Increased maternal cardiovascular mortality associated with pregnancy in women with Turner syndrome

In women with Turner syndrome, the risk for aortic dissection or rupture during pregnancy may be 2% or higher, and the risk of death during pregnancy is increased as much as 100-fold.

Clinical Management of Paroxysmal Nocturnal Hemoglobinuria in Pregnancy: A Case Report and Updated Review

Because women with paroxysmal nocturnal hemoglobinuria (PNH) are especially vulnerable to thromboembolic phenomena, pregnancy is a time of increased risk for both mother and fetus. However, pregnancies in affected women are rare; only case reports and small studies have been reported so far. We present the case of a 20-year-old woman with PNH who, while undergoing medical tests in preparation for a bone marrow transplant, was discovered to be pregnant. We also review the obstetric literature on pregnancy complicated by PNH, which indicates that both maternal and fetal mortality is exceptionally high (11.6% and 7.2%) with the major cause of maternal mortality being thromboembolism. Major maternal complications are more frequent postpartum (30.2%) than antepartum or intrapartum (16.3%).

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that paroxysmal nocturnal hemoglobinuria (PNH) during pregnancy increases adverse events for both the mother and the fetus, state that maternal and fetal mortality are both high, and explain that the major complications occur in the postpartum period.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a disorder in which initial left ventricular systolic dysfunction and symptoms of heart failure occur between the late stages of pregnancy and the early postpartum period. It is common in some countries and rare in others. The causes and pathogenesis are poorly understood. Molecular markers of an inflammatory process are found in most patients. Clinical presentation includes usual signs and symptoms of heart failure, and unusual presentations relating to thromboembolism. Clinicians should consider PPCM in any peripartum patient with unexplained disease. Conventional heart failure treatment includes use of diuretics, beta blockers, and angiotensin-converting enzyme inhibitors. Effective treatment reduces mortality rates and increases the number of women who fully recover left ventricular systolic function. Outcomes for subsequent pregnancy after PPCM are better in women who have first fully recovered heart function. Areas for future research include immune system dysfunction, the role of viruses, non-conventional treatments such as immunosuppression, immunoadsorption, apheresis, antiviral treatment, suppression of proinflammatory cytokines, and strategies for control and prevention.

Reports on Confidential Enquiries into Maternal Deaths: management strategies based on trends in maternal cardiac deaths over 30 years

In the latest Report of the Confidential Enquiries into Maternal and Child Health (CEMACH; formerly Confidential Enquiries into Maternal Deaths (CEMD)), cardiac disease was the second commonest cause of maternal mortality. Currently there is much emphasis on appropriate referral and multidisciplinary planning for women with known cardiac disease. However, examining all maternal cardiac deaths in the CEMACH/CEMD reports over the last 30 years, to see whether the condition was known before pregnancy or developed during pregnancy, suggests that while reported maternal mortality due to cardiac disease overall has approximately doubled, the number due to known disease has changed little. Thus significant and increasing numbers of deaths occur in women without known disease, either in those with risk factors or in those who develop conditions in the absence of risk factors. Therefore, while there is a continuing need to counsel, refer and appropriately manage women with known pre-existing cardiac disease, attention must also be paid to screening women before pregnancy for evidence of cardiac disease or risk factors, and also to cardiac disease that develops de novo during pregnancy, since early screening and referral strategies alone will not prevent units from encountering such cases. All units therefore require processes for monitoring and managing women for the development of cardiac disease throughout their pregnancies.

Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality

OBJECTIVE

The purpose of this study was to estimate the incidence, risk factors, and mortality from pregnancy-related venous thromboembolism.

STUDY DESIGN

The Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality for the years 2000 to 2001 was queried for all pregnancy-related discharges with a diagnosis of venous thromboembolism.

RESULTS

The rate of venous thromboembolism was 1.72 per 1000 deliveries with 1.1 deaths per 100,000. The risk of venous thromboembolism was 38% higher for women ages 35 and older and 64% higher for black women. Other significant risk factors included thrombophilia, lupus, heart disease, sickle cell disease, obesity, fluid and electrolyte imbalance, postpartum infection, and transfusion. The risk factor with the highest odds ratio, 51.8 (38.7-69.2) was thrombophilia.

CONCLUSION

The incidence of pregnancy-related venous thromboembolism was higher than generally quoted. Women ages 35 and older, black women, and women with certain medical conditions and obstetric complications appear to be at increased risk.

Acute myocardial infarction in pregnancy: a United States population-based study

BACKGROUND

The purpose of this study was to determine the incidence, mortality, and risk factors for pregnancy-related acute myocardial infarction in the United States.

