Pregnancy in Congenital Heart Disease, Complicated by Pulmonary Arterial Hypertension—A Challenging Issue for the Pregnant Woman, the Foetus, and Healthcare Professionals
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Statistical Analysis
3. Results
3.1. Baseline Data Characteristics
3.2. Management during Pregnancy
3.3. Pregnancy Outcomes, Delivery, and In-Hospital Management
3.4. Maternal Complications and Outcomes
3.5. Fetal and Neonatal Outcomes
3.6. Follow Up
4. Discussion
4.1. Risk Assessment and Pre-Pregnancy Management
4.2. Management during Pregnancy and Delivery
4.3. The Outcomes
5. Study Limitation
6. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Simonneau, G.; Montani, D.; Celermajer, D.S.; Denton, C.P.; Gatzoulis, M.A.; Krowka, M.; Williams, P.G.; Souza, R. Haemodynamic definitions and updated clinical classification of pulmonary hypertension. Eur. Respir. J. 2019, 53, 1801913. [Google Scholar] [CrossRef] [PubMed]
- Frost, A.; Badesch, D.; Gibbs, J.S.R.; Gopalan, D.; Khanna, D.; Manes, A.; Oudiz, R.; Satoh, T.; Torres, F.; Torbicki, A. Diagnosis of pulmonary hypertension. Eur. Respir. J. 2019, 53, 1801904. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Galiè, N.; Torbicki, A.; Barst, R.; Dartevelle, P.; Haworth, S.; Higenbottam, T.; Olschewski, H.; Peacock, A.; Pietra, G.; Rubin, L.J.; et al. Guidelines on diagnosis and treatment of pulmonary arterial hypertension. The Task Force on Diagnosis and Treatment of Pulmonary Arterial Hypertension of the European Society of Cardiology. Eur. Heart J. 2004, 25, 2243–2278. [Google Scholar] [CrossRef] [Green Version]
- Baumgartner, H.; De Backer., J.; Babu-Narayan., S.V.; Budts, W.; Chessa, M.; Diller, G.P.; Lung, B.; Luin, J.; Lang, I.M.; ESC Scientific Document Group; et al. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur. Heart J. 2021, 42, 563–645. [Google Scholar] [CrossRef]
- Rosenzweig, E.B.; Abman, S.H.; Adatia, I.; Beghetti, M.; Bonnet, D.; Haworth, S.; Ivy, D.; Berger, R.M. Paediatric pulmonary arterial hypertension: Updates on definition, classification, diagnostics and management. Eur. Respir. J. 2019, 53, 1801916. [Google Scholar] [CrossRef]
- Kaemmerer, H.; Gorenflo, M.; Huscher, D.; Pittrow, D.; Apitz, C.; Baumgartner, H.; Berger, F.; Bruch, L.; Brunnemer, E.; Budts, W.; et al. Pulmonary Hypertension in Adults with Congenital Heart Disease: Real-World Data from the International COMPERA-CHD Registry. J. Clin. Med. 2020, 9, 1456. [Google Scholar] [CrossRef]
- Dimopoulos, K.; Inuzuka, R.; Goletto, S.; Giannakoulas, G.; Swan, L.; Wort, S.J.; Gatzoulis, M.A. Improved Survival Among Patients with Eisenmenger Syndrome Receiving Advanced Therapy for Pulmonary Arterial Hypertension. Circulation 2010, 121, 20–25. [Google Scholar] [CrossRef] [Green Version]
- Diller, G.-P.; Körten, M.-A.; Bauer, U.M.; Miera, O.; Tutarel, O.; Kaemmerer, H.; Berger, F.; Baumgartner, H. Current therapy and outcome of Eisenmenger syndrome: Data of the German National Register for congenital heart defects. Eur. Heart J. 2016, 37, 1449–1455. [Google Scholar] [CrossRef]
