Congenital and Acquired Valvular Heart Disease in Pregnancy

Maternal Cardiac Disease and Perinatal Outcomes in a Single Tertiary Care Center

OBJECTIVE

This study aims to compare the perinatal outcomes of pregnant women with heart disease and a healthy pregnant control group, as well as the maternal and newborn outcomes of pregnant women with congenital heart disease and acquired heart disease.

MATERIAL METHOD

Pregnant women with heart disease and healthy control pregnant women were included in this retrospective study. Sociodemographic data of all patients included in the study were obtained from electronic records. Perinatal outcomes of all patients were compared.

RESULTS

A total of 258 pregnant women were included in the study. While 129 pregnant women were diagnosed with heart disease, 129 patients were low-risk pregnant women. Preeclampsia (p=0.004) and cesarean section (p=0.01) rates were higher in pregnant women with heart disease compared to healthy pregnant women. Compared with healthy pregnant women, pregnant women with heart disease had a lower birth weight (p=0.003), a higher fetal growth restriction (FGR) rate (p=0.036), lower birth percentiles (p=0.002), a lower 5-minute APGAR (p=0.0001), a higher neonatal intensive care unit (NICU) admission rate (p=0.001), and a longer NICU stay rate (p=0.001). The mean gestational age at birth of pregnant women with congenital heart disease was higher than that of those with acquired heart disease (p=0.017).

CONCLUSION

It was observed that all maternal heart diseases were associated with adverse perinatal outcomes compared to healthy pregnant women. In this series, perinatal adverse outcomes of pregnant women with congenital and acquired heart disease did not differ.

Role of MicroRNAs in Cardiac Disease with Stroke in Pregnancy

Pregnancy-related cardiovascular disease with stroke remains a considerable source of higher maternal morbidity and mortality occurs in periods of pregnancy, delivery, and postpartum. It is essential to counsel the mother before pregnancy by an expert cardiologist and obstetric team to discuss any event related to preexistent cardiac or past preeclampsia for estimation of maternal and fetal risks. In pregnancy, the cardiac state includes hypertensive disorders, ischemic heart disease, valvular disease, and postpartum stroke. The incidence of stroke is increasing in pregnancy, particularly in postpartum, and its strong relationship with hypertensive disorders of pregnancy (preeclampsia). The combined cardiologist and obstetrics team requires during pregnancy mainly due to the approach to the management of a cardiac disease that subsequently prevents stroke postpartum. Therefore, a general perception of cardiac disease during pregnancy, delivery, and postpartum should be a core knowledge extent for all cardiovascular and clinicians. Many studies provided linked that deregulation of microRNAs (miRNAs) in maternal circulation and placenta tissue may development of pregnancy complications including preeclampsia considered a diagnostic marker. The desire of this review provides a detailed outline of current knowledge and dealing in this field with strength on the physiological changes during pregnancy.

South Australian prospective cohort study evaluating outcomes of maternal kidney and cardiac disease in pregnancy: a protocol

INTRODUCTION

Chronic kidney disease (CKD) and cardiac disease are two significant health conditions that can impact a women's pregnancy; however, little is known about their prevalence and health impact within the population. These pregnancies are associated with significant risks of morbidity and mortality and propose a challenge to clinicians. The aim of this longitudinal cohort study is to prospectively record the incidence, prevalence, aetiology, outcomes and follow-up of maternal CKD and cardiac disease in the obstetric population of South Australia.

METHODS AND ANALYSIS

This study is a state-wide multicentre prospective cohort study in South Australia that will begin recruitment in 2022 and is planned for at least 5 years. Pregnant women with chronic or acquired kidney or cardiac disease will be enrolled across the state's major public obstetric hospitals. The data collected will focus on the chronic disease aetiology, peripartum interventions, delivery, obstetric and neonatal outcomes, progression of underlying disease and patient-related outcome measures. Women will have data collected each trimester during pregnancy and then at follow-up 6 weeks, 6 months and 12 months post partum. Clear inclusion and exclusion criteria have been developed which importantly includes new diagnosis of chronic disease in pregnancy.

ETHICS AND DISSEMINATION

Approval was obtained from the local Health Network Human Research Ethics Committee. Summary data will be reviewed and reported in accordance with Strengthening the Reporting of Observational Studies in Epidemiology criteria 6 monthly and results will be published in peer-reviewed journals and presented at conferences. Findings will be presented to relevant local clinicians and hospitals at regular intervals. Consumer versions of research outputs will be developed in conjunction with the consumer reference group.

