251
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Screening and evaluation of newly diagnosed cardiovascular diseases in first-trimester asymptomatic pregnant women in a tertiary antenatal care center in Turkey. Anatol J Cardiol 2020; 23:99-104. [PMID: 32011322 PMCID: PMC7040868 DOI: 10.14744/anatoljcardiol.2019.55267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Cardiovascular disease (CVD) is the leading cause of death during pregnancy. Therefore, its detection early in pregnancy is of great importance. In this study, we aimed to investigate the rate and spectrum of CVD among healthy women in the first trimester of pregnancy. METHODS A total of 900 women in the first trimester of pregnancy, who attended the antenatal outpatient clinic of a tertiary care center in Ankara, Turkey, for a routine pregnancy examination, were recruited into this prospective study. Patients with a history of chronic systemic diseases, CVD, and/or a family history of an early onset CVD, and multiple pregnancies were excluded. Patients who were included in the study underwent electrocardiography and transthoracic echocardiography by the same cardiologist. RESULTS The rate of newly diagnosed CVD cases among asymptomatic pregnant women without any cardiac or clinical risk factors was 5.2% (n=47). The following CVDs were detected: rheumatic heart disease (n=26; 55.3%), congenital heart disease (n=13; 27.6%), and isolated valve disease (moderate and severe) (n=8; 17%). The mitral valve prolapse was detected in 32 women (3.5%) and atrial septal aneurysm in 51 women (5.67%). Thirty women (3.3%) had arrhythmia. CONCLUSION The CVD rate of 5.2% among healthy women in the first trimester of pregnancy shows that the clinicians must keep in mind that during pregnancy, physiological changes in the cardiovascular system may aggravate an undiagnosed disease, and they should be alert even in case of mild cardiac symptoms that may interfere with pregnancy complaints.
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252
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Rudland VL, Price SAL, Hughes R, Barrett HL, Lagstrom J, Porter C, Britten FL, Glastras S, Fulcher I, Wein P, Simmons D, McIntyre HD, Callaway L. ADIPS 2020 guideline for pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol 2020; 60:E18-E52. [PMID: 33200400 DOI: 10.1111/ajo.13265] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
This is the full version of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The guideline encompasses the management of women with pre-existing type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The management of women with monogenic diabetes or cystic fibrosis-related diabetes in relation to pregnancy is also discussed.
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Affiliation(s)
- Victoria L Rudland
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah A L Price
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Diabetes, Royal Women's Hospital, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia.,Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Ruth Hughes
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
| | - Helen L Barrett
- Department of Endocrinology, Mater Health, Brisbane, Queensland, Australia.,Mater Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Janet Lagstrom
- Green St Specialists Wangaratta, Wangaratta, Victoria, Australia.,Denis Medical Yarrawonga, Yarrawonga, Victoria, Australia.,Corowa Medical Clinic, Corowa, New South Wales, Australia.,NCN Health, Numurkah, Victoria, Australia
| | - Cynthia Porter
- Geraldton Diabetes Clinic, Geraldton, Western Australia, Australia
| | - Fiona L Britten
- Department of Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Mater Private Hospital and Mater Mother's Private Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Sarah Glastras
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Ian Fulcher
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Peter Wein
- Mercy Hospital for Women, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - David Simmons
- Western Sydney University, Sydney, New South Wales, Australia.,Campbelltown Hospital, Sydney, New South Wales, Australia
| | - H David McIntyre
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Mater Health, Brisbane, Queensland, Australia
| | - Leonie Callaway
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Women's and Children's Services, Metro North Hospital and Health Service District, Brisbane, Queensland, Australia.,Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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253
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Bruyère M, Morau E, Beaumont É, Verspyck É. [Maternal mortality due to cardiovascular disease in France 2013-2015]. ACTA ACUST UNITED AC 2020; 49:27-37. [PMID: 33161192 DOI: 10.1016/j.gofs.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Between 2013 and 2015, cardiovascular diseases became one of the two leading causes of maternal mortality, with 36 deaths (13.7% of maternal deaths). The overall maternal mortality ratio for cardiovascular diseases is 1.5 per 100,000 live births, stable compared to the 2010-2012 period. The etiologies in order of decreasing frequency are: pre-existing cardiomyopathies (n=10), aortic dissections (n=9), peripartum cardiomyopathies (n=6), myocardial infarction (n=4), valvular cardiopathies (n=4). Non-optimal care occurred in 72% of cases, increasing since the previous triennium (50%). Similarly, there is a significant increase in the proportion of preventable deaths (possibly or probably) from 35% to 66%. In women with known cardiovascular disease, the lack of multidisciplinary prepregnancy assessment and pregnancy follow-up is most frequent. In patients with unknown cardiovascular disease, the lack of diagnosis of a cardiac event is the most common failure. Cardiovascular conditions or cardiovascular risk factors should be investigated in early pregnancy in order to monitor and refer women to appropriate maternity hospitals. Recent dyspnea, worsening at the end of pregnancy and postpartum, should suggest a cardiac complication. In presence of chest pain, aortic dissection should be considered with the same degree of emergency as myocardial infarction or pulmonary embolism. Cardiac ultrasonography, chest CT, Nt-proBNP and troponin should be considered in case of chest pain or recent dyspnea. Women with cardiac symptoms should be referred to an emergency department (not necessarily to the local maternity) for a complete cardiovascular check-up.
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Affiliation(s)
- M Bruyère
- Service d'anesthésie réanimation médecine périopératoire, hôpital Bicêtre, université Paris-Saclay, AP-HP, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France.
| | - E Morau
- Département d'anesthésie réanimation, hôpital universitaire Carémeau, place du Pr.-Robert-Debré, 30029 Nîmes, France
| | - É Beaumont
- Service de gynécologie et obstétrique, centre hospitalier de Polynésie française, 98713 Papeete-Tahiti, France
| | - É Verspyck
- Service de gynécologie et obstétrique, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
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254
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Malhamé I, Danilack VA, Raker CA, Hardy EJ, Spalding H, Bouvier BA, Hurlburt H, Vrees R, Savitz DA, Mehta N. Cardiovascular severe maternal morbidity in pregnant and postpartum women: development and internal validation of risk prediction models. BJOG 2020; 128:922-932. [PMID: 32946639 DOI: 10.1111/1471-0528.16512] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To develop and internally validate risk prediction models identifying women at risk for cardiovascular severe maternal morbidity (CSMM). DESIGN A retrospective cohort study. SETTING An obstetric teaching hospital between 2007 and 2017. POPULATION A total of 89 681 delivery hospitalisations. METHODS We created and evaluated two models, one predicting CSMM at delivery (delivery model) and the other predicting CSMM postpartum following discharge from delivery hospitalisation (postpartum CSMM). We assessed model discrimination and calibration and used bootstrapping for internal validation. MAIN OUTCOME MEASURES Cardiovascular severe maternal morbidity comprised the following confirmed conditions: pulmonary oedema/acute heart failure, myocardial infarction, aneurysm, cardiac arrest/ventricular fibrillation, heart failure/arrest during surgery or procedure, cerebrovascular disorders, cardiogenic shock, conversion of cardiac rhythm and difficult-to-control severe hypertension. RESULTS The delivery model contained 11 variables and 3 interaction terms. The strongest predictors were gestational hypertension, chronic hypertension, multiple gestation, cardiac lesions or valvular heart disease, maternal age ≥40 years and history of poor pregnancy outcome. The postpartum model comprised eight variables. The strongest predictors were severe pre-eclampsia, non-Hispanic Black race/ethnicity, chronic hypertension, gestational hypertension, non-severe pre-eclampsia and maternal age ≥40 years at delivery. The delivery and postpartum models had an area under the receiver operating characteristic curve of 0.87 (95% CI 0.85-0.89) and 0.85 (95% CI 0.80-0.90), respectively. Both models were adequately calibrated and performed well on internal validation. CONCLUSIONS These tools may help providers to identify women at highest risk of CSMM and enable future prevention measures. TWEETABLE ABSTRACT Risk assessment tools for cardiovascular severe maternal morbidity were developed and internally validated.
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Affiliation(s)
- I Malhamé
- Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada.,Department of Medicine, Women and Infants Hospital, Warren Alpert School of Brown University, Providence, RI, USA
| | - V A Danilack
- Department of Obstetrics and Gynecology, Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - C A Raker
- Department of Obstetrics and Gynecology, Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - E J Hardy
- Department of Medicine, Women and Infants Hospital, Warren Alpert School of Brown University, Providence, RI, USA.,Department of Obstetrics and Gynecology, Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - H Spalding
- Department of Medicine, Women and Infants Hospital, Warren Alpert School of Brown University, Providence, RI, USA
| | - B A Bouvier
- Department of Medicine, Women and Infants Hospital, Warren Alpert School of Brown University, Providence, RI, USA
| | - H Hurlburt
- Department of Medicine, Brigham and Women's Cardiovascular Associates of Care New England, Harvard Medical School, Boston, MA, USA
| | - R Vrees
- Department of Obstetrics and Gynecology, Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - D A Savitz
- Department of Obstetrics and Gynecology, Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - N Mehta
- Department of Medicine, Women and Infants Hospital, Warren Alpert School of Brown University, Providence, RI, USA.,Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
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255
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Abstract
The prevalence of arrhythmias in pregnant women are rising, particularly among women with a history of structural heart disease or prior arrhythmia. The physiological changes of pregnancy increase the risk of both benign and pathologic arrhythmias, with atrial fibrillation representing the most common pathologic arrhythmia. While bradyarrhythmias rarely require treatment during pregnancy, pharmacotherapy is frequently required for tachyarrhythmias. Electrophysiological procedures including cardioversions, ablations, and device placement are occasionally required during pregnancy and can be performed safely with proper precautions. This chapter will discuss the diagnosis and management of a broad array of cardiac arrhythmias that may be encountered in pregnant women.
