Pulmonary Arterial Hypertension in Pregnancy: Understanding the Maternal and Perinatal Risks

OBGYN Research Update:

Spotlight on Recent Research

Maternal and Perinatal Outcomes of Pregnant Women with Echocardiographically High Probability of Pulmonary Arterial Hypertension

Pregnancy complicated by pulmonary arterial hypertension (PAH) remains one of the most challenging scenarios in obstetric medicine. Despite advances in cardiovascular care and multidisciplinary management, PAH continues to be associated with significant maternal morbidity, mortality, and adverse neonatal outcomes.

A recent study published in the International Journal of Gynecology & Obstetrics examined maternal and perinatal outcomes among pregnant women identified as having a high echocardiographic probability of pulmonary arterial hypertension. The study adds to growing evidence that even when diagnosed through non-invasive screening methods, elevated pulmonary artery pressures during pregnancy warrant careful surveillance and specialized care.

Why PAH Matters in Pregnancy

Normal pregnancy produces profound cardiovascular changes, including increased blood volume, heart rate, and cardiac output. In women with pulmonary arterial hypertension, the pulmonary vasculature is unable to accommodate these physiological demands, resulting in elevated right ventricular workload and potential right heart failure.

Historically, maternal mortality rates in PAH pregnancies exceeded 30%. Although outcomes have improved substantially with modern therapies and multidisciplinary management, pregnancy is still considered high risk for women with established pulmonary hypertension. (PMC)

Key Clinical Concerns

Women with pulmonary hypertension face increased risks of:

• Right ventricular failure

• Arrhythmias

• Pulmonary hypertensive crises

• Thromboembolic events

• Maternal intensive care admission

• Cesarean delivery

• Postpartum cardiovascular decompensation

The postpartum period is particularly dangerous because rapid fluid shifts can further strain an already compromised right ventricle. Studies have shown that a substantial proportion of maternal deaths occur within the first few days following delivery. (PMC)

Impact on Fetal and Neonatal Outcomes

Maternal cardiovascular instability directly affects placental perfusion and fetal growth.

Published literature consistently demonstrates increased rates of:

• Preterm birth

• Fetal growth restriction

• Low birth weight

• Neonatal intensive care unit admission

• Perinatal mortality

The severity of pulmonary hypertension appears closely linked to worsening neonatal outcomes, with more severe disease associated with earlier delivery and lower birth weights. (Springer)

The Role of Echocardiography

Right-heart catheterization remains the diagnostic gold standard for pulmonary arterial hypertension. However, during pregnancy, transthoracic echocardiography serves as an essential screening and monitoring tool.

Echocardiographic assessment allows clinicians to:

• Estimate pulmonary artery pressures

• Evaluate right ventricular size and function

• Identify worsening hemodynamics

• Guide referral to specialized maternal-cardiology teams

The current study’s focus on women with a high echocardiographic probability of PAH highlights the growing importance of non-invasive cardiovascular surveillance during pregnancy.

Multidisciplinary Care Is Essential

Optimal outcomes require collaboration among:

• Maternal-Fetal Medicine specialists

• Obstetricians

• Cardiologists

• Pulmonary hypertension specialists

• Anesthesiologists

• Critical care teams

• Neonatologists

Current evidence suggests that women managed within specialized multidisciplinary programs experience better maternal and neonatal outcomes compared with historical cohorts. (MDPI)

Practical Implications for Obstetricians

For practicing obstetricians, several important lessons emerge:

1. Early recognition of symptoms such as dyspnea, syncope, chest discomfort, or exercise intolerance is critical.

2. Echocardiographic findings suggestive of pulmonary hypertension should prompt urgent specialist evaluation.

3. Delivery planning should occur at tertiary centers with expertise in high-risk cardiac pregnancy management.

4. Postpartum monitoring remains as important as antepartum surveillance due to the risk of delayed cardiovascular deterioration.

5. Comprehensive counseling regarding maternal and fetal risks should be provided before conception whenever possible.

Looking Ahead

While advances in pulmonary vasodilator therapy, critical care, and maternal cardiac medicine have improved survival, pulmonary arterial hypertension remains one of the highest-risk cardiovascular conditions encountered during pregnancy.

Studies examining echocardiographic predictors of adverse outcomes may help clinicians identify women at greatest risk and improve individualized care pathways. Future research focusing on risk stratification, optimal delivery timing, and targeted therapies will be essential to further improve outcomes for both mothers and infants.

Key Takeaway

A high echocardiographic probability of pulmonary arterial hypertension during pregnancy should be considered a significant warning sign requiring specialist evaluation and multidisciplinary management. Early detection, coordinated care, and vigilant postpartum monitoring remain the cornerstones of improving maternal and perinatal outcomes.

References

1. Maternal and perinatal outcomes of pregnant women with echocardiographically high probability of pulmonary arterial hypertension. International Journal of Gynecology & Obstetrics. 2025.

2. Rosenzweig EB, et al. Pulmonary arterial hypertension in pregnancy—a systematic review of outcomes in the modern era. Pulmonary Circulation. 2021.

3. Daraz Y, Murthy S, Wolfe D. Pregnancy in Pulmonary Arterial Hypertension: A Multidisciplinary Approach. Journal of Cardiovascular Development and Disease. 2022.

4. Maligireddy A, et al. Maternal and Fetal Outcomes in Pulmonary Hypertension During Pregnancy: A Contemporary Nationwide Analysis. American Journal of Cardiology. 2024.

5. Chen G, Zhang Z, Zhao X, et al. Maternal and neonatal outcomes in pregnancies complicated with pulmonary hypertension: a retrospective cohort study. European Journal of Medical Research. 2025.

6. Liu Y, Li H, Li Y, et al. Outcomes of pregnancy in women with different types of pulmonary hypertension. BMC Cardiovascular Disorders. 2023.

7. Luo J, et al. Pregnancy outcomes in patients with pulmonary arterial hypertension: A retrospective study. Medicine (Baltimore). 2020.

8. Marshall WH, et al. Maternal and fetal outcomes in pregnant women with pulmonary hypertension: The impact of left heart disease. International Journal of Cardiology Congenital Heart Disease. 2022.

9. Dolgun ZN, Inan C, Sayin C, et al. Maternal and fetal outcomes in pregnancies with pulmonary hypertension: Experience of a tertiary center. Taiwanese Journal of Obstetrics and Gynecology. 2018.