In recent days there has been a great deal of discussion regarding a particular abortion. The media seems to be treating this as if the woman would surely die if the baby was allowed to grow to viability. Thus, the headlines reflect an attitude of “Church Condemns Woman To Death”. But what are the real numbers?
Do any statistics exist regarding the results of women who were told their pregnancy would kill them choosing birth over abortion? I have anecdotal info about women I know personally who all survived “fatal” pregnancies, but I was wondering if there was a more scientific study.
During the past decade or so, new advanced therapies for the treatment of PAH have been developed, improving overall quality of life and prognosis for these patients.3,4 Moreover and perhaps more importantly, the management of high-risk pregnancies has improved owing to earlier recognition of the underlying disease, improved understanding of cardiopulmonary pathophysiology, better obstetric/anaesthetic management, and the introduction of a multidisciplinary approach.5 Whether these changes have translated into a reduction in maternal mortality remains unknown.
Fifteen (52%) CHD-PAH patients received advanced PAH therapy (Table 1). Eight (28%) patients died, all after delivery (median time to death 6 days post-partum, range 0–24); severe right heart failure was reported in six of them. Other causes of death included pulmonary thrombo-embolism, sudden cardiac death, pulmonary hypertension crisis, and bacterial endocarditis (Table 2). One late maternal death was reported 14 months following delivery, owing to severe right heart failure.
There were two (7%) foetal/neonatal deaths. One was a stillbirth at 36 weeks of gestation. The second was a baby delivered prematurely at 30 weeks of pregnancy, who died at 26 days of life because of sepsis. Intrauterine growth restriction was reported in seven (24%) newborns.
Seven (47%) oPH patients received advanced PAH therapy (Table 1). One patient died during pregnancy, whereas four died in the early post-partum [days 1 (*n
= 2), 2, and 21]. Causes of death were severe right heart failure and pulmonary thrombo-embolism (Table 2). The underlying causes of PAH in the patients who died were systemic lupus erythematosus (n = 1), chronic pulmonary thrombo-embolism (n = 1), appetite suppressant drugs (n = 1), antiphospholipid syndrome with previous pulmonary embolism, chronic active hepatitis (n = 1) and autoimmune hepatitis (n = 1). One patient with progressive systemic sclerosis died 24 months post-partum secondary to fulminant respiratory failure with lung infection.
The majority of deaths among parturients with PAH in the last decade and in previous decades occurred in the peri-partum period, mainly within the first month from delivery.1 This underscores the ongoing challenge of parturients with PAH to cope with the haemodynamic changes related to pregnancy, further exaggerated by acute changes during delivery and the post-partum. Pregnancy-induced systemic vasodilation and the increase in cardiac output may enhance right-to-left shunting and exacerbate pre-existing hypoxia in patients with CHD-PAH, leading to further pulmonary vasoconstriction. Further haemodynamic stress occurs during labour and delivery, when hypercarbia and acidosis may increase pulmonary hypertension acutely, leading to refractory right heart failure.53,55–57 The latter was, in fact, the main cause of peri-partum death in our study.
The effects of pregnancy on the cardiovascular system persist for several months after delivery.58 In this study, three late deaths were reported at 14, 19, and 24 months following delivery, but only nine (12%) patients were followed for more than 1 year. It is therefore purely speculative as to whether pregnancy itself may have an adverse effect on cardiopulmonary function,59 leading to premature death, or simply we have seen the guarded prognosis and natural history of PAH, or both.