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256
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Abstract
Valvular heart disease (VHD) is generally well tolerated during pregnancy; however, the dramatic changes in hemodynamics that occur during pregnancy can lead to clinical decompensation in high-risk women. Women with VHD considering pregnancy should undergo preconception counseling with a high-risk obstetrician and cardiologist to review the maternal, fetal, and obstetric risks of pregnancy and delivery. Vaginal delivery is recommended for most women with VHD. Given the complexity of managing VHD during pregnancy, women should be managed by a multidisciplinary Pregnancy Heart Team during pregnancy, consisting of a high-risk obstetrician, cardiologist, and cardiac anesthesiologist.
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Affiliation(s)
- Jennifer Lewey
- Division of Cardiology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, 2-East Pavilion, Philadelphia, PA 19104, USA.
| | - Lauren Andrade
- Philadelphia Adult Congenital Heart Center, University of Pennsylvania, Children's Hospital of Philadelphia, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, 2- East Pavilion, Philadelphia, PA 19104, USA
| | - Lisa D Levine
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104, USA
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257
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Rudland VL, Price SAL, Callaway L. ADIPS position paper on pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol 2020; 60:831-839. [PMID: 33135798 DOI: 10.1111/ajo.13266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/14/2020] [Indexed: 01/17/2023]
Abstract
This is an executive summary of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The summary focuses on the main clinical practice points for the management of women with type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The full guideline is available at https://doi.org/10.1111/ajo.13265.
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Affiliation(s)
- Victoria L Rudland
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sarah A L Price
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Vic., Australia.,Department of Diabetes, Royal Women's Hospital, Melbourne, Vic., Australia.,Mercy Hospital for Women, Melbourne, Vic., Australia.,Faculty of Medicine, University of Melbourne, Melbourne, Vic., Australia
| | - Leonie Callaway
- Women's and Children's Services, Metro North Hospital and Health Service District, Brisbane, Qld, Australia.,Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
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258
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Abstract
The United States is the only industrialized nation with an increasing maternal mortality. Many factors contribute to this worrisome US trend; among them, social and demographic factors, and congenital and acquired cardiac conditions. Cardiovascular disease is the leading cause of maternal mortality, and adverse outcomes related to cardiovascular disease disproportionately affect black and Hispanic mothers. This article addresses knowledge gaps related to the treatment of heart disease in pregnancy, initiatives to address these gaps, and guidelines and best practices surrounding the care of women affected by cardiovascular disease and their babies affected by cardiovascular disease.
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Affiliation(s)
- Anna Grodzinsky
- Saint Luke's Mid America Heart Institute and Muriel Kauffman Women's Heart Center, 4401 Wornall Road, Kansas City, MO 64111, USA.
| | - Laura Schmidt
- Saint Luke's Mid America Heart Institute and Muriel Kauffman Women's Heart Center, 4401 Wornall Road, Kansas City, MO 64111, USA
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259
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Abstract
Women with congenital heart disease are pursuing pregnancy in increasing numbers. Counseling about genetic transmission, medication management, maternal and fetal risks, and maternal longevity should be initiated well before pregnancy is considered. Although preconception medical and surgical optimization as well as coordinated multidisciplinary care throughout pregnancy decrease maternal and fetal risks, the rate of complications remains increased compared with the general population. Lesion-specific risk stratification and care throughout pregnancy further improve outcomes and decrease unnecessary interventions.
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Affiliation(s)
- Katherine B Salciccioli
- Adult Congenital Heart Disease, Department of Internal Medicine, University of Michigan, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109-4204, USA
| | - Timothy B Cotts
- Adult Congenital Heart Disease, Department of Internal Medicine, University of Michigan, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109-4204, USA; Adult Congenital Heart Disease, Department of Pediatrics, University of Michigan, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109-4204, USA.
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260
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Adding to the Denominator: A Case Report of Neuraxial Anesthesia for Cesarean Delivery in the Setting of Hemolysis, Elevated Liver Enzyme, Low Platelet, Thrombocytopenia, and Pulmonary Hypertension. A A Pract 2020; 14:144-148. [PMID: 31977323 DOI: 10.1213/xaa.0000000000001168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The acceptable platelet count for the safe provision of neuraxial anesthesia in obstetric patients is unknown. Comorbidities may sway a provider to perform neuraxial anesthesia, despite thrombocytopenia, as the putative risk of spinal-epidural hematoma may not outweigh the risks associated with general anesthesia. The case of a 22-year-old nulliparous woman undergoing a cesarean delivery with a new diagnosis of pulmonary hypertension and right heart failure, compounded with thrombocytopenia and possible Hemolysis, Elevated Liver Enzyme, and Low Platelet (HELLP) syndrome, is presented. Risks and benefits of general versus neuraxial anesthesia in this specific setting are reviewed.
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261
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Pregnancy and Congenital Heart Disease: A Brief Review of Risk Assessment and Management. Clin Obstet Gynecol 2020; 63:836-851. [PMID: 33074980 DOI: 10.1097/grf.0000000000000579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiac disease is a leading cause of morbidity and mortality in pregnant women. An increased prevalence of the cardiovascular disease has been found in women of childbearing age, in which the responsibility of the treating physician extends to the mother and to the unborn fetus. As a result, care of these high-risk pregnant women with cardiovascular disease including those with congenital heart disease (CHD) require a team approach including specialists in maternal-fetal medicine, adult congenital cardiology, and obstetrical anesthesia. The human body undergoes significant amounts of physiological changes during this period of time and the underlying cardiac disease can affect both the mother and the fetus. Today, most female children born with CHD will reach childbearing age. For many women with complex CHD, carrying a pregnancy has a moderate to high risk for both the mother and her fetus. This chapter will review the epidemiology, risk factors, clinical presentation including common signs and symptoms, physiological changes in pregnancy, and the medical approach including cardiac medications, percutaneous interventions, and surgical procedures for pregnant women with CHD.
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262
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Darlington AM, Fleisher JD, Briller JE. Peripartum Cardiomyopathy: Management Strategies for Pregnancy Termination. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2020; 1:463-467. [PMID: 33786512 PMCID: PMC7784760 DOI: 10.1089/whr.2020.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 11/12/2022]
Abstract
Some women have underlying cardiovascular disease that leads to increased morbidity and mortality with pregnancy. These women may choose to terminate a pregnancy rather than face this increased risk. The optimal approach for pregnancy termination in women with cardiomyopathy is not well defined. We present two women with peripartum cardiomyopathy, both modified World Health Organization (mWHO) class IV and with elevated Cardiac Disease in Pregnancy (CARPREG II) pregnancy risk stratification scores who are at the highest risk for pregnancy continuation. Both underwent induced abortion, although the procedure was performed in very different settings. These cases illustrate factors that influence the mode and setting of pregnancy termination performance.
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Affiliation(s)
- Ashley M. Darlington
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jonah D. Fleisher
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Joan E. Briller
- Division of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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263
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Abstract
The number of reproductive age women with valvular heart disease is rising and accounts for one third of all heart disease among pregnant women. Severe, symptomatic left-sided cardiac lesions, particularly mitral and aortic stenosis, and mechanical heart valves, are associated with adverse maternal and fetal outcomes. Decreasing maternal and fetal risk requires shared decision-making among patients and the heart team, consisting of obstetricians, maternal-fetal medicine subspecialists, and cardiologists.
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264
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Bucciarelli-Ducci C, Ostenfeld E, Baldassarre LA, Ferreira VM, Frank L, Kallianos K, Raman SV, Srichai MB, McAlindon E, Mavrogeni S, Ntusi NAB, Schulz-Menger J, Valente AM, Ordovas KG. Cardiovascular disease in women: insights from magnetic resonance imaging. J Cardiovasc Magn Reson 2020; 22:71. [PMID: 32981527 PMCID: PMC7520984 DOI: 10.1186/s12968-020-00666-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 09/01/2020] [Indexed: 02/06/2023] Open
Abstract
The presentation and identification of cardiovascular disease in women pose unique diagnostic challenges compared to men, and underrecognized conditions in this patient population may lead to clinical mismanagement.This article reviews the sex differences in cardiovascular disease, explores the diagnostic and prognostic role of cardiovascular magnetic resonance (CMR) in the spectrum of cardiovascular disorders in women, and proposes the added value of CMR compared to other imaging modalities. In addition, this article specifically reviews the role of CMR in cardiovascular diseases occurring more frequently or exclusively in female patients, including Takotsubo cardiomyopathy, connective tissue disorders, primary pulmonary arterial hypertension and peripartum cardiomyopathy. Gaps in knowledge and opportunities for further investigation of sex-specific cardiovascular differences by CMR are also highlighted.
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Affiliation(s)
- Chiara Bucciarelli-Ducci
- Bristol Heart Institute, Bristol National Institute of Health Research (NIHR) Biomedical Research Centre, University Hospitals Bristol and University of Bristol, Bristol, UK
| | - Ellen Ostenfeld
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital Lund, Lund University, Getingevägen 5, SE-22185 Lund, Sweden
| | | | - Vanessa M. Ferreira
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Luba Frank
- University of Texas Medical Branch, Galveston, TX USA
| | | | | | | | - Elisa McAlindon
- Heart and Lung Centre, New Cross Hospital, Wolverhampton, UK
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265
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Denayer N, Troost E, Santens B, De Meester P, Roggen L, Moons P, Van Calsteren K, Budts W, Van De Bruaene A. Comparison of risk stratification models for pregnancy in congenital heart disease. Int J Cardiol 2020; 323:54-60. [PMID: 32931856 DOI: 10.1016/j.ijcard.2020.09.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pregnancy in women with congenital heart disease (CHD) is associated with increased risk for maternal cardiac complications. Several risk stratification models are used to predict adverse cardiac outcome in women with CHD who become pregnant. This study was set up as an exploratory study to provide a head-to-head comparison of the 4 most commonly used models: CARPREG, CARPREG II and ZAHARA risk scores and mWHO risk classification. METHODS AND RESULTS We randomly selected 100 women from the database of paediatric and congenital heart disease of the University Hospitals Leuven. Individual pregnancy risk scores were retrospectively calculated and summarized in a weighted average risk for each risk stratification model. To evaluate accuracy of each model, the weighted average risk was plotted against the actual observed number of "cardiac events" as defined in the respective risk models. Maternal adverse cardiac events occurred in 8% of our study population. Weighted average risks were plotted versus the observed number of events for each model: 10.1% versus 4.0% for CARPREG, 8.6% versus 5.0% for CARPREG II, 11.1% versus 8.0% for ZAHARA and 12.4% versus 8.0% for the mWHO classification. CONCLUSION All risk models overestimated maternal cardiac risk. The ZAHARA risk model appeared to be a closer reflection of maternal risk in our cohort of CHD patients. More research on a larger study population is needed.
