal and fetal complications.Image Credit: ©Mediteraneo-stock.Adobe.Com
Priorities Prior to PregnancyAmong women with heart/cardiovascular disease who have PAH, the study authors recommend having pregnancy—even fertility—discussions soon after a diagnosis, so that safer contraception can be considered, such as that which contains progesterone instead of estrogen. Orally administered estrogen has been implicated in influencing the risk of high blood pressure.3 They also recommend counseling on 2 fronts: to address maternal and fetal risks, such as adjusting any current medications to avoid upping teratogenic-related complications, and to discuss genetic counseling for patients who have hereditary disease.
Priorities During PregnancyThe authors recommend a full clinical workup with the patient's multidisciplinary team, and this should encompass a comprehensive risk assessment, discussions on termination for patients facing an especially high risk, and recommendations for future contraception. Careful monitoring for potential anemia, infection, and arrhythmia is also necessary, and the patient's team should schedule regular evaluations of oxygen saturation and B-type natriuretic peptide, in addition to echocardiographies. Again, teratogenic risk from PAH medications needs to be investigated.
Priorities After PregnancyThe delivery method should be individualized by patient risk. Cesarean section is safer for women who have severe PAH, and vaginal delivery is appropriate for women who have mild PAH. Delivery in a tertiary care facility is advised in either case. Pain relief is a prominent concern, and for this, fluids should be continuously monitored. When spinal block becomes necessary, hemodynamic changes require constant monitoring. After delivery, the study authors noted again the importance of observing fluid levels, intervening with anticoagulation as needed, and follow-up.
"The outcome of pregnancy for some forms of PH is good while in others, including severe PAH, idiopathic PAH, [and] other forms of PAH, the outcomes are poor," the authors wrote. "Women considering pregnancy need to be counselled regarding the risks as although these have decreased significantly in the last 2 decades with better monitoring and targeted PAH therapy, pregnancy is still associated with a mortality rate of around 15% to 25% in some forms of PH."
References
1. Wander G, Montanaro C, Dixit P, Dob D, Johnson MR, Patel RR. Pregnancy and pulmonary artery hypertension: management challenges. Int J Cardiol Congenit Heart Dis. 2025:19:100566. Doi:10.1016/j.Ijcchd.2025.100566
2. Hemodynamics. Cleveland Clinic. Accessed March 18, 2025. Https://my.Clevelandclinic.Org/health/body/24013-hemodynamics
3. Women taking oral estrogen hormones may have increased risk of high blood pressure. News release. American Heart Association; June 5, 2023. Accessed March 18, 2025. Https://newsroom.Heart.Org/news/women-taking-oral-estrogen-hormones-may-have-increased-risk-of-high-blood-pressure
Pregnancy Should Not Be Ruled Out For All Women With Pulmonary Hypertension
February 09, 2023
2 min read
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A patient in her early 30s with a history of severe pulmonary hypertension came into my office and expressed that she would like to start a family.
For women with pulmonary hypertension (PH), blood flow from the heart to the lungs is under dangerously high resistance, leading to right heart failure, making pregnancy very risky. In fact, it is often life-threatening, with maternal-fetal mortality rates reported between 30% and 50%.
The combination of PH and pregnancy presents unique medical challenges, owing to the additional stress that pregnancy and delivery place on the heart.
Given those challenges, women with PH are often advised to avoid pregnancy. However, not every case of PH is the same, and pregnancy shouldn't be out of the question for all women with PH. When I first saw this patient years earlier, she had undiagnosed, untreated PH so severe that she would become short of breath doing routine household chores. She also had an atrial septal defect (ASD), which is a hole in the wall (septum) that divides the upper chambers of the heart. A previous surgery to address the ASD made the defect smaller but did not close it.
I diagnosed her PH and began medical treatment. She improved significantly, but still had symptoms with moderate activity. Once her PH symptoms improved, we turned our attention toward determining whether we could close the ASD for good. Typically, an ASD is left alone or only partially closed when a patient has significant PH. But my patient had responded so well to PH therapy, we had the needed combination of physiologic factors to safely proceed with surgery to close the ASD.
It was life-changing for her. She started living a more active life and even contemplated starting a family. Now that her PH was under control and the ASD was closed, would it be safe for her to carry a pregnancy?
We conducted two additional tests to help make this determination: an echocardiogram, which showed the right heart size and function had improved to near-normal levels, and a right heart catheterization to reassess the resistance in the pulmonary arteries. During the catheterization, we administered an inhaled PH medication that showed the resistance in the pulmonary arteries dropped to normal levels. We thus had the safety margin we needed to give the green light for pregnancy.
This patient was followed closely by our multidisciplinary team, including experts in PH, maternal fetal medicine, obstetric anesthesiology and cardiology.
As a group, we've developed an approach to the management of pregnant patients with PH that focuses on optimizing and monitoring right heart function throughout pregnancy and the postpartum period.
We regularly monitored the right side of the patient's heart and used serial imaging to adjust her medications as needed to achieve a safe pregnancy.
The patient did very well and gave birth to a healthy baby boy. A few years later she carried a second pregnancy, another boy. Both boys and our patient are doing great.
In recently published research, we showed that maternal-fetal mortality in select women with PH who become pregnant can be reduced to zero through a patient-tailored management approach like ours.
It's our hope that similar multidisciplinary efforts will be undertaken at other institutions so that outcomes can be improved for pregnant women with PH.