- Regitz-Zagrosek, V.; Roos-Hesselink, J.W.; Bauersachs, J.; Blomström-Lundqvist, C.; Cífková, R.; De Bonis, M.; Iung, B.; Johnson, M.R.; Kintscher, U.; Kranke, P.; et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy: The Task Force for the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur. Heart J. 2018, 39, 3165–3241. [Google Scholar] [CrossRef]
- Kiely, D.; Condliffe, R.; Webster, V.; Mills, G.; Wrench, I.; Gandhi, S.; Selby, K.; Armstrong, I.; Martín, L.; Howarth, E.; et al. Improved survival in pregnancy and pulmonary hypertension using a multiprofessional approach. BJOG Int. J. Obstet. Gynaecol. 2010, 117, 565–574. [Google Scholar] [CrossRef]
- Hemnes, A.R.; Kiely, D.G.; Cockrill, B.A.; Safdar, Z.; Wilson, V.J.; Al Hazmi, M.; Preston, I.R.; MacLean, M.R.; Lahm, T. Statement on Pregnancy in Pulmonary Hypertension from the Pulmonary Vascular Research Institute. Pulm. Circ. 2015, 5, 435–465. [Google Scholar] [CrossRef] [Green Version]
- Konstantinides, S.V. Trends in pregnancy outcomes in patients with pulmonary hypertension: Still a long way to go. Eur. J. Heart Fail. 2016, 18, 1129–1131. [Google Scholar] [CrossRef]
- Olsson, K.M.; Channick, R. Pregnancy in pulmonary arterial hypertension. Eur. Respir. Rev. 2016, 25, 431–437. [Google Scholar] [CrossRef] [Green Version]
- Sahni, S.; Palkar, A.V.; Rochelson, B.L.; Kępa, W.; Talwar, A. Pregnancy and pulmonary arterial hypertension: A clinical conundrum. Pregnancy Hypertens. Int. J. Women’s Cardiovasc. Health 2015, 5, 157–164. [Google Scholar] [CrossRef]
- Bédard, E.; Dimopoulos, K.; Gatzoulis, M.A. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension? Eur. Heart J. 2009, 30, 256–265. [Google Scholar] [CrossRef] [Green Version]
- Siu, S.C.S.M.; Sermer, M.; Harrison, D.A.; Grigoriadis, E.; Liu, G.; Sorensen, S.; Smallhorn, J.F.S.B.S.; Farine, D.; Amankwah, K.S.; Spears, J.C.; et al. Risk and Predictors for Pregnancy-Related Complications in Women with Heart Disease. Circulation 1997, 96, 2789–2794. [Google Scholar] [CrossRef]
- Weiss, B.M. Pulmonary vascular disease and pregnancy: Current controversies, management strategies, and perspectives. Eur. Heart J. 2000, 21, 104–115. [Google Scholar] [CrossRef] [Green Version]
- Avila, W.S.; Grinberg, M.; Snitcowsky, R.; Faccioli, R.; Luz, P.L.; Bellotti, G.; Pileggi, F. Maternal and fetal outcome in pregnant women with Eisenmenger’s syndrome. Eur. Heart J. 1995, 16, 460–464. [Google Scholar] [CrossRef]
- Curry, R.A.; Fletcher, C.; Gelson, E.; Gatzoulis, M.A.; Woolnough, M.; Richards, N.; Swan, L.; Steer, P.J.; Johnson, M.R. Pulmonary hypertension and pregnancy-a review of 12 pregnancies in nine women. BJOG Int. J. Obstet. Gynaecol. 2012, 119, 752–761. [Google Scholar] [CrossRef]
- Duarte, A.G.; Thomas, S.; Safdar, Z.; Torres, F.; Pacheco, L.D.; Feldman, J.; Deboisblanc, B. Management of Pulmonary Arterial Hypertension During Pregnancy: A retrospective, multicenter experience. Chest 2013, 143, 1330–1336. [Google Scholar] [CrossRef] [Green Version]
- Pieper, P.G.; Lameijer, H.; Hoendermis, E.S. Pregnancy and pulmonary hypertension. Best Pract. Res. Clin. Obstet. Gynaecol. 2014, 28, 579–591. [Google Scholar] [CrossRef]
