Mitral valve surgery and maternal and fetal outcome in valvular heart disease

Comparative study on maternal and fetal outcome in pregnant women with rheumatic heart disease and severe mitral stenosis undergoing percutaneous balloon mitral valvotomy before or during pregnancy

INTRODUCTION

Mitral stenosis due to rheumatic heart disease is a common problem in India causing significant morbidity and mortality. We have compared the maternal and fetal outcome of women with severe mitral stenosis undergoing percutaneous balloon mitral valvotomy before or during pregnancy.

METHODS

A total of 24 women of severe rheumatic mitral stenosis who underwent balloon mitral valvotomy before pregnancy (14 women, group 1) or during pregnancy (10 women, group 2) were included in the retrospective descriptive analysis.

RESULTS

The mean age was 25.5±3.6 yrs in group 1 and 25.7±3.5 yrs in group 2. There was no difference in characteristics -primigravidas, time since diagnosis from pregnancy, NYHA (New York Heart Association) class and associated medical problems in the two groups. There was significant difference in cardiac events during pregnancy in the two groups. New York Heart Association class deterioration was observed in only 3(21.4% women in group 1) as compared to all (10; 100% women) in group 2(p<0.001). The incidence of arrhythmias and atrial fibrillation was not different in two groups. Obstetric events were similar in the two groups. Mode of delivery and caesarean section rate was also similar in the two groups. There was no significant difference in mean birth weights (2399.75±601.8gm vs. 2641.70±580.6gm),rate of fetal growth restriction, still birth and congenital malformation rates in the two groups.

CONCLUSION

Percutaneous mitral valvotomy for patients with severe mitral stenosis can be safely performed during pregnancy and has equivalent maternal and fetal outcomes as that performed before pregnancy.

Maternal and fetal outcome in operated vs non-operated cases of congenital heart disease cases in pregnancy

OBJECTIVES

To study pregnancy outcomes in operated vs non-operated cases of congenital heart disease cases during pregnancy.

MATERIALS AND METHODS

A total of 55 patients of congenital heart disease who delivered in the authors unit in last 10 years were taken in this retrospective study. These were divided into two groups Group 1:29 (52.7%) patient who had no cardiac surgery and Group 2: 26(47.2%) who had cardiac surgery to correct their cardiac defect before pregnancy. All patients were evaluated for cardiac complications and outcome during pregnancy. Obstetric complications, mode of delivery and fetal outcome was compared in the two groups using statistical analysis.

RESULT

The commonest lesion was atrial septal defect (ASD) seen in 22(40%) patients followed by ventricular septal defect (VSD) in 16(29%) .Congenital valvular disease 8(14.5%) and patent ductus arteriosus in 4(7.2%) cases. The mean age was 25.9 ± 3.15 years in Group 1 and 26.3 ± 4.53 years in Group 2. The baseline characteristics were similar in the two groups. There was no difference in cardiac complications, NYHA deterioration and need of cardiac drugs in the two groups. Obstetric complications and mode of delivery were also similar in the two groups.Mean birth weight was 2516.65 ± 514.04 gm in Group 1 and 2683.00 ± 366.00 gm in Group 2 and was similar. APGAR < 8, stillbirth rate and other neonatal complications were also similar in two groups.

CONCLUSION

The maternal and fetal outcome was excellent in patients with congenital heart disease and was similar in unoperated and operated cases.

Fetomaternal outcome among women with mitral stenosis after balloon mitral valvotomy

OBJECTIVE

To compare pregnancy outcomes among patients with non-operated mitral stenosis and those who had balloon mitral valvotomy before pregnancy.

METHODS

In a study at a tertiary-care referral hospital in Kolkata, India, 48 women with mitral stenosis who delivered between July 2007 and June 2008 were separated into 2 groups according to whether they had cardiac surgery before pregnancy. Eighteen women in the test group had balloon mitral valvotomy before pregnancy, whereas 30 women in the control group had no cardiac surgery. Fetomaternal outcomes were compared between the 2 groups.

RESULTS

In the control group, significantly more patients had palpitations (P=0.032) and severe dyspnea (P=0.017) than in the test group. The incidence of preterm labor in the test group (1/18) was lower than that in the control group (10/30) (P=0.035). However, the groups did not differ in mode of delivery, mean birth weight, or neonatal complications.

CONCLUSION

Balloon mitral valvotomy improved maternal symptoms and should be done to prevent maternal morbidity and to reduce the incidence and complications of preterm labor.

Risk factors associated with preterm delivery in women with cardiac disease

BACKGROUND

The purpose of this study was to identify clinical characteristics of preterm delivery at less than 37 weeks of gestation (PD37G) and prenatal events associated with preterm delivery at less than 35 weeks of gestation (PD35G) in women with cardiac disease (WCD).

