Emergency cesarean section in pregnant women with severe pulmonary hypertension: the potential role of extracorporeal life support

BACKGROUND: The aim of this study was to present our institutional experience with periprocedural management of emergency cesarean section (CS) operations and maternal and fetal cardiac complications in pregnant women with pulmonary hypertension (PH).
METHODS: Thirteen patients who were diagnosed with PH during pregnancy and/or prior to pregnancy according to European Society of Cardiology (ESC) criteria, and who were referred to our hospital with a decision for emergency CS from an external center, were included in the study. For patients who underwent urgent surgery, the following data were recorded: demographic characteristics, time of diagnosis, treatments for pulmonary hypertension used before pregnancy, during pregnancy, and/or after CS, arterial blood gas values, pulmonary and systemic pressure values after induction and at the 12th postoperative hour, extracorporeal membrane oxygenation (ECMO) requirements, time to extubation, length of intensive care stay, and mortality rates.
RESULTS: Eight of the 13 patients were diagnosed with idiopathic pulmonary arterial hypertension (IPAH). The mean systolic systemic arterial pressure (BPs), systolic pulmonary arterial pressure (PAPs), and mean pulmonary arterial pressure were 130±14.2 mmHg, 93±28 mmHg, and 52±17 mmHg, respectively. Six of the 13 patients required ECMO support. The one-month mortality rate was 46%.
CONCLUSION: Pregnancy in women with PH is associated with significant maternal morbidity and mortality. If the underlying etiology is IPAH, the risk of mortality is higher than in other forms of PH. Mechanical circulatory support devices, including ECMO, may serve as a temporary bridge to lung transplantation in selected cases. Therefore, early diagnosis of IPAH, timely referral of patients to specialized centers, and planning of these operations by a multidisciplinary team consisting of cardiologists, gynecologists, and cardiac anesthesiologists are necessary.

Keywords: ECMO support, emergent cesarean section, pulmonary hypertension

Ciddi pulmoner hipertansiyonlu gebelerde acil sezaryen seksiyo ameliyatý – Olasý Extracorporeal yaþam desteði

AMAÇ: Bu çalýþmadaki amacýmýz, pulmoner hipertansiyonlu (PH) gebelerde acil sezaryen (CS) operasyonlarýnýn periprosedürel yönetimi ve maternal ve fetal kardiyak komplikasyonlar konusundaki klinik deneyimimizi sunmaktýr.
GEREÇ VE YÖNTEM: Avrupa Kardiyoloji Derneði (ESC) kriterlerine göre gebelik ve/veya gebelik öncesi PH tanýsý konulan ve dýþ merkezde acil CS kararý ile hastanemize sevk edilen 13 hasta çalýþmaya dahil edildi. Acil olarak operasyona alýnan hastalarýn demografik verileri, taný zamaný, gebelik öncesi, gebelik ve/veya CS sonrasý kullanýlan pulmoner hipertansiyon tedavileri, arteriyel kan gazlarý, indüksiyon sonrasý ve postoperatif 12. saat pulmoner basýnç ve sistemik basýnç deðerleri, ekstrakorporeal membran oksijenatör (ECMO) gereksinimleri, ekstübasyon ve yoðun bakým süresi ve mortalite oranlarý kaydedildi.
BULGULAR: 13 hastanýn sekizine idiyopatik pulmoner arteriyel hipertansiyon (IPAH) tanýsý kondu. Ortalama sistolik sistemik arter basýncý (KB), PAB ve ortalama pulmoner arter basýncý sýrasýyla 130±14.2 mmHg, 93±28 ve 52±17 olarak bulundu. 13 hastadan 6'sýnýn ECMO desteðine ihtiyacý oldu. 1 aylýk mortalite oraný %46 idi.
SONUÇ: PH'lu kadýnlarda gebelik, önemli derecede anne morbiditesi ve mortalitesi ile iliþkilidir. Altta yatan etiyoloji ÝPAH ise mortalite riski diðer PH türlerine göre daha yüksektir. ECMO dahil mekanik dolaþým destek cihazlarý, seçilmiþ vakalarda akciðer transplantasyonuna geçici bir köprü görevi görebilir. Bu nedenle ÝPAH'nýn erken teþhisi, hastalarýn merkezlere zamanýnda yönlendirilmesi ve bu operasyonlarýn kardiyoloji, jinekoloji ve kardiyak anestezi uzmanýndan oluþan multidisipliner bir ekiple planlanmasý gerekmektedir.

Anahtar Kelimeler: Acil sezaryen seksiyo, ECMO desteði, pulmoner hipertansiyon