The personal and clinical impact of screen-detected maternal rheumatic heart disease in Uganda: a prospective follow up study

BACKGROUND

Pre-existing maternal cardiac disease is a significant contributor to adverse maternal, fetal, and neonatal outcomes. In 2015-2017, our team conducted the first community-based study of maternal rheumatic heart disease (RHD) in sub-Saharan Africa and identified RHD in 88% of those with pre-existing heart disease. Here we conducted a follow up investigation of women previously identified with RHD, describing clinical and echocardiographic outcomes, identifying barriers to medical adherence and evaluating the personal impact of RHD.

METHODS

A 2 week prospective follow up was completed at sites in Central and Eastern Uganda. Participants underwent a three-step mixed methods study comprising of 1) direct structured interview targeting clinical history and medication adherence, 2) echocardiogram to evaluate left-sided heart valves, and 3) semi-structured guideline interview to elicit personal impacts of RHD.

RESULTS

The team evaluated 40 (80%) of the original 51 mothers with RHD at a median post-partum time of 2.5 years after delivery (IQR 0.5). Echocardiographic data showed improvement in nine women with the remaining 31 women showing stable echocardiographic findings. Adherence to Benzathine penicillin G (BPG) prophylaxis was poor, with 70% of patients either poorly adherent or non-adherent. Three major themes emerged from interviews: 1) social determinants of health (World Health Organization, Social determinants of health, 2019) negatively affecting healthcare, 2) RHD diagnosis negatively affecting female societal wellbeing, 3) central role of spouse in medical decision making.

CONCLUSIONS

Screening echocardiography can identify women with pre-existing rheumatic heart disease during pregnancy, but long-term follow-up in Uganda reveals adherence to medical care following diagnosis, including BPG, is poor. Additionally, mothers diagnosed with RHD may experience unintended consequences such as social stigmatization. As identification of occult RHD is critical to prevent adverse pregnancy outcomes, further research is needed to determine how to best support women who face a new diagnosis of RHD, and to determine the role of screening echocardiography in high-risk settings.

Ultrasound-Guided Percutaneous Balloon Aortic Valvuloplasty for Aortic Stenosis

Percutaneous balloon aortic valvuloplasty (PBAV), which is used to treat symptomatic aortic stenosis, requires ionizing radiation and contrast agent for imaging guidance. The aim of the study is to evaluate the feasibility and effectiveness of ultrasound-guided PBAV in patients with aortic stenosis. This case series included 30 patients (14 males; mean age, 61.5 ± 4.5 years) with moderate/severe aortic stenosis treated with ultrasound-guided PBAV at the Ultrasound Department, Fuwai Hospital, Beijing, China, between January 2016 and July 2019. Cardiac function (New York Heart Association grade) was assessed before PBAV and 1 month after the procedure. Aortic peak jet velocity, aortic valve orifice area (AVA), mean transvalvular pressure gradient (MTPG), left ventricular end-diastolic diameter (LVDD), left ventricular ejection fraction (LVEF), and left ventricular end-systolic diameter (LVESD) were determined before and immediately after PBAV using Doppler echocardiography. Preprocedural cardiac function was grade I in 3 cases, grade II in 9 cases, grade III in 10 cases, and grade IV in 8 cases. Postprocedural cardiac function was grade I in 22 cases, grade II in 4 cases, and grade III in 4 cases, suggesting that cardiac function was improved by PBAV. Ultrasound-guided PBAV resulted in significant improvements (P < 0.05) in aortic peak jet velocity (3.68 ± 0.811 m/s vs. 4.79 ± 0.63 m/s), MTPG (33.77 ± 13.85 mmHg vs. 54.54 ± 13.81 mmHg), AVA (1.96 ± 0.25 cm² vs. 0.98 ± 0.12 cm²), LVEDD (51.90 ± 3.21 mm vs. 65.60 ± 6.81 mm), LVEF (63.46 ± 11.29% vs. 56.31 ± 11.04%), and LVESD (35.50 2.62 mm vs. 45.20 ± 2.42 mm). Ultrasound-guided PBAV is feasible and achieves good short-term effects in patients with aortic stenosis.

