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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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2
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Wander G, van der Zande JA, Patel RR, Johnson MR, Roos-Hesselink J. Pregnancy in women with congenital heart disease: a focus on management and preventing the risk of complications. Expert Rev Cardiovasc Ther 2023; 21:587-599. [PMID: 37470417 DOI: 10.1080/14779072.2023.2237886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Congenital heart disease (CHD) is the most common cardiac disorder in pregnancy in the western world (around 80%). Due to improvements in surgical interventions more women with CHD are surviving to adulthood and choosing to become pregnant. AREAS COVERED Preconception counseling, antenatal management of CHDs and strategies to prevent maternal and fetal complications.Preconception counseling should start early, before the transition to adult care and be offered to both men and women. It should include the choice of contraception, lifestyle modifications, pre-pregnancy optimization of cardiac state, the chance of the child inheriting a similar cardiac lesion, the risks to the mother, and long-term prognosis. Pregnancy induces marked physiological changes in the cardiovascular system that may precipitate cardiac complications. Risk stratification is based on the underlying cardiac disease and data from studies including CARPREG, ZAHARA, and ROPAC. EXPERT OPINION Women with left to right shunts, regurgitant lesions, and most corrected CHDs are at lower risk and can be managed in secondary care. Complex CHD, including systemic right ventricle need expert counseling in a tertiary center. Those with severe stenotic lesions, pulmonary artery hypertension, and Eisenmenger's syndrome should avoid pregnancy, be given effective contraception and managed in a tertiary center if pregnancy does happen.
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Affiliation(s)
- Gurleen Wander
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Johanna A van der Zande
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roshni R Patel
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Mark R Johnson
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Jolien Roos-Hesselink
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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3
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Cupido B, Zühlke L, Osman A, van Dyk D, Sliwa K. Managing Rheumatic Heart Disease in Pregnancy: A Practical Evidence-Based Multidisciplinary Approach. Can J Cardiol 2021; 37:2045-2055. [PMID: 34571164 DOI: 10.1016/j.cjca.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 10/20/2022] Open
Abstract
Rheumatic heart disease (RHD) remains a leading cause of mortality and morbidity in pregnant patients in low- to middle-income countries. Apart from the clinical challenges, these areas face poor infrastructure and resources to allow for early detection, with many women presenting to medical services for the first time when they deteriorate clinically during the pregnancy. The opportunity for preconception counselling and planning may thus be lost. It is ideal for all women to be seen before conception and risk-stratified according to their clinical state and pathology. The role of the cardio-obstetrics team has emerged over the past decade with the aim of a seamless transition to and from the appropriate levels of care during pregnancy. Severe symptomatic mitral and aortic valve stenoses portend the greatest risk to both mother and fetus. In mitral stenosis, beta-blockers are the cornerstone of therapy and only a small number of patients require balloon valvuloplasty. Regurgitant lesions mostly require diuretics alone for the treatment of heart failure. The mode of delivery is usually vaginal; caesarean section is performed in those with obstetrical indications or in cases with severe stenosis and a poor clinical state. The postpartum period presents a second high-risk period for maternal adverse events, with heart failure and arrhythmias being the most frequent. This review aims to provide a practical evidence-based multi-disciplinary approach to the management of women with RHD in pregnancy.
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Affiliation(s)
- Blanche Cupido
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Liesl Zühlke
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross Children's Hospital, Cape Town, South Africa; Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa; The Deanery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ayesha Osman
- Department of Obstetrics and Gynaecology: Maternal Fetal Medicine Unit, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Dominique van Dyk
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Karen Sliwa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Williams DS, Mikhova K, Sodhi S. Arrhythmias and Pregnancy: Management of Preexisting and New-Onset Maternal Arrhythmias. Cardiol Clin 2021; 39:67-75. [PMID: 33222815 DOI: 10.1016/j.ccl.2020.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Arrhythmias are the most common cardiovascular complication of pregnancy in women with and without structural heart disease. Appropriate maternal diagnosis and management is of utmost importance to optimize maternal and fetal outcomes. A multidisciplinary care approach with cardiology, maternal fetal medicine, anesthesia, and pediatrics is important for preconceptional, pregnancy, and delivery planning.