- Sliwa, K.; van Hagen, I.M.; Budts, W.; Swan, L.; Sinagra, G.; Caruana, M.; Blanco, M.V.; Wagenaar, L.J.; Johnson, M.R.; Webb, G.; et al. Pulmonary hypertension and pregnancy outcomes: Data from the Registry of Pregnancy and Cardiac Disease (ROPAC) of the European Society of Cardiology. Eur. J. Heart Fail. 2016, 18, 1119–1128. [Google Scholar] [CrossRef] [Green Version]
- Ladouceur, M.; Benoit, L.; Radojevic, J.; Basquin, A.; Dauphin, C.; Hascoet, S.; Moceri, P.; Bredy, C.; Iserin, L.; Gouton, M.; et al. Pregnancy outcomes in patients with pulmonary arterial hypertension associated with congenital heart disease. Heart 2017, 103, 287–292. [Google Scholar] [CrossRef]
- Li, Q.; Dimopoulos, K.; Liu, T.; Xu, Z.; Liu, Q.; Li, Y.; Zhang, J.; Gu, H. Peripartum outcomes in a large population of women with pulmonary arterial hypertension associated with congenital heart disease. Eur. J. Prev. Cardiol. 2019, 26, 1067–1076. [Google Scholar] [CrossRef]
- Ntiloudi, D.; Giannakoulas, G. Pregnancy still contraindicated in pulmonary arterial hypertension related to congenital heart disease: True or false? Eur. J. Prev. Cardiol. 2019, 26, 1064–1066. [Google Scholar] [CrossRef] [Green Version]
- Zwicke, D.; Paulus, S. Pregnancy and Pulmonary Arterial Hypertension: 21st Century Approach. Chest 2018, 154, 1040A. [Google Scholar] [CrossRef]
- Katsuragi, S.; Yamanaka, K.; Neki, R.; Kamiya, C.; Sasaki, Y.; Osato, K.; Miyoshi, T.; Kawasaki, K.; Horiuchi, C.; Kobayashi, Y.; et al. Maternal Outcome in Pregnancy Complicated with Pulmonary Arterial Hypertension. Circ. J. 2012, 76, 2249–2254. [Google Scholar] [CrossRef] [Green Version]
- Hill, W.; Holy, R.; Traiger, G. EXPRESS: Intimacy, contraception, and pregnancy prevention in patients with pulmonary arterial hypertension: Are we counseling our patients? Pulm. Circ. 2018, 10, 2045894018785259. [Google Scholar] [CrossRef] [Green Version]
- Kamp, J.C.; von Kaisenberg, C.; Greve, S.; Winter, L.; Park, D.-H.; Fuge, J.; Kühn, C.; Hoeper, M.M.; Olsson, K.M. Pregnancy in pulmonary arterial hypertension: Midterm outcomes of mothers and offspring. J. Heart Lung Transplant. 2021, 40, 229–233. [Google Scholar] [CrossRef]
- Jais, X.; Olsson, K.M.; Barberà, J.A.; Blanco, I.; Torbicki, A.; Peacock, A.; Vizza, C.D.; Macdonald, P.; Humbert, M.; Hoeper, M.M. Pregnancy outcomes in pulmonary arterial hypertension in the modern management era. Eur. Respir. J. 2012, 40, 881–885. [Google Scholar] [CrossRef]
- Meng, M.-L.; Landau, R.; Viktorsdottir, O.; Banayan, J.; Grant, T.; Bateman, B.; Smiley, R.; Reitman, E. Pulmonary Hypertension in Pregnancy: A Report of 49 Cases at Four Tertiary North American Sites. Obstet. Gynecol. 2017, 129, 511–520. [Google Scholar] [CrossRef] [PubMed]
- Subbaiah, M.; Kumar, S.; Roy, K.K.; Sharma, J.B.; Singh, N. Pregnancy outcome in women with pulmonary arterial hypertension: Single-center experience from India. Arch. Gynecol. Obstet. 2013, 288, 305–309. [Google Scholar] [CrossRef] [PubMed]