Mitral Stenosis in Pregnancy: A Comprehensive Review of a Challenging Cardio-Obstetric Clinical Entity

BACKGROUND

Mitral stenosis is one of the most commonly encountered valvular heart diseases during pregnancy, the majority are rheumatic in origin and poorly tolerated due to cardiocirculatory changes that occur during pregnancy, labor and postpartum.

OBJECTIVE

The distinctive physiological events that arise during pregnancy and labor and the influence of mitral stenosis are tackled in this article.

METHODS

Through PUBMED and MEDLINE searches, we reviewed the literature of the last decade as well as the recommendations from guidelines of high-impact worldwide.

RESULTS

Cardiac decompensation usually takes place late in pregnancy as the hemodynamic burden of pregnancy become more pronounced as well as after delivery due to an abrupt increase of preload secondary to autotransfusion and aorto-caval decompression. The maternal and fetal complications correlate with the New York Heart Association (NYHA) functional classification and the grade of mitral stenosis. Medical therapy should be tried first. If symptoms continue in spite of optimal medical therapy, invasive procedures are recommended. Several studies revealed that vaginal delivery under epidural anesthesia is endurable and of low-risk unless obstetrically contraindicated.

CONCLUSION

Pregnancy and mitral stenosis remain a complex entity and a well-known trigger of maternal mortality during pregnancy and peri-partum period if not managed adequately. A good appreciation and recognition of the physiology of pregnancy and its impact on the pre-existing mitral stenosis and the presence of a specialized multidisciplinary team to handle such cases significantly decrease maternal and fetal mortality and morbidity.

No longer rare diseases and obstetric anesthesia

PURPOSE OF REVIEW

With new medical technologies and changing life styles, maternal demographics has changes and consequently older and sicker women are becoming pregnant.In this review, we present these different high-risk parturient populations, which were once considered rare for the practicing obstetric anesthesiologist.

RECENT FINDINGS

With lifestyle and medical advances, older and sicker women are getting pregnant. Older women are more prone to pregnancy complications. Cancer survivors are becoming pregnant and more pregnant women are being diagnosed with cancer. Previous neurological and cardiac conditions considered not compatible with pregnancy are now seen more frequently. As the rate of obesity increases so does the rate of obstructive sleep apnea, which is known to be associated with many adverse maternal and neonatal sequalae. Finally, increased use of both opioids and marijuana has led to increased number of pregnant women using these illicit substances.

SUMMARY

Future research and implementation of international guidelines for management of these high-risk parturient population is necessary in order to reduce maternal and neonatal morbidity.

State of the Art Management of Mechanical Heart Valves During Pregnancy

PURPOSE OF THE REVIEW

To review the management of women with mechanical heart valves during pregnancy, from preconception counseling through delivery with a summary of the latest guidelines.

RECENT FINDINGS

The hypercoagulability of pregnancy combined with the imperfect choices of anticoagulant agents contribute to a high risk of complications in pregnant women with mechanical heart valves. Valve thrombosis remains a major concern, much of which occurs during the first trimester transition to heparin-based products. The safest method of anticoagulation, with the best balance of maternal and fetal risk, is use of low-dose vitamin K antagonists, but only if therapeutic anticoagulation can be achieved with warfarin doses of ≤ 5 mg/day. Management of mechanical heart valves in pregnancy remains fraught with difficult decisions involving balancing of maternal and fetal risks as well as a high risk of maternal and fetal complications. Preconception counseling and planning is imperative. A risk-benefit discussion with the patient will help guide the choice of anticoagulation and outline the plan for safe delivery options. A multidisciplinary approach to management is advisable with close follow-up and care in a tertiary center.

Cardiac Arrhythmias and Pregnancy

PURPOSE OF REVIEWS

In this review, the challenges of managing cardiac arrhythmias and syncope in the setting of pregnancy will be discussed.

RECENT FINDINGS

Arrhythmias in pregnancy are increasing, as diagnostic and therapeutic options have advanced and women are older at the time of gestation. Atrial fibrillation has become the most common arrhythmia in pregnancy. Inherited arrhythmia has become a more common entity, with advances in treatments and genetic testing, and require specialized treatments in pregnancy. The majority of arrhythmias in pregnancy are benign. The potential risk of increased cardiac morbidity and mortality exists for mother and fetus, especially in women with structural heart disease, which is becoming increasingly common. Early evaluation, diagnosis, and appropriate treatment are necessary to achieve optimal outcomes for both mother and fetus.