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Affiliation(s)
- Dominique S Williams
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA.
| | - Krasimira Mikhova
- Cardiovascular Division, Electrophysiology, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA
| | - Sandeep Sodhi
- Department of Medicine, Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA
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Eckardt L. [Cardiac arrhythmias in pregnancy : Epidemiology, clinical characteristics, and treatment options]. Herzschrittmacherther Elektrophysiol 2021; 32:137-144. [PMID: 33740101 DOI: 10.1007/s00399-021-00752-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
Symptomatic arrhythmias rarely occur during pregnancy and are predominantly benign. However, the increasing average age of women who are pregnant, especially in Western European countries, has contributed to a significant increase in arrhythmias in pregnant women in recent years. Previous or existing heart diseases can increase the occurrence of arrhythmias. In most cases pregnancy is safe and without consequences for the child and/or mother. Further cardiological work-up (including ECG and echocardiography, and possibly cardiac MRI) should always be performed. The indication for treatment should be made in close cooperation between obstetricians and cardiologists considering symptoms, hemodynamics and prognosis. In the absence of larger studies on efficacy and side effects of antiarrhythmic drugs, these should be administered very cautiously, under strict indication and whenever possible by avoiding the first trimester. Cardiologists with special expertise in arrhythmias should always be consulted, especially in the case of complex and relevant rhythm disturbances.
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Affiliation(s)
- Lars Eckardt
- Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus1, Gebäude A1, 48149, Münster, Deutschland.
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Sliwa K, van der Meer P, Petrie MC, Frogoudaki A, Johnson MR, Hilfiker-Kleiner D, Hamdan R, Jackson AM, Ibrahim B, Mbakwem A, Tschöpe C, Regitz-Zagrosek V, Omerovic E, Roos-Hesselink J, Gatzoulis M, Tutarel O, Price S, Heymans S, Coats AJS, Müller C, Chioncel O, Thum T, de Boer RA, Jankowska E, Ponikowski P, Lyon AR, Rosano G, Seferovic PM, Bauersachs J. Risk stratification and management of women with cardiomyopathy/heart failure planning pregnancy or presenting during/after pregnancy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy. Eur J Heart Fail 2021; 23:527-540. [PMID: 33609068 DOI: 10.1002/ejhf.2133] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/22/2021] [Accepted: 02/17/2021] [Indexed: 12/12/2022] Open
Abstract
This position paper focusses on the pathophysiology, diagnosis and management of women diagnosed with a cardiomyopathy, or at risk of heart failure (HF), who are planning to conceive or present with (de novo or previously unknown) HF during or after pregnancy. This includes the heterogeneous group of heart muscle diseases such as hypertrophic, dilated, arrhythmogenic right ventricular and non-classified cardiomyopathies, left ventricular non-compaction, peripartum cardiomyopathy, Takotsubo syndrome, adult congenital heart disease with HF, and patients with right HF. Also, patients with a history of chemo-/radiotherapy for cancer or haematological malignancies need specific pre-, during and post-pregnancy assessment and counselling. We summarize the current knowledge about pathophysiological mechanisms, including gene mutations, clinical presentation, diagnosis, and medical and device management, as well as risk stratification. Women with a known diagnosis of a cardiomyopathy will often require continuation of drug therapy, which has the potential to exert negative effects on the foetus. This position paper assists in balancing benefits and detrimental effects.
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Affiliation(s)
- Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa & CHI, Department of Cardiology and Medicine, University of Cape Town, Cape Town, South Africa
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Mark C Petrie
- Department of Cardiology, Institute of Cardiovascular and Medical Sciences, Glasgow University, Glasgow, UK
| | - Alexandra Frogoudaki
- Adult Congenital Heart Disease Clinic, Second Cardiology Department ATTIKON University Hospital, Athens, Greece
| | - Mark R Johnson
- Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK
| | | | - Righab Hamdan
- Department of Cardiology, Beirut Cardiac Institute, Beirut, Lebanon
| | - Alice M Jackson
- Department of Cardiology, Institute of Cardiovascular and Medical Sciences, Glasgow University, Glasgow, UK
| | - Bassem Ibrahim
- Consultant Cardiologist & Heart Failure Lead. North Cumbria University Hospitals, Cumbria, UK
| | - Amam Mbakwem
- Department of Medicine, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Carsten Tschöpe
- Berlin- Institute of Health (BIH), Berlin-Brandenburger Center for Regenerative Therapies (BCRT), Department of Cardiology (CVK), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité University, Berlin, Germany
| | | | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital University of Gothenburg, Gothenburg, Sweden
| | - Jolien Roos-Hesselink
- Department of Adult Congenital Heart Disease, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Michael Gatzoulis
