Pulmonary hypertension in pregnancy: hemodynamic challenges, maternal risk, and multidisciplinary management

Abstract Pulmonary hypertension (PH) during pregnancy remains a high-risk clinical condition because normal gestational cardiovascular adaptation may exceed the reserve of the right ventricular (RV)-pulmonary circulation unit. Pregnancy is characterized by progressive increases in plasma volume, heart rate, stroke volume, and cardiac output, together with a reduction in systemic vascular resistance. These changes become particularly hazardous during labor, delivery, and the early postpartum period, when abrupt shifts in preload, venous return, and filling pressures may precipitate RV failure, hypoxemia, arrhythmia, or circulatory collapse. However, pregnancy-related risk in PH is heterogeneous and depends on the underlying PH phenotype, pulmonary vascular disease severity, RV function, oxygenation, and access to expert multidisciplinary care. This review summarizes the hemodynamic challenges of pregnancy in women with PH, phenotype-specific maternal and fetal risks, contemporary outcome data, treatment considerations, delivery planning, and postpartum management. Particular emphasis is placed on the first 24 to 72 h postpartum as a vulnerable period of hemodynamic stress and on the role of imaging, particularly echocardiographic surveillance, in identifying maladaptive RV responses and guiding timely escalation of care.