General anesthesia is an independent predictor for worse maternal outcome in pregnant pulmonary arterial hypertension patients without cardiac shunt but not for those with shunt

Abstract

Background: Although pregnancy imposes extra risk in patients with pulmonary arterial hypertension (PAH), hemodynamic characteristics vary between PAH patients with and without cardiac shunts. However, previous studies did not take hemodynamic differences in PAH patients into consideration for pregnancy outcome analysis. We aimed to identify predictors for peripartum outcome of PAH patients without/with cardiac shunt.

Methods: We retrospectively analyzed the medical records of PAH gravidae parturiated by cesarean delivery (C-section) from 4 hospitals. Maternal death and major adverse cardiac events (MACEs) occurring during pregnancy or within 6 weeks postpartum were defined as composite end points. Risk factors for end points were analyzed separately in patients with and without cardiac shunt. The effect of general anesthesia on MACEs and maternal death was analyzed considering cardiac shunts.

Results: One hundred and eighty-one PAH gravidae were included, of whom 85 had PAH without cardiac shunt and 96 with shunt. Patients who met combined end points were 19/85 in those without shunt compared with 23/96 in those with shunt. The mortality rates were 11.8% and 9.4%, respectively. Both World Health Organization functional class (WHO-FC) III/IV and general anesthesia were predictors for gravidae without shunt, whereas only WHO-FC III/IV was a predictor for gravidae with shunt. General anesthesia increased the MACE risk (odds ratio, 9.000; 95% confidence interval, 2.628-30.820) and maternal mortality (odds ratio, 11.000; 95% confidence interval, 2.595-46.622; P = 0.039) in patients without cardiac shunt but not in those with shunt during C-section.

Conclusion: All PAH gravidae with WHO-FC III/IV are at high risk and should receive intensive care. General anesthesia should be avoided during C-section for PAH gravidae without a cardiac shunt.

Keywords

Cardiac shunt / Composite end points / Mortality / General anesthesia / Pregnancy / Pulmonary hypertension

Conflict of interest statement

The authors declare no conflict of interest.

Author contributions

Cui X was involved in study conceptualization, data curation and interpretation, and manuscript writing, revision, and final approval; Li M, Ji F, and Li G were involved in data collection and interpretation; Feng H, Qie L, and Ling M were involved in data interpretation and formal analysis; Ji Q was involved in data collection, interpretation, validation, and formal analysis; Jiang F was involved in data interpretation, data validation, formal analysis, and manuscript writing; Lu W was involved in study conceptualization, data collection, formal analysis, manuscript writing, and final approval.

Funding

This study was supported by grants from Shandong Provincial Natural Science Foundation (ZR2021MH111 for Cui X), the Science and Technology Foundation of Jinan City (201805057 for Ling M), and Doctoral Program of Shandong Provincial Natural Science Foundation (ZR2017BH047 for Lu W).

Ethical approval of studies and informed consent

This study followed the principles of the Declaration of Helsinki as revised in 2013. The ethics approval of the study was approved by the steering committee of Institutional Human Ethics Committee of Qilu Hospital (reference no. 2018-155; September 11, 2018) and was approved by the ethics committee at each participating center. Written informed consent was waived by the steering committee of Institutional Human Ethics Committee of Qilu Hospital owing to the anonymized retrospective nature of the analysis.

Acknowledgments

None.

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