- Duan, R.; Xu, X.; Wang, X.; Yu, H.; You, Y.; Liu, X.; Xing, A.; Zhou, R.; Xi, M. Pregnancy outcome in women with Eisenmenger’s syndrome: A case series from west China. BMC Pregnancy Childbirth 2016, 16, 356. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Hartopo, A.B.; Anggrahini, D.W.; Nurdiati, D.S.; Emoto, N.; Dinarti, L.K. Severe pulmonary hypertension and reduced right ventricle systolic function associated with maternal mortality in pregnant uncorrected congenital heart diseases. Pulm. Circ. 2019, 9, 2045894019884516. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Luo, J.; Shi, H.; Xu, L.; Su, W.; Li, J. Pregnancy outcomes in patients with pulmonary arterial hypertension: A retrospective study. Medicine 2020, 99, e20285. [Google Scholar] [CrossRef]
- Elkayam, U.; Goland, S.; Pieper, P.G.; Silversides, C.K. High-Risk Cardiac Disease in Pregnancy: Part II. J. Am. Coll. Cardiol. 2016, 68, 502–516. [Google Scholar] [CrossRef]
- Low, T.T.; Guron, N.; Ducas, R.; Yamamura, K.; Charla, P.; Granton, J.; Silversides, C.K. Pulmonary arterial hypertension in pregnancy—A systematic review of outcomes in the modern era. Pulm. Circ. 2021, 11, 20458940211013671. [Google Scholar] [CrossRef]
- Keepanasseril, A.; Pillai, A.A.; Yavanasuriya, J.; Raj, A.; Satheesh, S.; Kundra, P. Outcome of pregnancies in women with pulmonary hypertension: A single-centre experience from South India. BJOG Int. J. Obstet. Gynaecol. 2019, 126, 43–49. [Google Scholar] [CrossRef] [Green Version]
- Sliwa, K.; Baris, L.; Sinning, C.; Zengin-Sahm, E.; Gumbiene, L.; Yaseen, I.; Youssef, G.; Johnson, M.; Farhan, H.A.; Lelonek, M.; et al. Pregnant Women with Uncorrected Congenital Heart Disease. JACC Heart Fail. 2019, 8, 100–110. [Google Scholar] [CrossRef]
- Schlichting, L.E.; Insaf, T.Z.; Zaidi, A.N.; Lui, G.K.; Van Zutphen, A.R. Maternal Comorbidities and Complications of Delivery in Pregnant Women with Congenital Heart Disease. J. Am. Coll. Cardiol. 2019, 73, 2181–2191. [Google Scholar] [CrossRef]
- Roos-Hesselink, J.; Baris, L.; Johnson, M.; De Backer, J.; Otto, C.; Marelli, A.; Jondeau, G.; Budts, W.; Grewal, J.; Sliwa, K.; et al. Pregnancy outcomes in women with cardiovascular disease: Evolving trends over 10 years in the ESC Registry of Pregnancy And Cardiac disease (ROPAC). Eur. Heart J. 2019, 40, 3848–3855. [Google Scholar] [CrossRef] [Green Version]
- Rex, S.; Devroe, S. Anesthesia for pregnant women with pulmonary hypertension. Curr. Opin. Anaesthesiol. 2016, 29, 273–281. [Google Scholar] [CrossRef]
- Sanghavi, M.; Rutherford, J.D. Cardiovascular Physiology of Pregnancy. Circulation 2014, 130, 1003–1008. [Google Scholar] [CrossRef]
- Leffert, L.R.; Dubois, H.M.; Butwick, A.J.; Carvalho, B.; Houle, T.T.; Landau, R. Neuraxial Anesthesia in Obstetric Patients Receiving Thromboprophylaxis with Unfractionated or Low-Molecular-Weight Heparin: A Systematic Review of Spinal Epidural Hematoma. Anesth. Analg. 2017, 125, 223–231. [Google Scholar] [CrossRef]
- Delgado, C.; Ring, L.; Mushambi, M.C. General anaesthesia in obstetrics. BJA Educ. 2020, 20, 201–207. [Google Scholar] [CrossRef]
- Hohmann, C.; Dumitrescu, D.; Gerhardt, F.; Kramer, T.; Rosenkranz, S.; Huntgeburth, M. High-risk pregnancy in a patient with pulmonary arterial hypertension due to congenital heart disease (PAH-CHD) with temporary shunt inversion and deoxygenation. Pulm. Circ. 2019, 9, 2045894019835649. [Google Scholar] [CrossRef] [Green Version]
