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PRIMARY PULMONARY HYPERTENSION IN PREGNANCY: A CASE
REPORT AND ANESTHETIC IMPLICATIONS
Maykon Hayak Pereira Lopes1
Abstract: Pulmonary arterial hypertension (PAH) is a rare and serious condition, especially during
pregnancy, with an increased risk of maternal and fetal morbidity and mortality. We report the case
of a pregnant woman with an echocardiographic diagnosis of PAH in hemodynamic decompensation
who underwent cesarean section under continuous epidural anesthesia. We describe the anesthetic
approach, maternal and neonatal outcomes, and discuss the anesthetic implications of PAH during
pregnancy, with an emphasis on hemodynamic monitoring and management. This case illustrates
the importance of individualized anesthetic treatment and intensive surveillance in these high-risk
scenarios.
Keywords: Pulmonary hypertension; Pregnancy; Obstetric anesthesia; Right ventricular failure;
Cesarean section.
1 Anesthesiologist certied by the Brazilian Society of Anesthesiology, he graduated in Medi-
cine from the University Center of Espírito Santo (UNESC) and completed a Medical Residency in
Anesthesiology. He also works as a Medical Residency Teacher in Anesthesiology at HMSJ.
Introduction
Pulmonary arterial hypertension (PAH) is a circulatory disorder characterized by
increased vascular resistance in the pulmonary circulation, usually by mixed mechanisms such as
vasoconstriction, arterial wall remodeling, and thrombosis in situ (Rosa VE, et al, 2008). This increase
in pulmonary vascular resistance (PVR) can progress to right ventricular failure (IVD), culminating
in early death. In pregnancy, the risk is exacerbated by physiological and hemodynamic changes that
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overload the right ventricle, making anesthesia and childbirth critical events (Avila WS, et al, 1999).
Case Report
A 33-year-old female patient, G5P3A1, at 29 weeks of gestation, was admitted with an
echocardiographic diagnosis of PAH in severe clinical decompensation. It was decided to resolve the
pregnancy via cesarean section, aiming at maternal hemodynamic stabilization.
The patient was referred to the operating room, where she received cardioscope monitoring,
invasive blood pressure, and pulse oximetry. Epidural anesthesia was performed in the L1–L2 space
with an 18G Tuohy needle, using the loss of resistance technique with positive Dogliotti and Figueiredo
tests. After puncture, 2% lidocaine with 1:200,000 adrenaline (3 mL) was administered, followed by a
fractional infusion of 1% ropivacaine (5 mL), associated with sufentanil (5 mcg) and morphine (2 mg),
at intervals of 5 minutes until reaching 20 mL and a sensory level at T4.
During the intraoperative period, milrinone was used in a continuous infusion pump (0.375
mcg/kg/min) and lactated ringer’s (1000 mL), in addition to oxytocin (5U) after fetal extraction. The
surgery was uneventful, lasting 2 hours. The patient remained hemodynamically stable, conscious,
and without respiratory alterations.
The newborn (female) had a weight of 1050 g and an Apgar score of 8 and 9 in the rst and
fth minutes, respectively. The patient was referred to the ICU at the end of the procedure, without
complications.
Discussion
PAH represents a relevant challenge for obstetric anesthesiologists, as gestational physiological
changes and anesthetic maneuvers can precipitate acute decompensation of PVR and IVD (Galiè N,
et al, 2015). Regional anesthesia, especially fractional epidural, offers advantages because it allows
gradual control of the block and less impact on preload.
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Close hemodynamic monitoring and support with inotropes and vasodilators, such as
milrinone, are essential. Patients with PAH without IVD can be managed with vasodilators alone,
while those with IVD require inotropic and diuretic support as indicated (McLaughlin VV, et al,
2009).
Anesthetic success depends on the maintenance of cardiovascular stability, abruptly avoiding
changes in afterload and intrathoracic pressure. This case illustrates the importance of individualized
planning, in a hospital environment with intensive support and an experienced multiprofessional team.
Conclusion
This case report highlights the anesthetic complexity involved in the management of
pregnant women with PAH. The appropriate choice of technique, intensive monitoring, and targeted
pharmacological support are determinant for a favorable outcome. The reported experience seeks to
contribute to the anesthesiological literature and stimulate the discussion of evidence-based conducts
in highly complex scenarios.
References
Rosa VE, et al. Idiopathic Pulmonary Arterial Hypertension Manifested during Pregnancy:
Anatomical-Clinical Correlation with Necropsy. Case Report. Rev Bras Clin Med. 2008;6:268-272.
Avila WS, et al. Guidelines of the Brazilian Society of Cardiology for Pregnancy and Family Planning
of Women with Heart Disease. Arq Bras Cardiol. 1999; 72 (supl III).
Galiè N, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension.
Eur Respir J. 2015; 46(4):903-975.
McLaughlin VV, et al. Management of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;
53(17):1573-1619.
