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Management of acutely decompensated chronic thromboembolic pulmonary hypertension in late pregnancy: a case report

BACKGROUND: Pregnancy in patients with pulmonary hypertension is associated with increased risk of maternal and fetal death. Physiological changes during pregnancy, labor and the postpartum period may all lead to acute decompensation of chronic right heart failure with rapid progression to circulato...

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Autores principales: Valko, Luca, Csosza, Gyorgyi, Merei, Akos, Muhl, Diana, Faludi, Reka, Karlocai, Kristof, Lorx, Andras, Gal, Janos
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6805312/
https://www.ncbi.nlm.nih.gov/pubmed/31638921
http://dx.doi.org/10.1186/s12884-019-2545-7
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author Valko, Luca
Csosza, Gyorgyi
Merei, Akos
Muhl, Diana
Faludi, Reka
Karlocai, Kristof
Lorx, Andras
Gal, Janos
author_facet Valko, Luca
Csosza, Gyorgyi
Merei, Akos
Muhl, Diana
Faludi, Reka
Karlocai, Kristof
Lorx, Andras
Gal, Janos
author_sort Valko, Luca
collection PubMed
description BACKGROUND: Pregnancy in patients with pulmonary hypertension is associated with increased risk of maternal and fetal death. Physiological changes during pregnancy, labor and the postpartum period may all lead to acute decompensation of chronic right heart failure with rapid progression to circulatory collapse. As such, guidelines discourage planned pregnancies in women suffering from pulmonary hypertension. There are, however, rare cases of pulmonary hypertension which have previously been undiagnosed and only become apparent during late stage pregnancy. These individuals require close monitoring and multidisciplinary management. CASE PRESENTATION: We describe the case of a 34-year-old female who presented with acute decompensation of previously undiagnosed pulmonary hypertension during the 30th week of her second pregnancy. Echocardiography and CT scan confirmed severe pulmonary hypertension and right heart failure with no new thromboembolic component. Following stabilization of cardiorespiratory parameters with high FiO(2) noninvasive ventilation, intravenous epoprostenol and levosimendan treatment, Cesarean section was performed under epidural anesthesia. Close monitoring was continued in the postoperative period and cardiovascular parameters were managed with ongoing inotropic and escalating vasodilator therapy. The findings were consistent with chronic thromboembolic pulmonary hypertension. Persistent hypoxia was found to be a result of right bronchial obstruction caused by blood clots, which resolved with bronchoscopic intervention. Ongoing postpartum management resulted in improved cardiovascular parameters and oxygenation. Epoprostenol treatment was successfully converted to subcutaneous treprostinil therapy and the patient was discharged home to care for her healthy baby girl. Optimal timing of pulmonary endarterectomy will be chosen based upon functional status and patient preference. CONCLUSIONS: The case described is the first published report of previously undiagnosed pulmonary hypertension presenting with acute right heart failure in late pregnancy successfully managed by pharmacological therapy, noninvasive ventilation and a Cesarean performed under epidural anesthesia. The case illustrates that despite the challenges, acutely discovered right heart failure can be successfully managed with a comprehensive multidisciplinary treatment plan.
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spelling pubmed-68053122019-10-24 Management of acutely decompensated chronic thromboembolic pulmonary hypertension in late pregnancy: a case report Valko, Luca Csosza, Gyorgyi Merei, Akos Muhl, Diana Faludi, Reka Karlocai, Kristof Lorx, Andras Gal, Janos BMC Pregnancy Childbirth Case Report BACKGROUND: Pregnancy in patients with pulmonary hypertension is associated with increased risk of maternal and fetal death. Physiological changes during pregnancy, labor and the postpartum period may all lead to acute decompensation of chronic right heart failure with rapid progression to circulatory collapse. As such, guidelines discourage planned pregnancies in women suffering from pulmonary hypertension. There are, however, rare cases of pulmonary hypertension which have previously been undiagnosed and only become apparent during late stage pregnancy. These individuals require close monitoring and multidisciplinary management. CASE PRESENTATION: We describe the case of a 34-year-old female who presented with acute decompensation of previously undiagnosed pulmonary hypertension during the 30th week of her second pregnancy. Echocardiography and CT scan confirmed severe pulmonary hypertension and right heart failure with no new thromboembolic component. Following stabilization of cardiorespiratory parameters with high FiO(2) noninvasive ventilation, intravenous epoprostenol and levosimendan treatment, Cesarean section was performed under epidural anesthesia. Close monitoring was continued in the postoperative period and cardiovascular parameters were managed with ongoing inotropic and escalating vasodilator therapy. The findings were consistent with chronic thromboembolic pulmonary hypertension. Persistent hypoxia was found to be a result of right bronchial obstruction caused by blood clots, which resolved with bronchoscopic intervention. Ongoing postpartum management resulted in improved cardiovascular parameters and oxygenation. Epoprostenol treatment was successfully converted to subcutaneous treprostinil therapy and the patient was discharged home to care for her healthy baby girl. Optimal timing of pulmonary endarterectomy will be chosen based upon functional status and patient preference. CONCLUSIONS: The case described is the first published report of previously undiagnosed pulmonary hypertension presenting with acute right heart failure in late pregnancy successfully managed by pharmacological therapy, noninvasive ventilation and a Cesarean performed under epidural anesthesia. The case illustrates that despite the challenges, acutely discovered right heart failure can be successfully managed with a comprehensive multidisciplinary treatment plan. BioMed Central 2019-10-21 /pmc/articles/PMC6805312/ /pubmed/31638921 http://dx.doi.org/10.1186/s12884-019-2545-7 Text en © The Author(s). 2019 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
spellingShingle Case Report
Valko, Luca
Csosza, Gyorgyi
Merei, Akos
Muhl, Diana
Faludi, Reka
Karlocai, Kristof
Lorx, Andras
Gal, Janos
Management of acutely decompensated chronic thromboembolic pulmonary hypertension in late pregnancy: a case report
title Management of acutely decompensated chronic thromboembolic pulmonary hypertension in late pregnancy: a case report
title_full Management of acutely decompensated chronic thromboembolic pulmonary hypertension in late pregnancy: a case report
title_fullStr Management of acutely decompensated chronic thromboembolic pulmonary hypertension in late pregnancy: a case report
title_full_unstemmed Management of acutely decompensated chronic thromboembolic pulmonary hypertension in late pregnancy: a case report
title_short Management of acutely decompensated chronic thromboembolic pulmonary hypertension in late pregnancy: a case report
title_sort management of acutely decompensated chronic thromboembolic pulmonary hypertension in late pregnancy: a case report
topic Case Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6805312/
https://www.ncbi.nlm.nih.gov/pubmed/31638921
http://dx.doi.org/10.1186/s12884-019-2545-7
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