- Dranenkiene, A.; Opitz, C.F.; Ewert, R.; Bühlmeyer, K.; Gumbiené, L.; Doma, B. Schwangerschaft bei Eisenmenger-Patientinnen. Erfahrungen aus Vilnius 1967–2003 (Pregnancy in patients with Eisenmenger’s syndrome. Experiences from Vilnius 1967–2003). DMW-Dtsch. Med. Wochenschr. 2004, 129, S35–S39. [Google Scholar] [CrossRef]
- Presbitero, P.; Somerville, J.; Stone, S.; Aruta, E.; Spiegelhalter, D.; Rabajoli, F. Pregnancy in cyanotic congenital heart disease. Outcome of mother and fetus. Circulation 1994, 89, 2673–2676. [Google Scholar] [CrossRef] [Green Version]
- Silversides, C.K.; Grewal, J.; Mason, J.; Sermer, M.; Kiess, M.; Rychel, V.; Wald, R.M.; Colman, J.M.; Siu, S. Pregnancy Outcomes in Women with Heart Disease: The CARPREG II study. J. Am. Coll. Cardiol. 2018, 71, 2419–2430. [Google Scholar] [CrossRef]
- Von Dadelszen, P.; Dwinnell, S.; Magee, L.A.; Carleton, B.C.; Gruslin, A.; Lee, B.; Lim, K.I.; Liston, R.M.; Miller, S.; Rurak, D.; et al. Sildenafil citrate therapy for severe early-onset intrauterine growth restriction. BJOG Int. J. Obstet. Gynaecol. 2011, 118, 624–628. [Google Scholar] [CrossRef]
- Kubo, M.; Umekawa, T.; Maekawa, Y.; Tanaka, H.; Nii, M.; Murabayashi, N.; Osato, K.; Kamimoto, Y.; Ikeda, T. Retrospective study of tadalafil for fetal growth restriction: Impact on maternal and perinatal outcomes. J. Obstet. Gynaecol. Res. 2017, 43, 291–297. [Google Scholar] [CrossRef]
- Daimon, A.; Iwanaga, N.; Ikeda, T.; Nakanishi, N.; Yoshimatsu, J.; Kamiya, C.A. Management of pulmonary vasodilator therapy in three pregnancies with pulmonary arterial hypertension. J. Obstet. Gynaecol. Res. 2017, 43, 935–938. [Google Scholar] [CrossRef]
Pts No. | Diagnosis (Procedures (at Age of)) | FC | Pregnancy; Delivery/ Age (Years) | SpO2 (%) before Pregnancy/III Trimester/at Last Follow-Up | Hgb (G/L) before Pregnancy/ III Trimester/Last Follow-Up | BNP (ng/L) before Pregnancy/III Trimester/at Last Follow-Up | 6MWT (M) before/during Pregnancy/ at Last Follow-Up | PAH Targeted Treatment during Pregnancy/Last Follow-Up | Duration of Breastfeeding (Months) |
---|---|---|---|---|---|---|---|---|---|
1 | VSD, ES | II–III | 1; 1 25 y.o. | 82/86/84 | 177/165/161 | <10/28/<10 | 420/360/430 | Sildenafil (from II trimester)/Sildenafil and Bosentan | No |
2 | SV, TGA, ES | III | 1; 1 35 y.o. | 57/63/80 | 198/183/191 | 76/265/60 | 469/480/480 | Sildenafil (from II trimester) + inhaled Iloprost (at early peripartum period)/Sildenafil, Ambrisentan | 4 months |
3 | PDA (surgical ligation (5 years)), residual PAH | II | 3; 2 31 y.o. | -/94/99 | -/132/140 | -/45/18 | -/360/550 | Sildenafil (from II trimester)/Sildenafil | 12 months |
4 | VSD, PDA, ES | III | 1; 0 26 y.o. | 78/-/83 | 175/-/163 | 37/-/13 | 460/480/510 | Sildenafil | - |
2; 1 28 y.o. | 89/-/82 | 177/135/162 | 13/28/27 | 515/450/405 | Sildenafil + Iloprost (at early peripartum period)/Sildenafil +, Bosentan (after delivery) | No | |||
5 | AVSD, ES | III | 1; 0 24 y.o. | 80/-/74 | 178/-/175 | 18/-/17 | 470/-/480 | Ambrisentan | |
2; 0 26 y.o. | 79/-/72 | 206/-/183 | 72/-/202 | 410/420/420 | Ambrisentan | ||||
3; 0 27 y.o. | 72/-/82 | 183/-/216 | 202/-/167 | 420/-/408 | Ambrisentan | ||||
6 | SV, TGA, ES | III–IV | 1; 0 23 y.o. | 74/-/75 | 192/-/177 | 228/-/45 | 400/-/420 | Sildenafil, Bosentan | - |
