Management of Fontan circulation in pregnancy: a multidisciplinary approach to care

Ultrasonographic placental edematous changes as predictive markers of unplanned preterm birth in post-Fontan pregnancies: A single-center observational study

AIM

Fontan surgery is a palliative procedure commonly performed for functional single-ventricle heart diseases. Fontan circulation is characterized by elevated central venous pressure and low cardiac output. It causes placental hypoxia, which could lead to poor obstetric outcomes. During post-Fontan pregnancies, ultrasonography may detect abnormal appearance of the placenta. We have focused on higher incidences of unexpected onset of labor when this ultrasonographic finding is present. In this study, we aimed to investigate whether this finding could be an indicator of premature delivery before pre-scheduled dates in post-Fontan pregnancies.

METHODS

During post-Fontan pregnancies, the placenta exhibits a mosaic pattern with areas of low and high echogenicity and unusually thick on ultrasonography. We refer to these changes as "ultrasonographic placental edematous changes." We retrospectively analyzed clinical charts and ultrasonograms for post-Fontan pregnancies between 2015 and 2022.

RESULTS

Fifteen patients were included in this study. Ultrasonographic placental edematous changes in the placenta during pregnancy were detected in eight cases (53%). Six (75%) of these patients experienced unexpected premature labor. Two patients underwent vaginal delivery because of sudden onset of labor. Four patients underwent emergency cesarean sections. Two patients underwent planned preterm cesarean sections. In the seven pregnancies without placental edematous changes, all deliveries occurred on the pre-scheduled dates determined based on the maternal heart condition.

CONCLUSIONS

Pregnancies with ultrasonographic placental edematous changes have a higher risk of unexpected preterm delivery than those without these changes. Ultrasonographic placental edematous changes may serve as predictive markers for unplanned preterm births in post-Fontan pregnancies.

Pregnancy in patients with the Fontan operation

Improved survival rates for patients with a Fontan circulation has allowed more women with this complex cardiac physiology to contemplate pregnancy. However, pregnancy in women with a Fontan circulation is associated with a high risk of adverse maternal and foetal outcomes, high rates of miscarriage, and preterm delivery. Factors associated with a successful pregnancy outcome are younger age, normal body weight, absence of significant functional limitation, no Fontan-related complications, and well-functioning single ventricle physiology. Appropriate care with timely preconception counselling and regular, frequent clinical reviews by a multidisciplinary team based at a tertiary centre improves the chance of a successful pregnancy. Empowerment of patients with education on their specific congenital cardiac condition and its projected trajectory helps them make informed choices regarding their health, reproductive choices, and assists them to achieve their life goals.

Cyanotic Congenital Heart Disease in Pregnancy: A Review of Pathophysiology and Management

The advancement of medical treatment and surgical technique, along with the invention of cardiopulmonary bypass, has allowed for long-term survival of patients with cyanotic congenital heart disease (CHD)-with many women with CHD now reaching child-bearing age and wishing to become pregnant. Pregnancy in these women is a major concern as the physiologic adaptations of pregnancy, including an increased circulating volume, increased cardiac output, reduced systemic vascular resistance, and decreased blood pressure, place a substantial load on the cardiovascular system. These changes are essential to meet the increased maternal and fetal metabolic demands and allow for sufficient placental circulation during gestation. However, in women with underlying structural heart conditions, they place an additional hemodynamic burden on the maternal body. Overall, with appropriate risk stratification, pre-conception counseling, and management by specialized cardiologists and high-risk obstetricians, most women with surgically corrected CHDs are expected to carry healthy pregnancies to term with optimization of both maternal and fetal risks. In this article, we describe the current understanding of 5 cyanotic CHDs-Tetralogy of Fallot, Transposition of the Great Arteries, Truncus Arteriosus, Ebstein's Anomaly, and Eisenmenger Syndrome-and explore the specific hemodynamic consequences, maternal and fetal risks, current guidelines, and outcomes of pregnancy in women with these conditions.

Obstetrical outcomes in cases of maternal heart disease with a risk of cardiac decompensation: A retrospective study since the establishment of a multidisciplinary consultation meeting "heart and pregnancy"

BACKGROUND

Pregnant women with chronic heart failure (CHF) are at increased risk for cardiac complications. However, the frequency of obstetrical and neonatal complications in pregnant women with CHF remains unclear.

OBJECTIVE

The objective of our study was to describe obstetrical and neonatal outcomes in pregnant with CHF.

