What is the clinical evidence from this study?

Study design: Observational. Population: Pulmonary hypertension in pregnancy (n=118). Intervention: Severe pulmonary hypertension (SPAP ≥ 70 mmHg) vs. Mild to moderate pulmonary hypertension (SPAP 40-70 mmHg). Primary outcome: Maternal mortality (p=< 0.001).

What does this research mean for the field?

Severe pulmonary hypertension and elevated NT-proBNP levels are strongly associated with increased maternal mortality, whereas mild to moderate pulmonary hypertension with preserved right heart function can result in favorable pregnancy outcomes. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

April 16, 2025Open Access

Clinical outcomes of pregnancy in patients with pulmonary hypertension: A single center observational study

Q: What are the key findings of this study?

Severe pulmonary hypertension (SPAP ≥ 70 mmHg) was associated with a significantly higher maternal mortality rate of 27.8% compared to 0% in mild and 4.6% in moderate pulmonary hypertension.

Q: What does this research mean for the field?

Severe pulmonary hypertension and elevated NT-proBNP levels are strongly associated with increased maternal mortality, whereas mild to moderate pulmonary hypertension with preserved right heart function can result in favorable pregnancy outcomes. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

Key Result

Severe pulmonary hypertension (SPAP ≥ 70 mmHg) was associated with a significantly higher maternal mortality rate of 27.8% compared to 0% in mild and 4.6% in moderate pulmonary hypertension.

Study Design

Type

Observational (n=118)

Multicenter

Structured PICO

Population

118 pregnant women with pulmonary hypertension (systolic pulmonary arterial pressure > 40 mmHg) followed retrospectively to assess maternal and fetal outcomes up to 1 year postpartum.

Outcome

Maternal mortality and fetal outcomes (offspring mortality, abortion rates)hard clinical

Pregnancy in women with severe pulmonary hypertension and elevated NT-proBNP carries a high risk of maternal mortality, whereas those with mild to moderate PH may have favorable outcomes with multidisciplinary management.

Main Result

Absolute Event Rate: 27.8% vs 1%

p-value: p=< 0.001

Limitations

Most cases of PH were diagnosed by echocardiography rather than right heart catheterization.
Postpartum follow-up was only 6 months to 1 year, potentially underestimating late mortality and long-term complications.
Heart function assessment relied on NYHA class rather than objective measures like 6-minute walking distance.
Single-center retrospective design with a small sample size limits generalizability.

Abstract

BACKGROUND: Pulmonary hypertension (PH) is associated with right ventricular failure in pregnant women and increases maternal morbidity and mortality during parturition and postpartum periods. According to current guidelines, pregnancy is contraindicated in women with PH. However, in recent decades, favorable outcomes have been observed in cases where the disease is well controlled. However, several questions remain unanswered regarding this issue. OBJECTIVE: This study aimed to investigate the medium-term outcomes of pregnancy in women with PH and to identify predictors for poor pregnancy outcomes in this population. METHODS: A retrospective review of the medical records at our hospital was conducted to identify pregnant women with PH between July 2017 and December 2021. We collected data on maternal age, gravidity, parity, PH category, New York Heart Association Function class, N-terminal-pro Brain natriuretic peptide (NT-ProBNP) levels, mode of delivery, type of anesthesia, use of advanced therapy, and fetal outcomes. Based on the severity of PH, patients were categorized into three groups: group A systolic pulmonary arterial pressure (SPAP) 40-50 mmHg, group B 50-70 mmHg, and group C SPAP ≥ 70 mmHg. RESULTS: The study included 78 individuals in group A, 22 in group B, and 18 in group C. Of the 118 individuals, 80 were classified as having pulmonary arterial hypertension (PAH), including congenital heart disease-associated PAH, idiopathic PAH, and other PAH subtypes, while 38 were classified as having PH associated with left heart disease (PH-LHD). The mortality rate was higher in the PAH category (6.3%, 5/80) than in the PH-LHD category (2.6%, 1/38). The NT-proBNP value was highest in group C (1723.5 ± 738.0pg/ml), compared with group B (196.6 ± 79.6 pg/ml) and group A (128.7 ± 54.3 pg/ml). Overall maternal mortality was 5.1% (6/118), with significantly higher mortality rates observed in group C (27.8%, 5/18) compared to group B (4.6%, 1/22), and no deaths in group A. Compared to groups A and B, gestational duration was shorter (median 26 weeks), and abortion rates were higher (38.9%, 7/18) in group C. Cesarean section rates were high across all three groups. The overall maternal mortality rate was 5.1% (6/118). Of them, five individuals were in group C, only one woman had moderate PH with perinatal cardiomyopathy and a lower LVEF of 15%. There was no maternal mortality in Group A with mild PH. All maternal deaths occurred postpartum. Excluding 17 cases of miscarriage (gestation less than 28 weeks), the overall offspring mortality rate was 4.0% (4/101), with one fetal mortality in group B, three fetal deaths in group C, and no fetal mortality observed in group A. CONCLUSION: Severe PH and high NT-proBNP levels are strongly correlated with increased maternal mortality rates in pregnant women. Conception should be contraindicated in cases of severe PAH with elevated NT-proBNP levels. In situations where unplanned pregnancy occurs in severe PAH patients with decompensated heart function, early pregnancy termination and multidisciplinary management are crucial to ensure maternal safety. However, pregnancy should be considered individually in women with moderate and mild PH and preserved right heart function.

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