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Treating Pulmonary Arterial Hypertension
Pulmonary arterial hypertension (PAH) is one of five types of pulmonary hypertension. It happens when the blood vessels in your lungs narrow and scar so much that it's hard for blood to move through them. This can trigger high blood pressure in the lungs.
PAH can be hard to diagnose. That's because the symptoms – like shortness of breath – are common to several other medical conditions. There's no cure. But there are FDA-approved treatments. Here's what you need to know.
How Is Pulmonary Arterial Hypertension Treated?What caused your PAH, the symptoms, and how advanced your condition is all impact what treatment might work best for you. It may take time to figure out, but your doctor is there to help.
Options include:
Prescription drugs called vasodilators specifically treat PAH. These may be taken by mouth or given through an IVor subcutaneously, meaning under the skin. Some you inhale, or breathe in, from a nebulizer.
In some cases, you may need more than one type of drug to get your condition under control. You might also need other therapies like extra oxygen along with diet and lifestyle changes to help you feel better.
Intravenous (IV) treatments
Epoprostenol is a vasodilator that relaxes your blood vessels so it's easier for blood to move through them. There are two brands: Flolan and Veletri.
Flolan. In 1995, this was the first drug the FDA approved to treat PAH. It's given as a continuous injection through a vein for short-term use. A doctor can also surgically place a special catheter for long-term use. One study found that it helped make exercise easier and boosted survival rates.
Flolan has to be mixed every day. You must also:
Your catheter also needs to be checked often for signs of possible infection.
Side effects may include:
Selexipag IV (Uptravi). It can help slow the progression of PAH and lower your risk of being hospitalized. It's used only in patients who temporarily can't take oral medication.
Treprostinil (Remodulin). This is another IV formula of the same class of drugs as Flolan and Veletri. It's also stable at room temperature and doesn't have to be mixed daily. It can also be given under the skin.
Veletri. It's a newer version of epoprostenol approved by the FDA in 2010. It doesn't have to be mixed daily, and you can keep it at room temperature. Your doctor may suggest Veletri if you have severe PAH and other treatments haven't worked.
Side effects for Veletri and Remodulin are similar to those of Flolan. Catheters used for IVs should be checked regularly to avoid infections.
Nebulizer treatments
Iloprost (Ventavis). You breathe it in through a nebulizer about six to nine times every day. If you have asthma or other conditions that can make it hard to breathe, this may worsen those symptoms.
Treprostinil (Tyvaso). Your doctor may recommend this drug if you have moderate to severe PAH symptoms. You'll likely take it about four times a day. Research suggests it can help you walk longer distances.
Side effects of iloprost and treprostinil are similar to those of IV-based PAH drugs. But you may have less flushing or diarrhea with iloprost. Treprostinil may cause a sore throat and cough when you first start to use it.
Oral treatments
Ambrisentan (Letairis). This is a once-a-day medication, but unlike bosentan, it doesn't affect your liver.
Bosentan (Tracleer). This medication is taken two times a day. The drug could affect your liver function and hemoglobin levels. It's important to get your blood count and liver function tested regularly when you're taking bosentan.
Neither bosentan nor ambrisentan is recommended for people who are pregnant. Experts recommend two separate birth control options. Monthly pregnancy tests are required to continue using these drugs.
Sildenafil (Revatio). Small studies suggest this drug can improve blood flow in your lungs. The recommended dose is a 20-milligram pill taken three times a day, but it can be increased if you have a more severe form of PAH.
Side effects of sildenafil include:
Tadalafil (Adcirca). This is a once-a-day pill prescribed if you have moderate to severe PAH.
Treprostinil (Orenitram) is the oral formulation of Remodulin and can substitute for the IV medications after you have stabilized.
Other Ways to Treat Pulmonary Arterial HypertensionThese include:
Calcium channel blockers. This class of drugs, in select patients, can help lower the blood pressure in your lungs.
Blood thinners. Your risk of forming blood clots is higher if you have PAH. Blood thinners, like warfarin (Coumadin), are given to most people with PAH to cut down on clots and improve overall survival. But warfarin interacts with several foods and drugs. Your doctor can tell you what to avoid.
Diuretic. Sometimes called water pills, diuretics can help your body get rid of extra salt and water. This happens to most people with PAH. Your doctor will usually recommend one pill a day. But if you have a severe form of PAH, they may up the dosage.
Digoxin. This is an older medication sometimes prescribed to people with severe PAH. It's designed to help your heart pump blood better.
Oxygen therapy
When you have moderate to severe PAH, it can make it hard to breathe properly and affect your day-to-day life. The low levels of oxygen can make the blood vessels constrict further, which can make your PAH worse.
Getting a little extra oxygen can help you not only breathe better but also be able to get through daily tasks and routines. It can also boost your mood and sleep. While some may need extra oxygen every now and then, others may need it continuously.
Oxygen therapy comes in three types:
Before you try oxygen therapy, ask your doctor how much you need and how often you may need it. They can also guide you toward the type that works best for your lifestyle.
Surgery
If you have severe PAH and medications aren't working, your doctor may recommend a lung transplant. Lung transplant surgery is challenging and can come with serious complications. These include:
Your health care team can help you decide if it's right for you.
Things You Can Do to Manage Pulmonary Arterial HypertensionThere are some lifestyle changes you can try to help ease your symptoms.
You can:
Try to exercise and stay as active as you can. But don't lift heavy weight or do intense workouts. Talk to your doctor first if you're not sure what's safe.
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