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Affiliation(s)
- Nathalie Denayer
- Faculty of Medicine, Department of Internal Medicine, KU Leuven, Belgium
| | - Els Troost
- Division of Structural and Congenital Cardiology, University Hospitals Leuven, Belgium
| | - Béatrice Santens
- Division of Structural and Congenital Cardiology, University Hospitals Leuven, Belgium
| | - Pieter De Meester
- Division of Structural and Congenital Cardiology, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Leen Roggen
- Division of Structural and Congenital Cardiology, University Hospitals Leuven, Belgium
| | - Philip Moons
- Department of Public Health and Primary Care, KU Leuven, Belgium; Institute of Health and Care Science, University of Gothenburg, Sweden; Department of Paediatrics and Child Health, University of Cape Town, South Africa
| | | | - Werner Budts
- Division of Structural and Congenital Cardiology, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Alexander Van De Bruaene
- Division of Structural and Congenital Cardiology, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Belgium.
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266
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Ashton DJ, Greenberg SB. Post Repair Transposition of the Great Arteries: What You Need to Know. Semin Roentgenol 2020; 55:312-319. [PMID: 32859347 DOI: 10.1053/j.ro.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel J Ashton
- Department of Radiology and Department of Pediatrics, Arkansas Children's Hospital/University of Arkansas for Medical Sciences, Little Rock, AR.
| | - S Bruce Greenberg
- Department of Radiology and Department of Pediatrics, Arkansas Children's Hospital/University of Arkansas for Medical Sciences, Little Rock, AR
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267
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Yokouchi-Konishi T, Kamiya CA, Shionoiri T, Nakanishi A, Iwanaga N, Izumi C, Yasuda S, Yoshimatsu J. Pregnancy outcomes in women with dilated cardiomyopathy: Peripartum cardiovascular events predict post delivery prognosis. J Cardiol 2020; 77:217-223. [PMID: 32739112 DOI: 10.1016/j.jjcc.2020.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/26/2020] [Accepted: 07/02/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The number of pregnant women with dilated cardiomyopathy (DCM) is relatively small, and therefore their prognosis after pregnancy is unknown. This study aims to elucidate pregnancy outcomes among women with DCM, as well as the long-term prognosis after pregnancy. METHODS Thirty-five pregnancies and deliveries in 30 women, diagnosed with DCM before pregnancy, were retrospectively analyzed. RESULTS All women had a left ventricular ejection fraction (LVEF) over 30% and belonged to the New York Heart Association (NYHA) class I or II before pregnancy. The mean gestational age at delivery was 36 weeks with 15 (43%) preterm deliveries. Eight pregnancies (23%) were complicated by peripartum cardiac events including 1 ventricular arrhythmia, 6 heart failures, and 1 significant deterioration in LVEF requiring termination of pregnancy. NYHA class II, pre-pregnancy use of angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker/diuretics, elevated brain natriuretic peptide (BNP), and advanced diastolic dysfunction assessed by Doppler echocardiography were defined as risk factors for cardiac events. Although the more severe cases took beta-blockers during pregnancy, the rates of cardiac events and decreasing LVEF did not differ significantly between those taking beta-blockers and those who were not. Values of LVEF decreased by almost 10% after the average 4-year post-delivery follow-up period. The long-term event-free survival was considerably worse among women with peripartum cardiac events than in those without (p<0.0001). CONCLUSIONS DCM women with pre-pregnancy LVEF over 30% tolerated pregnancy, but the rate of preterm delivery was high. Peripartum cardiovascular events occurred more often in women with NYHA class II, as well as those who received medications before and during pregnancy and showed more elevated BNP and advanced diastolic dysfunction before pregnancy. Beta-blockers likely allowed similar outcomes for DCM patients with lower initial LVEFs. Close monitoring later in life is required, particularly among the women with peripartum cardiac events.
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Affiliation(s)
- Tae Yokouchi-Konishi
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan; Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Chizuko A Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Tadasu Shionoiri
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Atsushi Nakanishi
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naoko Iwanaga
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Jun Yoshimatsu
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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268
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Affiliation(s)
- Uri Elkayam
- Division of Cardiology and the Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Hezzy Shmueli
- Division of Cardiology and the Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
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269
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Chu R, Chen W, Song G, Yao S, Xie L, Song L, Zhang Y, Chen L, Zhang X, Ma Y, Luo X, Liu Y, Sun P, Zhang S, Fang Y, Dong T, Zhang Q, Peng J, Zhang L, Wei Y, Zhang W, Su X, Qiao X, Song K, Yang X, Kong B. Predicting the Risk of Adverse Events in Pregnant Women With Congenital Heart Disease. J Am Heart Assoc 2020; 9:e016371. [PMID: 32662348 PMCID: PMC7660735 DOI: 10.1161/jaha.120.016371] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Women with congenital heart disease are considered at high risk for adverse events. Therefore, we aim to establish 2 prediction models for mothers and their offspring, which can predict the risk of adverse events occurred in pregnant women with congenital heart disease. Methods and Results A total of 318 pregnant women with congenital heart disease were included; 213 women were divided into the development cohort, and 105 women were divided into the validation cohort. Least absolute shrinkage and selection operator was used for predictor selection. After validation, multivariate logistic regression analysis was used to develop the model. Machine learning algorithms (support vector machine, random forest, AdaBoost, decision tree, k‐nearest neighbor, naïve Bayes, and multilayer perceptron) were used to further verify the predictive ability of the model. Forty‐one (12.9%) women experienced adverse maternal events, and 93 (29.2%) neonates experienced adverse neonatal events. Seven high‐risk factors were discovered in the maternal model, including New York Heart Association class, Eisenmenger syndrome, pulmonary hypertension, left ventricular ejection fraction, sinus tachycardia, arterial blood oxygen saturation, and pregnancy duration. The machine learning–based algorithms showed that the maternal model had an accuracy of 0.76 to 0.86 (area under the receiver operating characteristic curve=0.74–0.87) in the development cohort, and 0.72 to 0.86 (area under the receiver operating characteristic curve=0.68–0.80) in the validation cohort. Three high‐risk factors were discovered in the neonatal model, including Eisenmenger syndrome, preeclampsia, and arterial blood oxygen saturation. The machine learning–based algorithms showed that the neonatal model had an accuracy of 0.75 to 0.80 (area under the receiver operating characteristic curve=0.71–0.77) in the development cohort, and 0.72 to 0.79 (area under the receiver operating characteristic curve=0.69–0.76) in the validation cohort. Conclusions Two prenatal risk assessment models for both adverse maternal and neonatal events were established, which might assist clinicians in tailoring precise management and therapy in pregnant women with congenital heart disease.
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Affiliation(s)
- Ran Chu
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Wei Chen
- School of Control Science and Engineering Shandong University Jinan Shandong China
| | - Guangmin Song
- Department of Cardiovascular Surgery Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Shu Yao
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Lin Xie
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Li Song
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Yue Zhang
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Lijun Chen
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Xiangli Zhang
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Yuyan Ma
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Xia Luo
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Yuan Liu
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Ping Sun
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Shuquan Zhang
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Yan Fang
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Taotao Dong
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Qing Zhang
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Jin Peng
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Lu Zhang
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Yuan Wei
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Wenxia Zhang
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Xuantao Su
- School of Control Science and Engineering Shandong University Jinan Shandong China
| | - Xu Qiao
- School of Control Science and Engineering Shandong University Jinan Shandong China
| | - Kun Song
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Xingsheng Yang
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Beihua Kong
- Department of Obstetrics and Gynecology Qilu Hospital Cheeloo College of Medicine Shandong University Jinan Shandong China
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270
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Furenäs E, Eriksson P, Wennerholm UB, Dellborg M. Cardiac Complications during Pregnancy Related to Parity in Women with Congenital Heart Disease. Cardiology 2020; 145:533-542. [PMID: 32659772 DOI: 10.1159/000508649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 04/23/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe the frequency of cardiac complications during pregnancy related to parity in women with congenital heart defects. METHODS A retrospective tertiary single-center study at the Adult Congenital Heart Disease Centre that followed 307 women with congenital heart disease during the years 1997-2015 in Gothenburg, Sweden. Ma-ternal cardiac complications were noted for each pregnancy using medical and obstetric records. The CARPREG I and modified WHO (mWHO) risk classifications were used. Twin pregnancies, miscarriages before gestational week 13, and pregnancy terminations were excluded. RESULTS Five hundred seventy-one deliveries and 9 late miscarriages were analyzed. The mean parity was 1.74 per woman (range 1-8). Eighty-four (14.6%) maternal cardiac complications were experienced; arrhythmia (5.7%) and heart failure (4.4%) being the most prevalent, and there was 1 maternal death. Heart failure occurred during the first pregnancy in 12 women (3.9%), in the second pregnancy in 8 women (4.3%), and in the third pregnancy in 4 women (7.7%). CARPREG I and mWHO scores were associated with an increased risk of having a cardiac complication, while parity per se was not associated. The OR for having a maternally uneventful second pregnancy if the first pregnancy was without cardiac complications was 5.47 (95% CI 1.76-16.94) after controlling for CARPREG I and mWHO scores. CONCLUSION The risk of severe maternal cardiac complications during pregnancy in women with congenital heart disease is low. In this largest analysis to date with a focus on parity in 307 women, the risk classification predicts the maternal outcome more than parity per se. If the first pregnancy is uneventful, the OR is 5.5 for an uneventful second pregnancy if CARPREG I and mWHO scores remain unchanged.
