Risk Stratification in Pulmonary Hypertension and Pregnancy

Transcription

1 Risk Stratification in Pulmonary Hypertension and Pregnancy Dr Robin Condliffe Pulmonary Vascular Disease Unit Royal Hallamshire Hospital Sheffield United Kingdom

2 Conflicts of Interest Honorararia Actelion, GSK Research funds Bayer, Actelion, Pfizer Conference expenses GSK, Actelion, Pfizer, Bayer, United Therapeutics

3 ESC Pregnancy Guidelines ESC Pregnancy Guidelines. Eur Heart J 2011; 32:

4 Risk Stratification in PH Kiely DG, Condliffe R et al. BJOG 2010; 117:565-74

5 CONTRACEPTIVE ADVICE Kiely DG, Condliffe R et al. BJOG 2010; 117:565-74

6 Contraception and pulmonary hypertension Percent of women experiencing an unintended pregnancy within one year of use: Adapted from WHO Typical use (%) Perfect use (%) Periodic abstinence Condom 15 2 POP * Depoprovera Implanon * Cerazette * 0.05 Mirena IUS Female sterilisation Thorne S et al. Heart 2006; 92:

7 Women with PAH should be advised of the high risk of pregnancy with clear contraceptive advice

8 Case 1: Heritable PAH and 29 yrs pregnancy 2 sisters died of PAH one following childbirth Developed PAH in previous pregnancy CS at 35/40 with subsequent dramatic symptomatic improvement Despite counselling regarding the risks patient successfully became pregnant again

9 Despite the high risks of pregnancy patients with PH may still express a wish to conceive

10 DIAGNOSTIC INVESTIGATIONS DEPENDENT ON DIAGNOSTIC & PROGNOSTIC UNCERTAINTY Kiely DG, Condliffe R et al. BJOG 2010; 117:565-74

11 Case 2: Unexplained PH presenting in pregnancy 38 years old 24 weeks pregnant SOB 2 years, worse over 6/52 WHO Class IV OE: P 110, SaO2 94%, BP 120/70 PSM, RV Heave, ankle oedema DVT right leg diagnosed 5 months previously Previous i.v. drug user i.v. amphetamines Para x LSCS Last pregnancy 3 yrs ago post partum haemorrhage Chaotic social circumstances

12 Basic investigations Echo demonstrates SPAP of 110 mmhg with right sided dilatation, paradoxical septal motion, good LV and poor RV function with no evidence of a shunt or valvular heart disease

13 Possible Diagnosis 1. Idiopathic PAH 2. APAH with HIV 3. APAH with drugs 4. CTEPH

14 CTPA

15 Diagnosis 1. Idiopathic PAH 2. APAH with HIV 3. APAH with drugs 4. CTEPH

16 In pregnancy the need for further investigation is determined by the need for diagnostic certainty and prognostic information

17 DECISION MAKING REGARDING TERMINATION OR PROCEEDING (PROGNOSTICATION) Kiely DG, Condliffe R et al. BJOG 2010; 117:565-74

18 PH Group Hurdman J, Condliffe R et al. Eur Resp J 2012; 106:

19 PAH Prognostic Factors Condliffe R et alajrccm 2009; 179: Miyamoto S et al. AJRCCM 2000; 161: Fijalowski A et al. Chest 2006; 129: Forfia PR et al. AJRCCM 2006; 90:

20 Haemodynamics Humbert M, Sitbon O et al. Circulation 2010; Condliffe R, Kiely DG et al. AJRCCM 2009; 179:

21 ESC/ERS Guidelines. Eur Heart J 2009; 30:

22 Benza R, Gomberg-Maitland M et al. Chest 2012; 141:

23 Cardiac output (ml/min) Reasons for deterioration of patients with PH in pregnancy and post partum Cardiac output Peripheral resistance Weeks of pregnancy Robson SC, et al. Eur Heart J 1988; 9: Peripheral resistance ((dyn s)/cm 5 ) Unable to cope with increased CV demands Pulmonary vasoconstriction Volume loading impairing right ventricular function Thrombosis

24 Pregnancy in PH: Large Series & Systematic Reviews Time Period No Pregnancies PH Type Maternal Mortality Eisenmenger 52% IPAH Eisenmenger oph IPAH Eisenmenger oph 30% } 36% } Overall 56% } 38% 17% } 28% } Overall 33% } 25% 1 Gleicher N et al. Obst Gyn Surv 1979; 34: Weiss BM et al. JACC 1998; 31: Bedard E et al. Eur Heart J 2009; 30:

