[Preoperative risk factors analysis of pulmonary hypertension crisis during perioperative period for caesarean section of woman with severe pulmonary hypertension].

OBJECTIVE: To analyze preoperative risk factors of perioperative pulmonary hypertension crisis (PHC) for pregnant woman with severe pulmonary artery hypertension (PAH), and approach its clinical value.

METHODS: A retrospective analysis was conducted. The clinical data from 152 pregnant women with severe PAH underwent cesarean delivery admitted to Beijing Anzhen Hospital from January 1st 2008 to December 31st 2016 was collected. The patients were divided into two groups according to with perioperative PHC or not. Through the case management system, age, height, weight, gestational age, pregnancy time, type of PAH, emergency or selective surgery, New York Heart Association (NYHA) cardiac function classification, and preoperative ultrasound left ventricular ejection fraction (LVEF), left ventricular diastolic final diameter (LVEDD), the pulmonary artery systolic pressure (sPAP) estimated by ultrasonic TI method, radial artery systolic blood pressure (SBP) and diastolic blood pressure (DBP), heart rate (HR), pulse oxygen saturation (SpO2 ) without oxygen, oral sildenafil ingestion, having Swan-Ganz catheter placement or not, and whether used norepinephrine or not, as well as the occurrence of perioperative PHC and clinical outcomes were collected. Possible preoperative risk factors were compared between the two groups by single factor and multiple factors logistic regression analysis. The receiver-operating characteristic curve (ROC) was plotted to assess the diagnostic value of various risk factors.

RESULTS: A total of 152 patients were screened. Ten patients got heart surgery under general anesthesia at the same time, and 4 patients experiencing cesarean section with general anesthesia were excluded. 138 patients were enrolled finally, 27 patients underwent perioperative PHC (19.57%), and 17 patients died with a mortality of 62.96%. Compared with non-PHC group, the patients in PHC group were older (years: 25.07±3.55 vs. 27.64±4.82), had a poor cardiac function (NYHA cardiac function classification: 3.22±0.64 vs. 2.85±0.53), a smaller LVEDD (mm: 38.78±4.76 vs. 43.91±9.67), lower SpO2 without oxygen (0.83±0.12 vs. 0.92±0.06) and oral sildenafil ingestion rate (29.63% vs. 56.76%), and higher sPAP estimated by ultrasonic TI method [mmHg (1 mmHg = 0.133 kPa): 113.41±24.73 vs. 99.35±21.10] and DBP (mmHg: 79.63±13.23 vs. 75.23±12.14), more having Swan-Ganz catheter placement (85.19% vs. 57.66%), more Eisenmenger syndrome (70.37% vs. 37.84%), and more emergency operation (48.15% vs. 23.42%, all P ≤ 0.1). The variables with statistically significant differences showed by single factor analysis were collected, and it was shown by multiple factors logistic regression analysis that LVEDD [odds ratio (OR) = 0.878, 95% confidence interval (95%CI) = 0.796-0.968, P = 0.009], whether oral taken sildenafil (OR = 0.161, 95%CI = 0.051-0.515, P = 0.002) or not, SpO2 at room air (OR = 0.882, 95%CI = 0.829-0.938, P = 0.000), Swan-Ganz catheter placement or not (OR = 6.186, 95%CI = 1.533-24.964, P = 0.010) were independent risk factors of perioperative PHC in pregnant women with severe PAH. It was shown by ROC curve analysis that the area under the ROC curve (AUC) of four factors mentioned above combined diagnosis for PHC was 0.878 (P = 0.000) with the sensitivity of 88.89% and specificity of 76.58%.

CONCLUSIONS: PHC is very dangerous for gravida with severe PAH, and the mortality rate is very high. LVEDD, oral sildenafil, SpO2 at room air, Swan-Ganz catheter placement or not were independent risk factors of perioperative PHC for severe PAH maternal. Four preoperative factors of perioperative PHC joint diagnosis accuracy were higher.