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Affiliation(s)
- Eva Furenäs
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, .,Center for Adults with Congenital Heart Disease (ACHD), Department of Medicine/Östra, Sahlgrenska University Hospital, Gothenburg, Sweden,
| | - Peter Eriksson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Center for Adults with Congenital Heart Disease (ACHD), Department of Medicine/Östra, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ulla-Britt Wennerholm
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Mikael Dellborg
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Center for Adults with Congenital Heart Disease (ACHD), Department of Medicine/Östra, Sahlgrenska University Hospital, Gothenburg, Sweden
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271
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Abstract
Women with heart disease are at increased risk for maternal and fetal complications in pregnancy. Therefore, all women with heart disease should undergo evaluation and counseling, ideally before conception, or as early in pregnancy as possible. In this article we will review the role of risk assessment, the history of development of the cardiac risk prediction tools, and the role of current cardiac risk prediction tools.
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272
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Manolis TA, Manolis AA, Apostolopoulos EJ, Papatheou D, Melita H, Manolis AS. Cardiac arrhythmias in pregnant women: need for mother and offspring protection. Curr Med Res Opin 2020; 36:1225-1243. [PMID: 32347120 DOI: 10.1080/03007995.2020.1762555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cardiac arrhythmias are the most common cardiac complication reported in pregnant women with and without structural heart disease (SHD); they are more frequent among women with SHD, such as cardiomyopathy and congenital heart disease (CHD). While older studies had indicated supraventricular tachycardia as the most common tachyarrhythmia in pregnancy, more recent data indicate an increase in the frequency of arrhythmias, with atrial fibrillation (AF) emerging as the most frequent arrhythmia in pregnancy, attributed to an increase in maternal age, cardiovascular risk factors and CHD in pregnancy. Importantly, the presence of any tachyarrhythmia during pregnancy may be associated with adverse maternal and fetal outcomes, including death. Thus, both the mother and the offspring need to be protected from such consequences. The use of antiarrhythmic drugs (AADs) depends on clinical presentation and on the presence of underlying SHD, which requires caution as it promotes pro-arrhythmia. In hemodynamically compromised women, electrical cardioversion is successful and safe to both mother and fetus. Use of beta-blockers appears quite safe; however, caution is advised when using other AADs, while no AAD should be used, if at all possible, during the first trimester when organogenesis takes place. Regarding the anticoagulation regimen in patients with AF, warfarin should be substituted with heparin during the first trimester, while direct oral anticoagulants are not indicated given the lack of data in pregnancy. Finally, for refractory arrhythmias, ablation and/or device implantation can be performed with current techniques in pregnant women, when needed, using minimal exposure to radiation. All these issues and relevant current guidelines are herein reviewed.
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273
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Ramlakhan KP, Ahmed I, Johnson MR, Roos-Hesselink JW. Congenital heart disease and family planning: Preconception care, reproduction, contraception and maternal health. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2020. [DOI: 10.1016/j.ijcchd.2020.100049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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274
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Affiliation(s)
- Iris M van Hagen
- Cardiology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
- Cardiology, Maasstad Hospital, Rotterdam, Zuid-Holland, The Netherlands
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275
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Baghel J, Keepanasseril A, Pillai AA, Mondal N, Jeganathan Y, Kundra P. Prediction of adverse cardiac events in pregnant women with valvular rheumatic heart disease. Heart 2020; 106:1400-1406. [PMID: 32601124 DOI: 10.1136/heartjnl-2020-316648] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the incidence of adverse cardiac events in pregnant women with rheumatic valvular heart disease (RHD) and to derive a clinical risk scoring for predicting it. METHODS This is an observational study involving pregnant women with RHD, attending a tertiary centre in south India. Data regarding obstetric history, medical history, maternal complications and perinatal outcome till discharge were collected. Eight-hundred and twenty pregnancies among 681 women were included in the analysis. Primary outcome was composite adverse cardiac event defined as occurrence of one or more of complications such as death, cardiac arrest, heart failure, cerebrovascular accident from thromboembolism and new-onset arrhythmias. RESULTS Of the 681 women with RHD, 180 (26.3%) were diagnosed during pregnancy. Composite adverse cardiac outcome during pregnancy/post partum occurred in 122 (14.9%) pregnancies, with 12 of them succumbed to the disease. In multivariate analysis, prior adverse cardiac events (OR=8.35, 95% CI 3.54 to 19.71), cardiac medications at booking (OR=0.53, 95% CI 0.32 to 0.86), mitral stenosis (mild OR=2.48, 95% CI 1.08 to 5.69; moderate OR=2.23, 95% CI 1.19 to 4.18; severe OR=7.72,95% 4.05 to 12.89), valve replacement (OR=2.53, 95% CI 1.28 to 5.02) and pulmonary hypertension (OR=6.90, 3.81 to 12.46) were predictive of composite adverse cardiac events with a good discrimination (area under the curve=0.803) and acceptable calibration. A predictive score combining these factors is proposed for clinical utility. CONCLUSION Heart failure remains the most common adverse cardiac event during pregnancy or puerperium. Combining the lesion-specific characteristics and clinical information into a predictive score, which is simple and effective, could be used in routine clinical practice.
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Affiliation(s)
- Jyoti Baghel
- Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Anish Keepanasseril
- Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Ajith Ananthakrishna Pillai
- Cardiology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nivedita Mondal
- Neonatology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Yavanasuriya Jeganathan
- Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Pankaj Kundra
- Anaesthesiology & Critical Care, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
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276
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Wang J, Lu J. Anesthesia for Pregnant Women with Pulmonary Hypertension. J Cardiothorac Vasc Anesth 2020; 35:2201-2211. [PMID: 32736999 DOI: 10.1053/j.jvca.2020.06.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 12/12/2022]
Abstract
Despite advances in the therapy for pulmonary hypertension over the past decades, the prognosis of pregnant patients with pulmonary hypertension remains poor, with high maternal mortality. This poses a particular challenge for the mother and her medical team. In the present review, the authors have updated the classification and definition of pulmonary hypertension, summarized the current knowledge with regard to perioperative management and anesthesia considerations for these patients, and stressed the importance of a "pregnancy heart team" to improve long-term outcomes of pregnant women with pulmonary hypertension.
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Affiliation(s)
- Jiawan Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jiakai Lu
- Department of Anesthesiology, Beijing An-Zhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China.
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277
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Jayasooriya G, Silversides C, Raghavan G, Balki M. Anesthetic management of women with heart failure during pregnancy: a retrospective cohort study. Int J Obstet Anesth 2020; 44:40-50. [PMID: 32739747 DOI: 10.1016/j.ijoa.2020.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/08/2020] [Accepted: 06/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of heart failure among pregnant women with pre-existing cardiac disease is quoted as 13%, with 10% requiring hospitalization. There is limited literature on heart failure in the pregnant population. The study objective was to describe the etiology and management of women hospitalized in our institution for heart failure during pregnancy. METHODS A retrospective cohort study investigated women who presented with heart failure in pregnancy between 2004 and 2017. Hospital records were interrogated using International Classification of Diseases v10 codes for heart failure. Patient characteristics, investigations, treatment, obstetric and anesthetic management, and maternal-fetal outcome data were collected and summarized using descriptive statistics. RESULTS One-hundred-and-twenty cases (in 93 122 deliveries) were identified across the 13-year period (antepartum heart failure 51%, postpartum heart failure 49%).The most common etiologies were pre-eclampsia (28%), cardiomyopathy (22%), and valvular heart disease (18%). Cesarean delivery occurred in 76% of cases (13% because of the maternal cardiac condition). Neuraxial techniques were used for most deliveries (cesarean 83%; vaginal 90%). For cesarean delivery, titrated epidural or general anesthesia was employed in 48% and 16%, respectively. Cardiac arrest occurred in two cases (1.7%) and 44% required coronary or intensive care unit admission. CONCLUSIONS The incidence of heart failure was 0.13% (1:776 deliveries). Pre-eclampsia was the leading cause but may have been historically under-acknowledged. Anesthetic and obstetrical decisions were tailored by means of multidisciplinary input, with cesarean delivery and regional anesthesia used in the majority. The postpartum period warrants heightened attention for these patients.
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Affiliation(s)
- G Jayasooriya
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Canada
| | - C Silversides
- Division of Cardiology, Pregnancy and Heart Disease Program, Department of Medicine, Mount Sinai Hospital, University of Toronto, Canada
| | - G Raghavan
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Canada
| | - M Balki
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Canada; Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Canada.