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and Imperial College, London, UK
| | - Oktay Tutarel
- Adult Congenital Heart Disease, TUM School of Medicine, Munich, Germany
| | - Susanna Price
- Division of Cardiology and Metabolism, National Heart and Lung Institute, Royal Brompton Hospital, London, UK
| | - Stephane Heymans
- Department of Cardiology, Maastricht University, CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Christian Müller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu' and University of Medicine Carol Davila, Bucuresti, Romania
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Ewa Jankowska
- Centre for Heart Diseases, Faculty of Health Sciences, Wrocław Medical University, Wrocław, Poland
| | - Piotr Ponikowski
- Centre for Heart Diseases, Faculty of Health Sciences, Wrocław Medical University, Wrocław, Poland
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
| | - Giuseppe Rosano
- Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Cardiology Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK
| | - Petar M Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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Ahmad SY, Ahmad A, Raheel FS. Interpreting the Need for Implantable Loop Recorder Monitoring in Pregnant Women at High Risk of Arrhythmias. JAMA Cardiol 2021; 5:1304. [PMID: 32845279 DOI: 10.1001/jamacardio.2020.3521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Syed Yousaf Ahmad
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Awais Ahmad
- Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Falaq Syed Raheel
- College of Medical and Dental Services, University of Birmingham, Birmingham, United Kingdom
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8
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Viljoen C, Sliwa K, Chin A. Interpreting the Need for Implantable Loop Recorder Monitoring in Pregnant Women at High Risk of Arrhythmias-Reply. JAMA Cardiol 2021; 5:1304-1305. [PMID: 32845277 DOI: 10.1001/jamacardio.2020.3545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Charle Viljoen
- Cardiology, University of Cape Town, Cape Town, South Africa
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ashley Chin
- University of Cape Town, Cape Town, South Africa
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9
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Eckardt L, Schmitz R. Rhythmusstörungen in der Schwangerschaft. AKTUELLE KARDIOLOGIE 2020. [DOI: 10.1055/a-1283-5661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ZusammenfassungSymptomatische Rhythmusstörungen treten während einer Schwangerschaft selten auf und sind überwiegend gutartig. Sie stellen dennoch eine besondere klinische Herausforderung dar, wobei sich diagnostische und therapeutische Möglichkeiten in Zusammenhang mit gleichzeitig älterem Durchschnittsalter bei Schwangerschaften in den vergangenen Jahren deutlich verbessert haben. In der Regel ist eine Schwangerschaft trotz Auftreten von Rhythmusstörungen sicher und ohne Folgen für das Kind. Vorbekannte oder vorhandene Herzerkrankungen können das Auftreten von Rhythmusstörungen begünstigen. Es sollte immer eine weiterführende kardiologische Diagnostik (u. a. EKG und Echokardiografie) erfolgen. Die Indikation zur Therapie sollte in enger Absprache zwischen Geburtsmediziner und Kardiologen/Rhythmologen erfolgen und dabei Symptomatik, Hämodynamik und Prognose berücksichtigen. Bei fehlenden größeren Studien zu Wirksamkeit und Nebenwirkungen von Antiarrhythmika sollten diese nur sehr
zurückhaltend, unter strenger Indikation und am ehesten unter Umgehung des 1. Trimenons verabreicht werden. Insbesondere bei komplexen und prognostisch relevanten Rhythmusstörungen sollten immer Kardiologen mit besonderer rhythmologischer Erfahrung hinzugezogen werden.
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Affiliation(s)
- Lars Eckardt
- Klinik für Kardiologie II – Rhythmologie, Universitätsklinikum Münster, Deutschland
| | - Ralf Schmitz
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Münster, Deutschland
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Hogan AM, Christmas T, Missfelder-Lobos H, Wilson A, Belham M. The anesthetist as cardiologist: a case of heart block identified in the peripartum period. Int J Obstet Anesth 2020; 44:101-105. [PMID: 32931999 DOI: 10.1016/j.ijoa.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/29/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
We describe a case of undiagnosed heart block which was detected during the postpartum surgical repair of a vaginal tear, and the subsequent investigations that confirmed diagnosis of atrio-ventricular heart block.
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Affiliation(s)
- A M Hogan
- Department of Anaesthetics, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK; Cognitive Neuroscience & Psychiatry, UCL Great Ormond Street Institute of Child Health, London, UK.
| | - T Christmas
- Department of Anaesthetics, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - H Missfelder-Lobos
- Department of Obstetrics & Gynaecology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - A Wilson
- Department of Obstetrics & Gynaecology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - M Belham
- Department of Cardiology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
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