METHODS AND RESULTS

The Nationwide Inpatient Sample for the years 2000 to 2002 was queried for all pregnancy-related discharges. A total of 859 discharges included a diagnosis of acute myocardial infarction, for a rate of 6.2 (95% confidence interval [CI] 3.0 to 9.4) per 100,000 deliveries. Among these, there were 44 deaths, for a case fatality rate of 5.1%. The odds of acute myocardial infarction were 30-fold higher for women aged 40 years and older than for women <20 years of age. Single independent variables that were statistically and clinically significant, including age, race, and certain medical conditions and obstetric complications, were entered into a multivariable logistic regression model. Hypertension (odds ratio [OR] 21.7, 95% CI 6.8 to 69.1), thrombophilia (OR 25.6, 95% CI 9.2 to 71.2), diabetes mellitus (OR 3.6, 95% CI 1.5 to 8.3), smoking (OR 8.4, 95% CI 5.4 to 12.9), transfusion (OR 5.1, 95% CI 2.0 to 12.7), postpartum infection (OR 3.2, 95% CI 1.2 to 10.1), and age 30 years and older remained as significant risk factors for pregnancy-related acute myocardial infarction. Black race was eliminated as a risk factor in the multivariable analysis, which suggests that the increased incidence among black women is explained by an increased prevalence of other cardiovascular risk factors.

CONCLUSIONS

Although acute myocardial infarction is a rare event in women of reproductive age, pregnancy increases the risk 3- to 4-fold. Certain medical conditions and complications of pregnancy increase the risk further and are potentially modifiable risk factors.

[Study on the maternal mortality ratio from 1995 to 2004 among residential and migrant women in Beijing]

OBJECTIVE

To analyze the maternal mortality ratio (MMR) of residential and migrant women in Beijing.

METHODS

A retrospective study from 1995 to 2004 was performed to analyze data from the maternal death cases.

RESULTS

The MMR of resident and migrant of Beijing from 1995 to 2004 were 17.9 and 51.3 per ten thousand respectively. The main reasons of maternal deaths among residents were embolism (21.2%), hypertensive disorder complicating pregnancy (18.3%), postpartum hemorrhage (14.4%) and ectopic pregnancy/heart disease (9.6%). The main reasons of migrant maternal deaths were postpartum hemorrhage (25.2%), embolism (19.7%), hypertensive disorder complicating pregnancy (17.3%) and liver disease (9.5%). The avoidable deaths were accounted for 18.9%.

CONCLUSION

The MMR in Beijing local residents was close to that in developed countries. To further reduce MMR in Beijing would depend on the better administration of related issues among floating population. Poor quatily delivery must be banned together with strengthening the training programs on health workers. It is also important to improve the knowledge and skills of medical staff for rescuing the complications of pregnancy and ectopic pregnancy.

Anticoagulants in Pregnancy

Venous thromboembolic (VTE) complications are a leading cause of maternal mortality in the developed world. To reduce the incidence of VTE in pregnancy, and improve outcomes, a wider understanding of the risk factors involved and a better identification of women at risk of thrombosis coupled with effective thromboprophylaxis and treatment of VTE are required. As coumarin is unsuitable for use in pregnancy because of problems with embryopathy and risk of fetal bleeding, anticoagulation therapy in pregnancy centres on the use of low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH). There is now extensive experience of the safety and efficacy of LMWH in pregnancy. LMWH's, such as enoxaparin and dalteparin, have clinical and practical advantages compared with UFH in terms of improved safety (significantly lower incidence of osteoporosis and heparin induced thrombocytopenia), and patient convenience with once daily dosing for the majority of women. Such therapy is not restricted only to prevention and treatment of VTE but is now being assessed in additional clinical situations such as the prevention of pregnancy complications.

Maternal mortality in the U.S. Department of Defense, 1993-1998

OBJECTIVE

To determine the maternal mortality ratio (MMR) in Department of Defense medical facilities from 1993 to 1998.

STUDY DESIGN

We conducted a retrospective review of birth data from military medical facilities using the Standard Inpatient Data Records from 1993 through 1998. The total number of live births and dispositions due to maternal death were obtained.

RESULTS

Twenty-two maternal deaths occurred in the study time out of 398,107 live births, for an MMR of 5.5 per 100,000 live births. The ratiosfor the service branches were: Army 7.0, Navy 5.3 and Air Force 3.6. The leading cause of death was embolic disease.

CONCLUSION

The military MMR is closer to the Healthy People 2010 goal of 3.3 than is the national ratio, 13.2. Improved reporting of cases, patient education and treating high-risk conditions may help further decrease pregnancy-related mortality.