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278
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Duarte VE, Graf JA, Marshall AC, Economy KE, Valente AM. Transcatheter Pulmonary Valve Performance During Pregnancy and the Postpartum Period. JACC Case Rep 2020; 2:847-851. [PMID: 34317364 PMCID: PMC8302026 DOI: 10.1016/j.jaccas.2020.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 02/26/2020] [Indexed: 11/30/2022]
Abstract
Increasing numbers of women with congenital heart disease are undergoing pregnancy after transcatheter pulmonary valve replacement (TPVR). We present the course of 9 pregnancies in 7 women with TPVR, noting pre-pregnancy, antepartum, and postpartum gradients, as well as maternal cardiac, obstetric, and neonatal outcomes. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Valeria E Duarte
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Julia A Graf
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Katherine E Economy
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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279
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Mehta LS, Warnes CA, Bradley E, Burton T, Economy K, Mehran R, Safdar B, Sharma G, Wood M, Valente AM, Volgman AS. Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e884-e903. [DOI: 10.1161/cir.0000000000000772] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardio-obstetrics has emerged as an important multidisciplinary field that requires a team approach to the management of cardiovascular disease during pregnancy. Cardiac conditions during pregnancy include hypertensive disorders, hypercholesterolemia, myocardial infarction, cardiomyopathies, arrhythmias, valvular disease, thromboembolic disease, aortic disease, and cerebrovascular diseases. Cardiovascular disease is the primary cause of pregnancy-related mortality in the United States. Advancing maternal age and preexisting comorbid conditions have contributed to the increased rates of maternal mortality. Preconception counseling by the multidisciplinary cardio-obstetrics team is essential for women with preexistent cardiac conditions or history of preeclampsia. Early involvement of the cardio-obstetrics team is critical to prevent maternal morbidity and mortality during the length of the pregnancy and 1 year postpartum. A general understanding of cardiovascular disease during pregnancy should be a core knowledge area for all cardiovascular and primary care clinicians. This scientific statement provides an overview of the diagnosis and management of cardiovascular disease during pregnancy.
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280
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Downing KF, Tepper NK, Simeone RM, Ailes EC, Gurvitz M, Boulet SL, Honein MA, Howards PP, Valente AM, Farr SL. Adverse Pregnancy Conditions Among Privately Insured Women With and Without Congenital Heart Defects. Circ Cardiovasc Qual Outcomes 2020; 13:e006311. [PMID: 32506927 DOI: 10.1161/circoutcomes.119.006311] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background In women with congenital heart defects (CHD), changes in blood volume, heart rate, respiration, and edema during pregnancy may lead to increased risk of adverse outcomes and conditions. The American Heart Association recommends providers of pregnant women with CHD assess cardiac health and discuss risks and benefits of cardiac-related medications. We described receipt of American Heart Association-recommended cardiac evaluations, filled potentially teratogenic or fetotoxic (Food and Drug Administration pregnancy category D/X) cardiac-related prescriptions, and adverse conditions among pregnant women with CHD compared with those without CHD. Methods and Results Using 2007 to 2014 US healthcare claims data, we ascertained a retrospective cohort of women with and without CHD aged 15 to 44 years with private insurance covering prescriptions during pregnancy. CHD was defined as ≥1 inpatient code or ≥2 outpatient CHD diagnosis codes >30 days apart documented outside of pregnancy and categorized as severe or nonsevere. Log-linear regression, accounting for multiple pregnancies per woman, generated adjusted prevalence ratios (aPRs) for associations between the presence/severity of CHD and stillbirth, preterm birth, and adverse conditions from the last menstrual period to 90 days postpartum. We identified 2056 women with CHD (2334 pregnancies) and 1 374 982 women without (1 524 077 pregnancies). During the last menstrual period to 90 days postpartum, 56% of women with CHD had comprehensive echocardiograms and, during pregnancy, 4% filled potentially teratogenic or fetotoxic cardiac-related prescriptions. Women with CHD, compared with those without, experienced more adverse conditions overall (aPR, 1.9 [95% CI, 1.7-2.1]) and, specifically, obstetric (aPR, 1.3 [95% CI, 1.2-1.4]) and cardiac conditions (aPR, 10.2 [95% CI, 9.1-11.4]), stillbirth (aPR, 1.6 [95% CI, 1.1-2.4]), and preterm delivery (aPR, 1.6 [95% CI, 1.4-1.8]). More women with severe CHD, compared with nonsevere, experienced adverse conditions overall (aPR, 1.5 [95% CI, 1.2-1.9]). Conclusions Women with CHD have elevated prevalence of adverse cardiac and obstetric conditions during pregnancy; 4 in 100 used potentially teratogenic or fetotoxic medications, and only half received an American Heart Association-recommended comprehensive echocardiogram.
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Affiliation(s)
- Karrie F Downing
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities (K.F.D., R.M.S., E.C.A., M.A.H., S.L.F.), Centers for Disease Control and Prevention, Atlanta, GA
| | - Naomi K Tepper
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion (N.K.T.), Centers for Disease Control and Prevention, Atlanta, GA
| | - Regina M Simeone
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities (K.F.D., R.M.S., E.C.A., M.A.H., S.L.F.), Centers for Disease Control and Prevention, Atlanta, GA
| | - Elizabeth C Ailes
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities (K.F.D., R.M.S., E.C.A., M.A.H., S.L.F.), Centers for Disease Control and Prevention, Atlanta, GA
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA (M.G., A.M.V.).,Department of Medicine, Division of Cardiovascular Disease, Brigham and Women's Hospital, Boston, MA (M.G., A.M.V.)
| | - Sheree L Boulet
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA (S.L.B.)
| | - Margaret A Honein
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities (K.F.D., R.M.S., E.C.A., M.A.H., S.L.F.), Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Anne M Valente
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA (M.G., A.M.V.).,Department of Medicine, Division of Cardiovascular Disease, Brigham and Women's Hospital, Boston, MA (M.G., A.M.V.)
| | - Sherry L Farr
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities (K.F.D., R.M.S., E.C.A., M.A.H., S.L.F.), Centers for Disease Control and Prevention, Atlanta, GA
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281
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Guasch E, Brogly N, Gilsanz F. Combined spinal epidural for labour analgesia and caesarean section: indications and recommendations. Curr Opin Anaesthesiol 2020; 33:284-290. [DOI: 10.1097/aco.0000000000000866] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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282
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Hu J, Ye Y, Lu A, Chen L, Mai Y, Huang G, Wang S. Pregnancy Outcomes in Patients With Heart Disease in China. Am J Cardiol 2020; 125:1718-1724. [PMID: 32284176 DOI: 10.1016/j.amjcard.2020.02.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/20/2020] [Accepted: 02/24/2020] [Indexed: 11/29/2022]
Abstract
To analyze pregnancy outcomes of patients with heart disease in a single center and to explore the risk factors of adverse outcomes. One thousand thirty-three pregnant women with heart disease were retrospectively included from 2010 to 2017. We collected data of maternal, obstetric, and fetal outcomes. Among 1,086 pregnancies, 295 (27.1%) with congenital heart disease, 244 (22.5%) with rheumatic heart disease, 387 (35.6%) with arrhythmia, and 55 (5.1%) with cardiomyopathy. There were 8 (0.7%) maternal deaths. Risk factors of mortality were New York Heart Association (NYHA) classification IV (p <0.001), cardiac surgery during pregnancy (p <0.001), and general anesthesia (p <0.001). Maternal cardiac complications occurred in 6.7% of women, with most in the cardiomyopathy (26.0%) and rheumatic heart disease (32.9%) groups. Multivariate logistic regression modeling was used to analyze the potential risk factors. NYHA classification III and IV independently predicted worse maternal outcomes. Peripartum intensive care unit admission rate was 10.2%. Admission to intensive care unit was associated with NYHA classification II/III/IV, modified World Health Organization (mWHO) classification II-III/III/IV, and cardiac surgery during pregnancy. In conclusion, pregnancy with heart disease is at higher risk of complications for both women and neonates. In our findings, maternal morbidity is associated with NYHA classification and mWHO classification.
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Affiliation(s)
- Jiaqi Hu
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Yingxian Ye
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Anyi Lu
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Liwen Chen
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Yongjian Mai
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Guiting Huang
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Sheng Wang
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China.
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283
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Grewal J, Siu SC, Lee T, D’Souza R, Dvir M, Singer J, Rychel V, Kiess M, Sermer M, Silversides CK. Impact of Beta-Blockers on Birth Weight in a High-Risk Cohort of Pregnant Women With CVD. J Am Coll Cardiol 2020; 75:2751-2752. [DOI: 10.1016/j.jacc.2020.03.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/25/2020] [Accepted: 03/23/2020] [Indexed: 01/09/2023]
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284
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Anwar AD, Winarno GNA, Anggraeni EN. Correlation Between Risk or Severity of Heart Failure and Outcome of Pregnancy. Int J Gen Med 2020; 13:201-206. [PMID: 32547161 PMCID: PMC7246308 DOI: 10.2147/ijgm.s240613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 04/28/2020] [Indexed: 11/23/2022] Open
Abstract
Background The incidence of heart failure in pregnancy increases by 1–4% every year and causes 9% of maternal mortality worldwide. Determinant factors, characteristics, and risk factors influence the incidence of heart disease in pregnancy, so the early detection of determinant factors can reduce the incidence of heart disease in pregnancy. This study aimed to find the relationship between determinant factors of maternal and fetal outcomes with the severity of heart disease in pregnancy. Methods This was an observational cross-sectional analytical study. We used 342 cases of heart disease in pregnancy that were recorded in medical records at Dr. Hasan Sadikin Hospital, Bandung, Indonesia, from January 2014 to December 2018. The data were grouped based on the severity of heart disease according to the New York Heart Association (NYHA) classification. The relationship of maternal determinant factors with the severity of heart disease was analyzed based on the NYHA classification. Results Maternal occupation was significantly associated with a higher risk of NYHA class III–IV heart disease. Most of the patients with NYHA class III-IV were housewives. The severity of heart disease was also influenced by severe preeclampsia (p<0.05) as a risk factor. Maternal outcome with heart disease of severity NYHA class III–IV was worse than with NYHA class I–II. The risk of maternal death was higher, and the mother’s length of stay in hospital and her need for monitoring were also increased. There were no significant differences in the outcome of the fetus, but the incidence of fetal mortality increased in patients with heart disease severity III–IV. Conclusion Maternal determinant factors did not correlate with the severity of heart disease in pregnancy. Maternal outcomes were worse with increasing severity of heart disease. Fetal mortality was correlated with severity of heart disease but other outcomes were not affected.