METHOD

This single-center retrospective cohort study involves pregnant women with a CHF who delivered at Jeanne de Flandre, the Lille's university hospital, from 2017 to 2021. The frequency of obstetrical, neonatal, and cardiovascular complications was collected.

RESULT

During this period, we identified 26 pregnant women with a CHF. The main cardiac diseases responsible for CHF were cardiomyopathies (53.8%) and congenital heart disease (46.2%). Acute heart failure occurred in 30.8% of the cases and mainly concerned patients with no follow-up of their heart disease. The main obstetrical complications were fetal growth restriction (38.5%) and premature rupture of fetal membranes (19.2%). The 26 pregnancies comprised 25 live births and 1 stillbirth. Newborn infants were delivered via cesarean in 69.2%. Of the live births, 60% were preterm at a median gestational age of 36 (34-38) weeks.

CONCLUSION

Pregnant women with CHF had a higher risk for obstetrical and neonatal outcomes.

Pregnancy Outcomes in Women after the Fontan Procedure

Women with single ventricle physiology after the Fontan procedure, despite numerous possible complications, can reach adulthood and give birth. Pregnancy poses a hemodynamic burden for distorted physiology of Fontan circulation, but according to the literature, it is usually well tolerated unless the patient is a "failing" Fontan. Our study aimed to assess maternal and fetal outcomes in patients after the Fontan procedure followed up in two tertiary Polish medical centers. We retrospectively evaluated all pregnancies in women after the Fontan procedure who were followed up between 1995-2022. During the study period, 15 women after the Fontan procedure had 26 pregnancies. Among 26 pregnancies, eleven ended with miscarriages, and 15 pregnancies resulted in 16 live births. Fetal complications were observed in 9 (56.3%) live births, with prematurity being the most common complication (n = 7, 43.8%). We recorded 3 (18.8%) neonatal deaths. Obstetrical complications were present in 6 (40%) out of 15 completed pregnancies-two (13.3%) cases of abruptio placentae, two (13.3%) pregnancies with premature rupture of membranes, and two (13.3%) patients with antepartum hemorrhage. There was neither maternal death nor heart failure decompensation during pregnancy. In two (13.3%) women, atrial arrhythmia developed. One (6.7%) patient in the second trimester developed ventricular arrhythmia. None of the patients suffered from systemic thromboembolism during pregnancy. Pregnancy in women after the Fontan procedure is well tolerated. However, it is burdened by a high risk of miscarriage and multiple obstetrical complications. These women require specialized care provided by both experienced cardiologists and obstetricians.

Fontan-associated Liver Disease in Adults: What a Cardiologist Needs to Know. A Comprehensive Review for Clinical Practitioners

Nowadays most patients with a univentricular heart after Fontan repair survive until adulthood. One of the hallmarks of Fontan circulation is permanently elevated central venous pressure, which leads to congestive hepatopathy. Subsequently, liver fibrosis, cirrhosis, or hepatocellular carcinoma may occur, all of them constituting an entity called Fontan-associated liver disease (FALD). Given that these complications convey poor prognosis, the need for life-long hepatic surveillance is not in doubt. Many serum biomarkers and sophisticated imaging techniques have been proposed to avoid invasive liver biopsy in this cohort, but none proved to be a relevant surrogate of liver fibrosis seen in histopathological specimens. The surveillance models proposed to date require an extensive diagnostic work-up, which can be problematic, particularly in resource-depleted countries. Moreover, the question of combined heart–liver transplant is gaining more attention in the Fontan cohort. The aim of this study is to provide practical information on the pathophysiology of FALD and to propose a simplified framework for the routine assessment of liver status in Fontan patients that would be helpful in the decision-making process.

Reproductive Issues in Patients With the Fontan Operation

Patients with the Fontan operation have a unique circulation, with a limited ability to increase cardiac output, and high central venous pressure. They may have diastolic and/or systolic ventricular dysfunction, arrhythmias, thromboembolic complications, or multiorgan dysfunction. All of these factors contribute to reproductive issues, including menstrual irregularities, infertility, recurrent miscarriage, and complications during pregnancy. Although atrial arrhythmias are the most common cardiac complications during pregnancy, patients can develop heart failure and thromboembolic events. Obstetric bleeding, including postpartum hemorrhage, is common. In addition to maternal complications, adverse fetal and neonatal events, such as prematurity and low birthweight, are very common. Counselling about these reproductive issues should begin early. For those who become pregnant, care should be provided by a multidisciplinary cardio-obstetric team familiar with the specific issues and needs of the Fontan population. In this review, we discuss infertility, contraception, and pregnancy in patients with the Fontan operation.