Surgery for acute type A aortic dissection in pregnant patients with Marfan syndrome

OBJECTIVE

Acute type A aortic dissection during pregnancy can be fatal to both the mother and the fetus. The goal of the present study was to characterize the prevalence, treatment and outcomes of this dangerous condition in an effort to determine optimal management.

METHODS

A retrospective study was conducted using data from four Marfan patients with acute type A aortic dissection during pregnancy at our institution between 1991 and 2003.

RESULTS

The mean gestational period at the time of operative repair was 31 weeks, with a range of 26-34 weeks, and the aortic root diameter ranged from 35 to 85 mm. Two of the four patients underwent a combined operation with cesarean section followed by aortic repair. One patient underwent operative aortic repair following spontaneous delivery. The final patient underwent aortic repair with the fetus remaining in situ. Median sternotomy and cardiopulmonary bypass were established via the femoral artery with direct right atria drainage and left atrial venting in all patients. Composite graft replacement combined with re-implantation of the coronary artery and aortic valve replacement were performed in three patients, and aortic valve replacement with coronary artery bypass grafting of the right coronary artery was performed in one patient. Three of four patients underwent aortic arch repair utilizing antegrade cerebral perfusion and deep hypothermia with total circulatory arrest. The patient that underwent operative correction with the fetus remaining in situ experienced fetal demise with miscarriage just after cardiac surgery, and the patient died 4 days later secondary to disseminated intravascular coagulation and multi-organ failure. The remaining three cases recovered uneventfully, and the mothers and babies were discharged in good condition.

CONCLUSIONS

Based on these data, we advocate cesarean section with concomitant aortic repair for patients with Marfan syndrome and acute type A aortic dissection during pregnancy. Minimization of deep hypothermic circulatory arrest time is also recommended for cases in which the fetus remains in situ.

Evaluation and outcome of pregnancy complicated by heart disease

OBJECTIVE

To assess the maternal and fetal outcome in pregnancies associated with maternal heart disease.

METHODS

The study included 50 pregnant cardiac patients from the Department of Obstetrics and Gynaecology Unit-I Nishtar Hospital, Multan. Age, parity, type of cardiac lesions, class of disease, specific treatment given, obstetric and cardiac complications, maternal and fetal outcome were analyzed.

RESULTS

Out of 5100 obstetric patients, 50 cases of heart disease were diagnosed, giving a frequency of 0.98%. The ages of the women ranged between 26-35 years (64%) and 52% were multigravida. Congenital Heart Disease (CHD) was present in 28% cases and 66% had Rheumatic Heart Disease (RHD) and mitral stenosis which was the dominant lesion. Anticoagulation was given to 3 (6%) cases, Digoxin was required in 20 (40%) cases, Diuretics 18 (36%) while antihypertensive and beta blockers were given to 4 (8%) cases each, whereas prophylactic antibiotic was given to all (100%) patients. Congestive Cardiac Failure (CCF) was seen in 10 (20%) cases, infective endocarditis and thromboembolism in one (2%) case each. Maternal mortality occurred in one (2%) case and one (2%) neonatal death was encountered. Cardiomyopathy was seen in 2 (4%) cases. Vaginal delivery was had in 91.49% women and 80% were term pregnancies. Preterm deliveries were 14% and 42.55% babies were of low birth weight.

CONCLUSION

Although, heart disease is rare among pregnant women, it needs to be carefully managed in a tertiary care setting by a team of obstetrician, cardiologist and anaesthesiologist, to obtain good maternal and foetal outcome.

Primary pulmonary hypertension and pregnancy

Primary pulmonary hypertension (PPH) is a disorder intrinsic to the pulmonary vascular bed characterized by sustained elevation in pulmonary artery pressure and pulmonary vascular resistance with normal pulmonary artery wedge pressure, in the absence of a known cause. Cardiovascular disorders are the most common cause of morbidity and mortality in pregnant women. Risk is so great with some cardiovascular abnor-malities that recommendation of avoidance or interruption of pregnancy is supportable, one of these conditions is pulmonary hypertension. In this article two patients with primary pulmonary hypertension who sustained two pregnancies each are described. Both patients had uneventful pregnancies and deliveries, with all neonates surviving. When evaluating primary pulmonary hypertension and pregnancy, early studies reported a maternal mortality rate as high as 50%. More recent studies report a maternal mortality of 30%. In this article, cases of primary pulmonary hypertension undergoing pregnancy from 1978 to 2005 were reviewed, revealing a 22% maternal mortality for the total number of pregnancies. Despite advances in treatment, primary pulmonary hypertension continues to carry considerable maternal morbidity and mortality, and prevention of pregnancy is still the main recommendation. Early diagnosis and treatment is critical and a multi-disciplinary approach is required when dealing with a patient with PPH who desires to continue pregnancy.

