**11. Considerations for special populations**

#### **11.1. Surgery**

Elective surgery involves an increased risk in patients with PAH. The increased risk is proportionate to the severity of the disease. It is not clear which type of anesthesia is advisable, but probably local and regional anesthesia are better tolerated than general anesthesia. Surgery preferably is performed at referral centers with experienced anesthesia and pulmonary hypertension teams that can deal with potential complications.[36],[53] Anticoagulant treatment should be interrupted for as short a period as possible. In patients with CTEPH, bridging with heparin is recommended to minimize the time off anticoagulation.

#### **11.2. Pregnancy**

Although successful pregnancies have been reported in PAH patients, pregnancy and delivery in PAH patients are associated with an increased mortality rate of 30% to 50%, and pregnancy should be avoided or terminated. An appropriate method of birth control is highly recom‐ mended in all women with pulmonary hypertension who have childbearing potential. Unfortunately, there is no current consensus on the most appropriate birth control method in PAH patients. Because of the increased risk of thrombosis with estrogen-based contraception, some experts suggest the use of estrogen-free products, surgical sterilization, or barrier methods.[24], [35]