25 Maternal mortality (%) ipah CHD-PAH opah 17 p= Maternal mortality significantly lower in last decade p=0.047 High mortality 1 week postpartum Higher proportion of premature delivery and lower proportion of vaginal delivery in General vs regional anaesthesia higher mortality OR 4.37, p=0.02 Primigravidae higher mortality OR 3.70, p=0.03 Bédard E, et al. Eur Heart J 2009; 30:

26 Severe pulmonary hypertension during pregnancy Retrospective review 10- year period, single centre 3 cases early deterioration 12, 20, 23 weeks 5 patients stable (NYHA I/II pre-pregnancy) Maternal Mortality 36% Death in Death postpartum pregnancy CHD (6) +1/52 IPAH (4) 12/40 +3/12 CTEPH (2) +3/52 Fenfluramine (1) 23/40 HIV (1) MCTD (1) Bonin M, et al. Anaesthesiology 2005; 102:

27 Mortality of patients with pulmonary hypertension remains high even with expert care Early deterioration without intervention is associated with a poor outcome Significant early post-partum mortality

28 1 BJOG 2010; 117: BJOG 2012; 119: Eur Resp J 2012; In Press

29 Curry et al, 2012 Kiely et al, 2010 Jais, X et al, 2012 Time period Pregnancies Terminations Continued with pregnancy Miscarriages (2 deaths) Deliveries * Maternal deaths or requiring transplant PAH/LHD/RESP/ CTEPH/other /1/1/0/0 12/0/0/1/0 26/0/0/0/0 CS / NVD 9/0 9/1 15/1 LA / GA 2/7 10/0 15/3 PH Rx 5/9 9/9? 18 * 8 of 18 patients were calcium channel responders

30 Jais X, Ollson KM et al. Eur Resp J 2012; In Press

31 Pt 3: PH and pregnant with good functional class 23 yrs IPAH diagnosed age 20 mrap 1 mmhg mpap 38 mmhg PCWP 10 mmhg CO 5.9 L/min PVR 380 dyne.s.cm -5 svo 2 68 % + ve vasodilator response WHO III No clinical response to high dose diltiazem Clinically improved on bosentan WHO II Warned re teratogenicity bosentan Seen by gynaecologist re contraception

32 Presented 6/40 pregnant spap ECHO 50mmHg Normal size & function RV Counselled re termination Bosentan stopped and neb 8/40 plus LMWH Followed monthly At 22 weeks: WHO II ISWD 320m

33 Deterioration at 24 weeks Dry cough +/- minor SOB Echo unchanged Threatened labour 24+4/40 given steroids 25/40 syncope iv iloprost commenced CS + 5/7 with combined epidural/ spinal, live birth Day 1 Day 5 pre- CS Day 5 CS + 4 hr Fi O MPAP (mmhg) RA (mmhg) TPR (dyne.s.cm - 5 ) CO (l/min)

34 Good functional class and clinical stability do not guarantee uncomplicated course in pregnancy

35 Pt 4: Poor compliance 16 year old VSD closed age 13 Pretreated with sildenafil and bosentan mpap 3/12 post closure 37mmHg Came off targeted therapy aged 15 Poor attendance Referred to our unit 13/40 pregnant WHO III No significant deterioration

36 Echo RV mildly dilated Normal RV function spap 45mmHg + RAP LV normal ISWD 220m Needle-phobic Counselled re risk of mortality and offered termination Pt chose to proceed with pregnancy Commenced sildenafil 25mg tds at 13/40

37 Some improvement on sildenfil WHO II/III Nebulised iloprost added at 23/40 Pt non-compliant with neb iloprost Remained WHO II/III with stable ISWD Echo unchanged

38 Individual management plans

39 Planned CS at 34 weeks Pt refused combined spinal epidural Commenced on iv iloprost in addition to sildenafil for few days CS under GA Moderate bleeding Low dose syntocinon infusion Monitored with C-Line and LiDCO Minor increase CVP diuretics commenced Day 2 platelets fell iv iloprost increased Cardiac Arrest

40 The optimal plan from the perspective of the multi-professional team may not coincide with the wishes of the patient

41 Conclusions Pregnancy remains high risk but outlook improved Risk Stratification to confidently recommend continuation of pregnancy is difficult Milder PH (? Ca ++ responders) may have good outcome However still significant risk of deterioration Patients with PH should be advised of high risk of pregnancy with clear contraceptive advice and if needed early interruption of pregnancy