Peripartum cardiomyopathy: inflammatory markers as predictors of outcome in 100 prospectively studied patients

AIMS

Peripartum cardiomyopathy (PPCM) is a disorder of unknown aetiology with a course and outcome that is largely unpredictable. We evaluated the prognostic role of multiple inflammatory markers in the plasma of a large cohort of African patients with PPCM.

METHODS AND RESULTS

The study of 100 patients with newly diagnosed PPCM was single-centred, prospective, and longitudinal. Clinical assessment, echocardiography, and blood analysis were done at baseline and after 6 months of standard therapy. Inflammatory markers were measured at baseline only. Fifteen patients died. Left ventricular ejection fraction (LVEF) improved from 26.2+/-8.2 to 42.9+/-13.6% at 6 months (P<0.0001). However, normalization of LVEF (>50%) was only observed in 23%. Baseline levels of C-reactive protein correlated positively with baseline LV end-diastolic (rs=0.33, P=0.0026) and end-systolic (rs=0.35, P=0.0012) diameters and inversely with LVEF (rs=-0.27, P=0.015). Patients who died presented with significantly lower mean EF and higher Fas/Apo-1 plasma values (P<0.05). Fas/Apo-1 and New York Heart Association functional class (NYHA FC) predicted mortality at baseline.

CONCLUSION

Plasma markers of inflammation were significantly elevated and correlated with increased LV dimensions and lower LVEF at presentation. Baseline Fas/Apo-1 and higher NYHA FC were the only predictors of mortality. Normalization of LVEF was only observed in 23% of this African cohort.

The spectrum of adult congenital heart disease in Europe: morbidity and mortality in a 5 year follow-up period

AIMS

To describe clinical and demographic characteristics at baseline of a European cohort of adults with congenital heart disease (CHD) and to assess mortality and morbidity in a 5 year follow-up period.

METHODS AND RESULTS

Data collected as part of the Euro Heart Survey on adult CHD was analysed. This entailed information transcribed from the files of 4110 patients diagnosed with one of eight congenital heart conditions ('defects'), who consecutively visited the outpatient clinics of one of the participating centres in 1998. The patients were included retrospectively and followed until the end of 2003 for a median follow-up of 5.1 years. Notwithstanding their overall relatively good functional class and low mortality over the follow-up period, a considerable proportion of the patients had a history of endocarditis, arrhythmias, or vascular events. There were major differences between the eight defects, both in morbidity and regarding specific characteristics. Outcomes were worst in cyanotic defects and in the Fontan circulation, but a considerable proportion of the other patients also suffer from cardiac symptoms. In particular, arrhythmias are common.

CONCLUSION

The spectrum of adult CHD in Europe emerging from this survey is one of a predominantly young population with substantial morbidity but relatively low mortality in a 5 year period.

Mortality from venous thromboembolism in young Swedish women and its relation to pregnancy and use of oral contraceptives – an approach to specifying rates

BACKGROUND

Pregnancy and use of combined oral contraceptives (COCs) are major risk factors for venous thromboembolism (VTE) in young women and we wanted to obtain accurate VTE mortality data overall, by age, associated with the use of COCs and pregnancy.

METHODS

From the Swedish Cause of Death Register (CDR) we identified women aged 15-44 with VTE as underlying or contributory cause of death during the period 1990-1999. We scrutinized medical records and included verified VTE cases without active cancer or terminal disease. Pregnancy statistics and COC utilization data were obtained from national databases.

RESULTS

Of the 120 cases included, 9 (8%) were associated with pregnancy and 28 (23%) with current COC use. The overall refined VTE mortality rate in current COC users was 7.5[4.7; 10.3] per million user-years and the corresponding pregnancy-related rate was 8.9[4.1;17.0] per million pregnancy years, rates increasing with age. For ages 15-24, the rate was significantly higher in current COC users than in non-pregnant women not using COCs: 6.0[3.1; 10.5] per million user-years vs. 0.3[0.0; 1.2] per million woman years. Underlying cause mortality data included 82% of VTE deaths associated with COCs, and 56% of maternal deaths had a pregnancy-related code.

CONCLUSION

Mortality figures from VTE associated with the use of COCs and pregnancy were similar. COC use had an important impact on the total VTE mortality in the youngest age group. Standard mortality statistics do not allow accurate monitoring of VTE mortality in young women due to missing data, misdiagnoses and coding rules.