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Affiliation(s)
- Anita Deborah Anwar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Gatot N A Winarno
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Elsy Nur Anggraeni
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
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285
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Heland S, de Chellis A, Rieder W, Sleeman M, Johns J, Lancefield T, Robinson A, Fung A, Walker S. Good at heart: Developing a tertiary perinatal cardiac service; the first eight years of experience. Aust N Z J Obstet Gynaecol 2020; 60:760-765. [PMID: 32323865 DOI: 10.1111/ajo.13160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 03/01/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Maternal cardiac disease is the most common cause of indirect maternal death, and women with pre-existing cardiac disease have complex medical, obstetric and anaesthetic requirements. Our hospital commenced a multidisciplinary perinatal cardiac service in 2009 to optimise outcomes in women with cardiac disease. AIM To assess the maternal and perinatal outcomes of women referred to the clinic to evaluate clinical practice and inform future service provision. MATERIALS AND METHODS This is a single-centre retrospective study of women referred to the perinatal cardiac service between 2009-2016. Data collected included: demographic details; cardiac diagnosis; pregnancy outcomes, including anaesthetic and delivery complications, and admission to intensive care unit (ICU)/high dependency unit (HDU). RESULTS One hundred and fifty-two women were referred for care in 165 pregnancies. Congenital heart disease was the most common indication for referral (35%), followed by maternal cardiac arrhythmia (26%) and valvular disease (18%). The perinatal mortality rate was 2%, median gestational age at delivery was 38 weeks 4 days, fetal growth restriction (customised birthweight <10th centile) was 9% although 25 (17%) pregnancies resulted in preterm birth, 36% of which were spontaneous and 64% were iatrogenic. Maternal outcomes were favourable and there were no maternal deaths. However, 51% of women required a caesarean section, and 23% who achieved a live birth required ICU/HDU admission. CONCLUSION This study confirmed that women with cardiac disease are at increased risk of preterm birth, and high acuity in the peripartum period but otherwise good maternal and perinatal outcomes. An integrated multidisciplinary perinatal cardiac service can optimise perinatal outcomes in these women.
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Affiliation(s)
- Sarah Heland
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Adam de Chellis
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Wawrzyniec Rieder
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Matthew Sleeman
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Jennifer Johns
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Terase Lancefield
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Andrew Robinson
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Alison Fung
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | - Susan Walker
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
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286
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287
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Wang TKM, Lowe B, Hlohovsky S, O'Donnell C. Performance of risk models predicting cardiac complications in pregnant women with congenital heart disease: a meta‐analysis. Intern Med J 2020; 50:481-484. [DOI: 10.1111/imj.14810] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/28/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Tom Kai Ming Wang
- Paediatric and Congenital Cardiac ServiceStarship Hospital Auckland New Zealand
- Green Lane Cardiovascular ServiceAuckland City Hospital Auckland New Zealand
| | - Boris Lowe
- Paediatric and Congenital Cardiac ServiceStarship Hospital Auckland New Zealand
- Green Lane Cardiovascular ServiceAuckland City Hospital Auckland New Zealand
| | - Stephanie Hlohovsky
- Paediatric and Congenital Cardiac ServiceStarship Hospital Auckland New Zealand
| | - Clare O'Donnell
- Paediatric and Congenital Cardiac ServiceStarship Hospital Auckland New Zealand
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288
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Morbidity in Pregnant Women with a Prosthetic Heart Valve. Am J Obstet Gynecol MFM 2020; 2:100105. [PMID: 33345864 DOI: 10.1016/j.ajogmf.2020.100105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Women with a prosthetic heart valve are perceived to be at higher risk for adverse outcomes, but their absolute and relative risk of experiencing maternal morbidity and cardiac complications is largely unknown. OBJECTIVE The objective of the study was to determine the risk of maternal morbidity and cardiac complications in women with a prior heart valve replacement, compared with matched counterparts without known cardiac disease. STUDY DESIGN A retrospective population-based matched cohort study was completed in the province of Ontario, Canada, where there is universal health care. Included were all women of child-bearing age who had bioprosthetic or mechanical replacement of the mitral or aortic valve, April 1994 to March 2016 (valve replacement group). Those in the valve replacement group, and who had at least 1 birth, were 1:4 matched to a community comparison group without heart disease and who also had at least 1 birth. Matching was by maternal age at cohort entry, year of cohort entry, geographic area, income level, and age at first birth. Maternal outcomes included severe maternal morbidity, all-cause mortality, and cardiac morbidity as well as a prolonged hospital length of stay >7 days. Relative risks and 95% confidence intervals were further adjusted for age at birth and immigration status. RESULTS There were 90 live births among the 64 women in the valve replacement group and 404 live births among the 253 women in the matched community comparison group. There were no stillbirths. Severe maternal morbidity occurred in 13 pregnancies (14.4%) in the valve replacement group and 6 (1.5%) in the community comparison group (adjusted relative risk, 9.73, 95% confidence interval, 3.70-25.59); there were no maternal deaths. The corresponding rates of prolonged hospital length of stay were 37.8% and 18.8% (adjusted relative risk, 2.33, 95% confidence interval, 1.48-3.67). CONCLUSION Pregnant women who had aortic or mitral valve replacement were more likely to experience severe maternal morbidity, as well as prolonged hospital length of stay, than matched counterparts without heart disease. This information can enhance shared decision making about the timing of valve replacement and pregnancy planning in young and middle-aged women. To determine the absolute and relative risk of maternal morbidity and cardiac complications in women with prior heart valve replacement, a retrospective population-based matched cohort study was completed in the province of Ontario, Canada, where there is universal health care. Included were all women of child-bearing age who had bioprosthetic or mechanical replacement of the mitral or aortic valve, April 1994 to March 2016 (valve replacement group). Those in the valve replacement group, and who had at least one birth, were 1:4 matched to a community comparison group without heart disease and who also had at least 1 birth. There were 90 live births among the 64 women in the valve replacement group and 404 live births among the 253 women in the matched community comparison group. Severe maternal morbidity occurred in 13 pregnancies (14.4%) in the valve replacement group and 6 (1.5%) in the community comparison group (adjusted relative risk, 9.73); there were no maternal deaths. The corresponding rates of prolonged hospital length of stay were 37.8% and 18.8% (adjusted relative risk, 2.33). In summary, pregnant women who had an aortic or mitral valve replacement were more likely to experience severe maternal morbidity, as well as prolonged hospital length of stay, than matched counterparts without heart disease.
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289
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Weiniger CF. What's new in obstetric anesthesia in 2018? Int J Obstet Anesth 2020; 42:99-108. [PMID: 32278531 DOI: 10.1016/j.ijoa.2020.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/20/2020] [Accepted: 03/11/2020] [Indexed: 10/24/2022]
Abstract
The Gerard W. Ostheimer Lecture presented at the annual meeting of the Society of Obstetric Anesthesia and Perinatology (SOAP) is a one-year summary of the literature published in domains of interest to anesthesiologists who manage and care for obstetric patients. One individual is asked to review the literature and present the lecture. This manuscript summarizes aspects of the Gerard W. Ostheimer Lecture presented at the 2019 SOAP meeting; the relevant literature from 2018 was summarized. The topics included in this review are maternal morbidity, antibiotic prophylaxis, anaphylaxis, the Lancet series on increasing cesarean delivery rates, the Robson Ten-Group Classification System, pelvic floor disorders, timing of delivery in nulliparous women, placenta accreta disorders, anesthesia for cesarean delivery, labor analgesia (including parturients with thrombocytopenia and tattoos, and epidural maintenance with the programmed intermittent epidural bolus technique), ultrasound use in obstetric anesthesia, and drugs in pregnancy.
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Affiliation(s)
- C F Weiniger
- Division of Anesthesia, Critical Care and Pain, Tel Aviv Sourasky Medical Center, Israel.