2; 0 29 y.o. | 66/-/75 | 164/-/214 | 40/-/29 | 420/-/- | Sildenafil/Sildenafil + Bosentan | - | |||
7 | VSD (surgical closure (4 years)), CoA surgical correction (2 months), re-CoA balloon angioplasty (17 years), residual PAH | II | 1; 1 30 y.o. | 94/-/- | 127/-/126 | -/173/- | -/-/- | None | 12 months |
2; 2 32 y.o. | -/-/- | 126/-/118 | /81/- | -/-/- | None | 14 months | |||
8 | VSD (surgical closure (4 years), residual PAH | II | 1; 1 18 y.o. | 95/99/- | 134/103/118 | 161/223/- | 530/480/- | Sildenafil/ * | 8 days |
Patient | Age/Diagnosis | FC | ASA | Pregnancy; Delivery/ Mode of Delivery or ToP/Weeks of Gestation | Anaesthesia Type | Newborn Weight, High, Apgar Score | Hospitalisation/ICU or PACU Time (Days) |
---|---|---|---|---|---|---|---|
1 | 25 y.o. ES | III | IV | 1; 1/CS/34 WG | GA | 2160 g, 49 cm, Apgar 8/9 | 6 days ICU—3 days |
2 | 35 y.o. ES | IV | IV | 1; 1/CS/32 WG | GA | 1400 g, 40 cm, Apgar 9/10 | 22 days ICU—7 days |
3 | 31 y.o. Residual PH | II | IIIE | 3; 2/VD/36 WG | RA (EA) | 2790 g, 49 cm, Apgar 9/9 | 8 days ICU—4 days |
4 | 26 y.o. ES | III | III | 1; 0/missed abortion /6 WG | IV | - | 2 days ICU—1 day |
28 y.o. ES | III | IV | 2; 1/CS/27 WG | GA | 900 g, 33 cm, Apgar 8/9 | 19 days ICU—7 days | |
5 | 24 y.o. ES | III | - | 1; 0/miscarriage/6 WG | - | - | - |
26 y.o. ES | III | III | 2; 0/missed abortion/7 WG | IV | - | 5 days ICU—1 day | |
27 y.o. ES | III | IV | 3; 0/ToP/8 WG | IV | - | 1 day PACU—1 h | |
6 | 23 y.o. ES | III | III | 1; 0/ToP/7 WG | IV | - | 7 days ICU—1 day |
29 y.o. ES | III | IIIE | 2; 0/ToP/7 WG | IV | - | 1 day PACU—1 h | |
7 | 30 y.o. Residual PH | I | - | 1; 1/VD/40 WG | No anaesthesiological intervention | 2960 g, 51 cm, Apgar 8/9 | 3 days |
32 y.o. Residual PH | I | - | 2; 2/VD/37 WG | No anaesthesiological intervention | 3240 g, 51 cm, Apgar 8/9 | 4 days | |
8 | 18 y.o. Residual PH | III/IV | * | 1; 1/CS/37 WG | RA (EA) | 2610 g, 48 cm, Apgar 9/9 | 5 days ICU—1 day |
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Rudienė, V.; Kaplerienė, L.; Jančauskaitė, D.; Meškėnė, E.; Palevičiūtė, E.; Laukytė-Slėnienė, M.; Gasiūnaitė, D.; Ramašauskaitė, D.; Jurevičienė, E.; Gumbienė, L. Pregnancy in Congenital Heart Disease, Complicated by Pulmonary Arterial Hypertension—A Challenging Issue for the Pregnant Woman, the Foetus, and Healthcare Professionals. Medicina 2022, 58, 476. https://doi.org/10.3390/medicina58040476
Rudienė V, Kaplerienė L, Jančauskaitė D, Meškėnė E, Palevičiūtė E, Laukytė-Slėnienė M, Gasiūnaitė D, Ramašauskaitė D, Jurevičienė E, Gumbienė L. Pregnancy in Congenital Heart Disease, Complicated by Pulmonary Arterial Hypertension—A Challenging Issue for the Pregnant Woman, the Foetus, and Healthcare Professionals. Medicina. 2022; 58(4):476. https://doi.org/10.3390/medicina58040476
Chicago/Turabian StyleRudienė, Virginija, Lina Kaplerienė, Dovilė Jančauskaitė, Emilija Meškėnė, Eglė Palevičiūtė, Monika Laukytė-Slėnienė, Diana Gasiūnaitė, Diana Ramašauskaitė, Elena Jurevičienė, and Lina Gumbienė. 2022. "Pregnancy in Congenital Heart Disease, Complicated by Pulmonary Arterial Hypertension—A Challenging Issue for the Pregnant Woman, the Foetus, and Healthcare Professionals" Medicina 58, no. 4: 476. https://doi.org/10.3390/medicina58040476