Hypertension pulmonaire et grossesse

Because of high maternal mortality, pulmonary hypertension (PH) remains a formal contraindication to pregnancy despite clear therapeutic advances. Therapeutic education including adequate contraception should be offered to any patient with PH. Management of pregnancy should be carried out in a PH referral center. A therapeutic abortion must be systematically proposed and practiced as soon as possible. If pregnancy is continued, regular multidisciplinary follow-up is required to adapt the background treatment and screen for respiratory, hemodynamic and obstetric complications. Vaginal or cesarean delivery requires a dedicated team and must be scheduled. Cesarean section, carried out between 34 and 36 weeks of gestational age, remains the preferred mode of delivery because it avoids hemodynamic constraints linked to pain during labor and to expulsive efforts. Nevertheless, vaginal delivery is possible under strict monitoring and reduces the risk of bleeding, infection and venous thromboembolic disease compared with cesarean section. Neuraxial anesthesia is preferred regardless of the delivery route, as general anesthesia is probably associated with higher mortality. Close monitoring in intensive care unit is required during several days in the post-partum period due to the high rate of complications.