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290
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Millington S, Arstall M, Dekker G, Magarey J, Clark R. Adherence to clinical practice guidelines for South Australian pregnant women with cardiac conditions between 2003 and 2013. PLoS One 2020; 15:e0230459. [PMID: 32182282 PMCID: PMC7077829 DOI: 10.1371/journal.pone.0230459] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/01/2020] [Indexed: 12/19/2022] Open
Abstract
Background For pregnant women with a known cardiac condition or those who develop cardiac disease during pregnancy, there is an increased risk of complications during pregnancy, to both mother and foetus. To reduce this risk, best practice guidelines have been developed and available in South Australia for several years. Measuring clinical practice against the guideline recommendations verifies real-life practice and an essential part of any clinical practice quality improvement project by identifying gaps. This study is the first report on adherence to statewide perinatal guidelines for these women in South Australia. Objectives Design A retrospective cross-sectional observational design that analysed data from medical records. Setting Three SA Health public metropolitan, university-affiliated teaching hospitals with an obstetric service within a ten-year timeframe (2003–2013). Participants 271 admissions of women who were categorised as ‘pre-existent’ or ‘newly acquired’ cardiac condition during their pregnancy. Outcome measures Adherence to guidelines was measured using a purposefully designed scoring system across the three sites. The researcher chose a minimum acceptable score of 17 applicable to the ‘newly acquired’ group and 35 for the ‘pre-existent’ group. Results Overall adherence to the perinatal guidelines for the combined groups (n = 271) reported a mean score of 16.3, SD ± 6.7, with a median score of 17. Women in the ‘newly acquired’ group scored less compared to women in the ‘pre-existent’ group (Estimate -2.3, CI -3.9,-0.7). Variance in adherence was observed across the three hospitals (P value <0.0001). The most significant predictor of adherence to guidelines was pre-pregnancy cardiac consultation which increased the likelihood of preconception care by Odds ratio 18.5 (95%, CI 2, 168). Similarly, compliance with mental health screening was associated with improved adherence to antenatal assessments (OR: 11.3(95% CI 4.7, 27.3). Conclusion There was overall suboptimal adherence to the statewide guidelines for women with cardiac conditions in pregnancy. The variance in the level of adherence across the three hospitals correlated with the exposure to higher acuity cases, and that appropriate up- referral to a higher acuity hospital was intrinsically linked to better adherence. Recommendations include preconception counselling, and to ensure that all health practitioners have the skills, sufficient training and time to complete a comprehensive initial antenatal assessment Trial registration ACTRN12617000417381
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Affiliation(s)
- Sandra Millington
- Adelaide Nursing School and Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia
- * E-mail:
| | - Margaret Arstall
- Department of Cardiology at the Northern Adelaide Local Health Network (NAHLN) and the University of Adelaide, Adelaide, South Australia
| | - Gustaaf Dekker
- Obstetrics & Gynaecology for the Women’s and Children’s Division of Northern Adelaide Health Network (Lyell McEwin Hospital and Modbury Hospitals) and the University of Adelaide, Adelaide, South Australia
| | - Judith Magarey
- Adelaide Nursing School, Faculty of Health and Medical Sciences, the University of Adelaide, Adelaide, South Australia
| | - Robyn Clark
- College of Nursing and Health Science, Flinders University, Adelaide, South Australia
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291
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Arya R. Pregnancy outcomes in women with mechanical prosthetic heart valves. Thromb Res 2020; 181 Suppl 1:S37-S40. [PMID: 31477226 DOI: 10.1016/s0049-3848(19)30365-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/28/2019] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
Abstract
Pregnancy outcomes in women with mechanical heart valves (MHV) remain poor. The thrombogenicity of MHV, the hypercoagulable state of pregnancy and limitations of current anticoagulation strategies combine to give a very high risk state. Recent additions to the literature in the form of registry data as well as meta-analyses and systematic reviews have highlighted the risks of thrombotic and haemorrhagic events in mothers and increased fetal complication rates. There remains a lack of consensus about the optimal anticoagulation approach to mitigate the risks to mother and fetus and registry data confirm poor quality of care. Current guidelines recommend the sequential use of heparin and vitamin K antagonists, but low molecular weight heparin is often used throughout the pregnancy, with inadequate monitoring in many instances. There is an urgent need to standardise the management of such women, which should be undertaken in specialist centres, supported by research on optimal anticoagulation regimens and the impact on pregnancy outcomes.
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Affiliation(s)
- Roopen Arya
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, UK.
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292
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Raskind-Hood C, Saraf A, Riehle-Colarusso T, Glidewell J, Gurvitz M, Dunn JE, Lui GK, Van Zutphen A, McGarry C, Hogue CJ, Hoffman T, Rodriguez III FH, Book WM. Assessing Pregnancy, Gestational Complications, and Co-morbidities in Women With Congenital Heart Defects (Data from ICD-9-CM Codes in 3 US Surveillance Sites). Am J Cardiol 2020; 125:812-819. [PMID: 31902476 DOI: 10.1016/j.amjcard.2019.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/27/2019] [Accepted: 12/04/2019] [Indexed: 12/13/2022]
Abstract
Improved treatment of congenital heart defects (CHDs) has resulted in women with CHDs living to childbearing age. However, no US population-based systems exist to estimate pregnancy frequency or complications among women with CHDs. Cases were identified in multiple data sources from 3 surveillance sites: Emory University (EU) whose catchment area included 5 metropolitan Atlanta counties; Massachusetts Department of Public Health (MA) whose catchment area was statewide; and New York State Department of Health (NY) whose catchment area included 11 counties. Cases were categorized into one of 5 mutually exclusive CHD severity groups collapsed to severe versus not severe; specific ICD-9-CM codes were used to capture pregnancy, gestational complications, and nongestational co-morbidities in women, age 11 to 50 years, with a CHD-related ICD-9-CM code. Pregnancy, CHD severity, demographics, gestational complications, co-morbidities, and insurance status were evaluated. ICD-9-CM codes identified 26,655 women with CHDs, of whom 5,672 (21.3%, range: 12.8% in NY to 22.5% in MA) had codes indicating a pregnancy. Over 3 years, age-adjusted proportion pregnancy rates among women with severe CHDs ranged from 10.0% to 24.6%, and 14.2% to 21.7% for women with nonsevere CHDs. Pregnant women with CHDs of any severity, compared with nonpregnant women with CHDs, reported more noncardiovascular co-morbidities. Insurance type varied by site and pregnancy status. These US population-based, multisite estimates of pregnancy among women with CHD indicate a substantial number of women with CHDs may be experiencing pregnancy and complications. In conclusion, given the growing adult population with CHDs, reproductive health of women with CHD is an important public health issue.
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293
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D'Souza RD, Silversides CK, Tomlinson GA, Siu SC. Assessing Cardiac Risk in Pregnant Women With Heart Disease: How Risk Scores Are Created and Their Role in Clinical Practice. Can J Cardiol 2020; 36:1011-1021. [PMID: 32502425 DOI: 10.1016/j.cjca.2020.02.079] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/03/2020] [Accepted: 02/19/2020] [Indexed: 01/05/2023] Open
Abstract
Pregnancy, which is associated with profound cardiovascular changes and higher risk of thrombosis, increases the risk of cardiovascular complications in women with pre-existing heart disease. A comprehensive history and physical examination, 12-lead electrocardiogram, and transthoracic echocardiogram remain the foundation of assessing cardiac risk during pregnancy in women with heart disease. These are often combined to generate risk scores, which are statistically derived. Several statistically derived risk and 1 lesion-specific classification system are currently available. A suggested clinical approach to risk stratification is first to identify pregnancies in women with cardiac lesions at risk for serious or life-threatening maternal cardiac complications and for the remainder to use the Cardiac Disease in Pregnancy II (CARPREG II) risk score, integrating additional lesion-specific and patient-specific information. Conversely, clinicians can use the modified World Health Organization (mWHO) risk classification system and integrate general risk predictors and patient-specific information. Importantly, cardiac-risk assessment should always incorporate clinical judgement in addition to the use of risk scores or risk-classification systems. As pregnant women with heart disease are also at risk for obstetric and fetoneonatal complications, risk assessment should be performed by a multidisciplinary team, preferably before conception, or as soon as conception is confirmed, and repeated at regular intervals during the course of pregnancy.
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Affiliation(s)
- Rohan D D'Souza
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Candice K Silversides
- University of Toronto Pregnancy and Heart Disease and Obstetric Medicine Program, Toronto, Ontario, Canada; Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - George A Tomlinson
- Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Samuel C Siu
- University of Toronto Pregnancy and Heart Disease and Obstetric Medicine Program, Toronto, Ontario, Canada; Division of Cardiology, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
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Abstract
Maternal heart disease has emerged as a major threat to safe motherhood and women's long-term cardiovascular health. In the United States, disease and dysfunction of the heart and vascular system as "cardiovascular disease" is now the leading cause of death in pregnant women and women in the postpartum period () accounting for 4.23 deaths per 100,000 live births, a rate almost twice that of the United Kingdom (). The most recent data indicate that cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths (). Of further concern are the disparities in cardiovascular disease outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women. Contributing factors include barriers to prepregnancy cardiovascular disease assessment, missed opportunities to identify cardiovascular disease risk factors during prenatal care, gaps in high-risk intrapartum care, and delays in recognition of cardiovascular disease symptoms during the puerperium. The purpose of this document is to 1) describe the prevalence and effect of heart disease among pregnant and postpartum women; 2) provide guidance for early antepartum and postpartum risk factor identification and modification; 3) outline common cardiovascular disorders that cause morbidity and mortality during pregnancy and the puerperium; 4) describe recommendations for care for pregnant and postpartum women with preexisting or new-onset acquired heart disease; and 5) present a comprehensive interpregnancy care plan for women with heart disease.
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Lumsden R, Barasa F, Park LP, Ochieng CB, Alera JM, Millar HC, Bloomfield GS, Christoffersen-Deb A. High Burden of Cardiac Disease in Pregnancy at a National Referral Hospital in Western Kenya. Glob Heart 2020; 15:10. [PMID: 32489783 PMCID: PMC7218778 DOI: 10.5334/gh.404] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 11/13/2019] [Indexed: 11/20/2022] Open
Abstract
Background Cardiac disease is a leading cause of non-obstetric maternal death worldwide, but little is known about its burden in sub-Saharan Africa. Objectives and Methods We conducted a retrospective case-control study of pregnant women admitted to a national referral hospital in western Kenya between 2011-2016. Its purpose was to define the burden and spectrum of cardiac disease in pregnancy and assess the utility of the CARPREG I and modified WHO (mWHO) clinical risk prediction tools in this population. Results Of the 97 cases of cardiac disease in pregnancy, rheumatic heart disease (RHD) was the most common cause (75%), with over half complicated by severe mitral stenosis or pulmonary hypertension. Despite high rates of severe disease and nearly universal antenatal care, late diagnosis of cardiac disease was common, with one third (38%) of all cases newly diagnosed after 28 weeks gestational age and 17% diagnosed after delivery. Maternal mortality was 10-fold higher among cases than controls. Cases had significantly more cardiac (56% vs. 0.4%) and neonatal adverse events (61% vs. 27%) compared to controls (p < 0.001). Observed rates of adverse cardiac events were higher than predicted by both CARPREG I and mWHO risk scores, with high cardiac event rates despite low or intermediate risk scores. Conclusions Cardiac disease is associated with significant maternal and neonatal morbidity and mortality among pregnant women in western Kenya. Existing clinical tools used to predict risk underestimate adverse cardiac events in pregnancy and may be of limited utility given the unique spectrum and severity of disease in this population.