Severe Pulmonary Hypertension during Pregnancy

Background

Available literature on pregnant women with severe pulmonary hypertension (PH) relies mainly on anecdotal case reports and two series only.

Methods

The authors reviewed the charts of all pregnant women with severe PH who were followed up at their institution during the past 10 yr, to assess the multidisciplinary treatment and outcome of these patients.

Results

Fifteen pregnancies in 14 women with severe PH were managed during this period: There were 4 cases of idiopathic pulmonary arterial hypertension (PAH), 6 cases of congenital heart disease-associated PAH, 1 case of fenfluramine-associated PAH, 1 case of mixed connective tissue-associated PAH, 1 case of human immunodeficiency virus-associated PAH, and 2 cases of chronic thromboembolic PH. PH presented during pregnancy in 3 patients. Two patients died before delivery at 12 and 23 weeks' gestation. Four patients had vaginal deliveries with regional anesthesia: One died 3 months postpartum, one worsened, and two remained stable. Four had cesarean deliveries during general anesthesia: One died 3 weeks postpartum, one worsened, and two remained stable. Five had cesarean deliveries during low-dose combined spinal-epidural anesthesia: One died 1 week postpartum, and four remained stable. There were two fetal deaths: one related to therapeutic abortion at 21 weeks' gestation and one stillbirth at 36 weeks' gestation followed by the death of the mother 1 week later.

Conclusions

Despite the most modern treatment efforts, the maternal mortality was 36%. Scheduled cesarean delivery during combined spinal-epidural anesthesia seemed to be an attractive approach, but there was no evidence of actual benefit. Therefore, pregnancy must still be discouraged in patients with severe PH.

Maternal and perinatal outcome of pregnancies complicated by cardiac disease

OBJECTIVE

The aim of this study was to assess the maternal and perinatal outcome of pregnancies complicated by cardiac disease in a tertiary care center in Egypt.

METHODS

During a 1-year period, a total of 86 pregnant women with cardiac disease were admitted. Maternal and perinatal morbidity and mortality were calculated and compared with a control group.

RESULTS

Seventy-seven (89.5%) patients were due to rheumatic affection, and 60 patients were classified as NYHA classes I-II. There was one case of maternal mortality (1.16%), and 10 other cases developed life-threatening complications. Two perinatal mortalities (2.32%) occurred in this series. Birth weight of babies born to mothers with functional classes III and IV were significantly lower than those of functional classes I-II and control group.

CONCLUSION

Rheumatic heart disease with pregnancy is still predominant in Egypt. Maternal and perinatal morbidity and mortality are strongly correlated to maternal cardiac functional classification.

Cardiac arrest during pregnancy

This case involves cardiac arrest of a 29-week old pregnant African American woman, occurring 2 days after surgical correction of an incarcerated ventral hernia with small bowel obstruction. The patient could not be resuscitated from this arrest. Details of the case are presented, and diagnostic and unique management considerations for this uncommon occurrence are set forth.

Increased maternal cardiovascular mortality associated with pregnancy in women with Turner syndrome

In women with Turner syndrome, the risk for aortic dissection or rupture during pregnancy may be 2% or higher, and the risk of death during pregnancy is increased as much as 100-fold.

[Pregnancy in patients with Eisenmenger's syndrome. Experiences from Vilnius 1967-2003]

Pregnancy in patients with Eisenmengers syndrome is associated with high maternal and fetal mortality rates and effective contraception or termination of pregnancy is strongly recommended. When these patients decide to begin or continue a pregnancy against advice a coordinated multi-specialist care at a center for congenital heart disease is mandatory. So far, experience with this demanding group of patients is limited. This report reviews the outcome of 30 pregnancies in 10 patients from a group of 35 women with Eisenmengers syndrome who have been treated at the University Hospital in Vilnius, Lithuania, between 1967 and 2003. The most frequent underlying lesion was a ventricular septal defect in 5 patients, their mean age was 26.2 +/- 5,4 years and they were in functional class II or III (9/1) at the beginning of the pregnancy. In this group 13 pregnancies were terminated (43 %), 4 spontaneous abortions (13 %) occurred at less than 21 weeks of pregnancy and one stillbirth at 23 weeks of gestation. Twelve children were born alive, 10 were premature and 2 term deliveries. One maternal death occurred on the third day following an emergency delivery in week 36 and another patient decompensated immediately following delivery, but could be stabilized with intensive care therapy. During long-term follow-up all of these 9 patients were alive at 10/2003 despite a significant deterioration in functional class. These data are comparable to previously published observations in pregnant women with Eisenmengers syndrome.