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Affiliation(s)
- Rebecca Lumsden
- Department of Medicine, Duke University Hospital, Durham, NC, US
- Duke Global Health Institute, Duke University, Durham, NC, US
| | - Felix Barasa
- Department of Cardiology, Moi Teaching and Referral Hospital, Eldoret, KE
| | - Lawrence P. Park
- Department of Medicine, Duke University Hospital, Durham, NC, US
- Duke Global Health Institute, Duke University, Durham, NC, US
| | | | - Joy M. Alera
- Directorate of Reproductive Health, Moi Teaching and Referral Hospital, Eldoret, KE
| | - Heather C. Millar
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, CA
| | - Gerald S. Bloomfield
- Department of Medicine, Duke University Hospital, Durham, NC, US
- Duke Global Health Institute, Duke University, Durham, NC, US
- Duke Clinical Research Institute, Duke University, Durham, NC, US
| | - Astrid Christoffersen-Deb
- Directorate of Reproductive Health, Moi Teaching and Referral Hospital, Eldoret, KE
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, CA
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296
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Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) is the leading cause of maternal death and cases of cardiovascular death are often associated with failure to provide timely risk-appropriate care. This review outlines considerations for creation of a team focused on the care of women with CVD during pregnancy and beyond. RECENT FINDINGS Improved outcomes for women with complex medical or obstetric conditions managed by a multidisciplinary care team inspired national guidelines advising the creation of a Pregnancy Heart Team for women with CVD in pregnancy. The recommendations from the European Society of Cardiology provide general guidance for risk-appropriate care without elaborating on the details of these specialized care teams. A Pregnancy Heart Team led by providers from cardiology, maternal-fetal medicine, obstetrics, obstetric anesthesia, pharmacy, and nursing support a holistic approach to patient care while facilitating opportunities for cross-disciplinary education. This team should focus on frequent antepartum risk stratification, multidisciplinary delivery planning, and comprehensive preconception and postpartum care. Available evidence suggests that a consistent and integrated approach to care for women with CVD in pregnancy has the potential to decrease severe maternal morbidity and mortality. The cost-effectiveness of this approach and the impact of this comprehensive care model on a woman's long-term cardiovascular health warrant future study.
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297
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Bryant E, Tsai S, Levin E, Fleischman D, Ansari J, Fischbein M, Bianco K, Khandelwal A. Bicuspid Aortic Valve and Ascending Aortic Aneurysm in a Twin Pregnancy. JACC Case Rep 2020; 2:96-100. [PMID: 34316973 PMCID: PMC8301692 DOI: 10.1016/j.jaccas.2019.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/04/2019] [Accepted: 12/04/2019] [Indexed: 11/18/2022]
Abstract
Bicuspid aortic valve with ascending aortic aneurysm is a common condition encountered in pregnancy. There are limited data on how to manage these patients. To our knowledge, we report the only case of a bicuspid aortic valve and aortic aneurysm with twin gestations. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Eryn Bryant
- Division of Cardiovascular Medicine, Stanford School of Medicine, Stanford, California
| | - Sandra Tsai
- Division of Cardiovascular Medicine, Stanford School of Medicine, Stanford, California
- Department of Primary Care and Population Health, Stanford School of Medicine, Stanford, California
| | - Eleanor Levin
- Division of Cardiovascular Medicine, Stanford School of Medicine, Stanford, California
| | - Dominic Fleischman
- Department of Radiology, Stanford School of Medicine, Stanford, California
| | - Jessica Ansari
- Division of Obstetric Anesthesia, Stanford School of Medicine, Stanford, California
| | - Michael Fischbein
- Division of Cardiothoracic Surgery, Stanford School of Medicine, Stanford, California
| | - Katherine Bianco
- Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, California
| | - Abha Khandelwal
- Division of Cardiovascular Medicine, Stanford School of Medicine, Stanford, California
- Address for correspondence: Dr. Abha Khandelwal, Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, H2156 MC 5319, Stanford, California 94305.
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298
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Pregnancy in Familial Left Ventricular Noncompaction-Associated Cardiomyopathy. JACC Case Rep 2020; 2:120-124. [PMID: 34316978 PMCID: PMC8301519 DOI: 10.1016/j.jaccas.2019.11.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 11/20/2022]
Abstract
Left ventricular (LV) noncompaction is a phenotypic variant of LV structure; however, it also can be associated with cardiomyopathies. Pregnancy in the setting of LV dysfunction carries a risk of maternal and fetal morbidity and mortality. Multidisciplinary cardio-obstetrical care is paramount in the management of pregnancy in this unique population. (Level of Difficulty: Intermediate.)
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299
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Easter SR, Rouse CE, Duarte V, Hynes JS, Singh MN, Landzberg MJ, Valente AM, Economy KE. Planned vaginal delivery and cardiovascular morbidity in pregnant women with heart disease. Am J Obstet Gynecol 2020; 222:77.e1-77.e11. [PMID: 31310750 DOI: 10.1016/j.ajog.2019.07.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/30/2019] [Accepted: 07/10/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although consensus guidelines on the management of cardiovascular disease in pregnancy reserve cesarean delivery for obstetric indications, there is a paucity of data to support this approach. OBJECTIVE The objective of the study was to compare cardiovascular and obstetric morbidity in women with cardiovascular disease according to the plan for vaginal birth or cesarean delivery. STUDY DESIGN We assembled a prospective cohort of women delivering at an academic tertiary care center with a protocolized multidisciplinary approach to management of cardiovascular disease between September 2011 and December 2016. Our practice is to encourage vaginal birth in women with cardiovascular disease unless there is an obstetric indication for cesarean delivery. We allow women attempting vaginal birth a trial of Valsalva in the second stage with the ability to provide operative vaginal delivery if pushing leads to changes in hemodynamics or symptoms. Women were classified according to planned mode of delivery: either vaginal birth or cesarean delivery. We then used univariate analysis to compare adverse outcomes according to planned mode of delivery. The primary composite cardiac outcome of interest included sustained arrhythmia, heart failure, cardiac arrest, cerebral vascular accident, need for cardiac surgery or intervention, or death. Secondary obstetric and neonatal outcomes were also considered. RESULTS We included 276 consenting women with congenital heart disease (68.5%), arrhythmias (11.2%), connective tissue disease (9.1%), cardiomyopathy (8.0%), valvular disease (1.4%), or vascular heart disease (1.8%) at or beyond 24 weeks' gestation. Seventy-six percent (n = 210) planned vaginal birth and 24% (n = 66) planned cesarean delivery. Women planning vaginal birth had lower rates of left ventricular outflow tract obstruction, multiparity, and preterm delivery. All women attempting vaginal birth were allowed Valsalva. Among planned vaginal deliveries 86.2% (n = 181) were successful, with a 9.5% operative vaginal delivery rate. Five women underwent operative vaginal delivery for the indication of cardiovascular disease without another obstetric indication at the discretion of the delivering provider. Four of these patients tolerated trials of Valsalva ranging from 15 to 75 minutes prior to delivery. Adverse cardiac outcomes were similar between planned vaginal birth and cesarean delivery groups (4.3% vs 3.0%, P = 1.00). Rates of postpartum hemorrhage (1.9% vs 10.6%, P < .01) and transfusion (1.9% vs 9.1%, P = .01) were lower in the planned vaginal birth group. There were no differences in adverse cardiac, obstetric, or neonatal outcomes in the cohort overall or the subset of women with high-risk cardiovascular disease or a high burden of obstetric comorbidity. CONCLUSION These findings suggest that cesarean delivery does not reduce adverse cardiovascular outcomes and lend support to a planned vaginal birth for the majority of women with cardiovascular disease including those with high-risk disease.
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300
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Gill SS, Shum KK, Shah SB. Pregnancy Management in a Patient With Congenital Heart Disease and Severe Right Ventricle to Pulmonary Artery Conduit Stenosis. Ochsner J 2020; 20:452-455. [PMID: 33408586 PMCID: PMC7755544 DOI: 10.31486/toj.19.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Pregnancy causes multiple hemodynamic changes that place significant stress on the cardiovascular system. With advancements in medical care, individuals with complex congenital heart disease are living into their childbearing years. Much remains to be understood about the effects and management of pregnancy in individuals with complex congenital heart disease. Case Report: We describe the management and delivery of a 29-year-old pregnant female with repaired tetralogy of Fallot or ventricular septal defect with pulmonary atresia. The patient presented at 21 weeks' gestation with New York Heart Association class II symptoms and pulmonary conduit stenosis, with a mean gradient of 52 mmHg. At 36.5 weeks' gestation, she developed severe pulmonary conduit stenosis with a mean gradient of >75 mmHg. The patient was admitted at 37 weeks' gestation for planned delivery. After a successful cesarean section and bilateral tubal ligation, the patient had an uncomplicated postoperative course. She was scheduled for follow-up for severe conduit stenosis at 6 weeks postpartum to discuss management options. Conclusion: Management of a pregnant patient with adult congenital heart disease should involve risk stratification for complications (commonly congestive heart failure exacerbation and arrhythmias) using tools such as the modified World Health Organization pregnancy risk classification. Based on the risk category, decisions must be made about frequency of follow-up, anesthesia, and mode of delivery. Patients in moderate to high-risk stratification should be managed by a multidisciplinary team at a specialty center, and all patients should undergo an anesthesia consultation prior to delivery. The decision for vaginal or cesarean delivery should be made on a case-by-case basis with consideration given to patient preference. Patients with asymptomatic moderate to severe pulmonic stenosis can be managed conservatively with appropriate follow-up and cardiac imaging, allowing intervention to be completed after delivery.
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Affiliation(s)
- Sajan S. Gill
- The University of Queensland Faculty of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Kelly K. Shum
- Department of Cardiovascular Disease, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA
| | - Sangeeta B. Shah
- Department of Cardiovascular Disease, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA
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