METHODS

A case-control study was conducted of 599 pregnancies in 479 single pregnant women with congenital or acquired cardiac lesions or cardiac arrhythmias. The relevant variables were compared between women who had PD35G (n=37) and the controls (n=562). Cardiac dysfunction was defined as the appearance of clinical symptoms of heart failure, abnormal electrocardiogram, or cardiac ultrasonography.

RESULTS

PD37G occurred in 77 cases (12.9%). The spontaneous and indicated preterm delivery was 26 (33.8%) and 51 (66.2%) cases, respectively. The presence of cardiac dysfunction [odds ratio (OR) 21.82, 95% confidence interval (CI) 8.3-57.49], New York Heart Association class II (OR 3.96, 95% CI 1.05-14.93), cardiomyopathy (OR 7.74, 95% CI 1.69-35.45) and pregnancy-induced hypertension (PIH) (OR 3.15, 95% CI 1.37-7.24) was significantly associated with an increased risk of PD35G. No maternal death was seen within one year after delivery.

CONCLUSIONS

Although pregnancy and delivery are generally safe in WCD, it is necessary to be aware of the risk factors of cardiac dysfunction, cardiomyopathy, and PIH from the aspect of PD35G.

Treatment of valvular heart disease during pregnancy for improving maternal and neonatal outcome

BACKGROUND

Valvular heart disease constitutes the majority of all causes of heart disease in pregnancy. In the presence of valvular heart disease, the necessary haemodynamic changes of pregnancy might cause heart failure, leading to severe maternal and fetal morbidity and even mortality. Treatment of valvular heart disease is indicated when patients experience a deterioration of symptoms and in case of a severe valvular lesion. Whether medical therapy or interventional therapy is the optimal treatment for both mother and child is unclear.

OBJECTIVES

To assess effectiveness and adverse effects of the different treatment modalities of valvular heart disease in pregnancy to improve maternal and neonatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011), EMBASE (1980 to 23 March 2011) and the reference lists of background review articles.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled and cluster-randomised controlled trials comparing medical therapy with percutaneous or surgical intervention for the treatment of valvular heart disease in pregnancy.

DATA COLLECTION AND ANALYSIS

We identified no (randomised) controlled trials to assess the effectiveness and adverse effects of the treatment of valvular heart disease in pregnancy.

MAIN RESULTS

There were no randomised controlled trials, quasi-randomised controlled trials or cluster-randomised trials identified from the search strategy.

AUTHORS' CONCLUSIONS

There is insufficient evidence to define the most effective treatment of valvular heart disease in pregnancy to improve maternal and neonatal outcomes.

Anticoagulation therapy during pregnancy of patients with artificial heart valves: fetomaternal outcome

OBJECTIVES

The major problem is the need for anticoagulant therapy in patient with mechanical heart valves.

STUDY DESIGN

The aim of the study was to analyze the course and outcome of pregnancies of patients with artificial mechanical heart valves with anticoagulant therapy. Study included 43 pregnancies leaded and terminated at the Institute of Gynecology and Obstetrics Clinical Center of Serbia in 20 years. We divided the patients in two groups depending on the type of anticoagulation therapy. Group I included 21 patients who were under Ethylbiscumacetate (Pelenthan) during the first 36 weeks of gestation, and intravenous Heparin in the last 4 weeks and after the delivery. Group II included 22 patients who received oral anticoagulant therapy all the time.

RESULTS

Worsening of the heart functional status happened in 6 patients (13.9%). The incidence of heart failure during the pregnancy was 13.9% and after the delivery 9.3%. The incidence of hemorrhagic complications was 11.6% during pregnancy and 14% after the delivery. Four patients had thromboembolic events before the pregnancy. The incidence of postpartal thromboembolic complications was 6.9% in group I. Two patients died due to the heart failure 3-7 days after the vaginal delivery. Maternal mortality was 4.6%. One neonatus died of hydrocephalus (2.5%) in group II. In our study there were no fetuses with congenital heart disease.

CONCLUSIONS

Pregnancies of patients with mechanical heart valves should be planned. We suggest ethylbiscumacetate in combination with Heparin as anticoagulation therapy during the pregnancy.

Maternal cardiac disease

PURPOSE OF REVIEW

An estimated 0.5-4% of pregnant patients have cardiac disease, such as rheumatic disease, which is decreasing in Western countries, uncorrected congenital heart disease, cardiomyopathy and ischaemic heart disease. There has been an increase in maternal mortality due to cardiac causes. Congenital heart disease is becoming the most common source of cardiac problems in the pregnant patient, because patients are increasingly likely to survive to childbearing age with the improvement of surgery.

RECENT FINDINGS

The increasing age of patients conceiving their first child is also an important factor. A comprehensive understanding of the physiology of pregnancy and the pathophysiology of maternal cardiac disease is of great importance for anaesthesiologists, gynaecologists and cardiologists involved in peripartum care.

SUMMARY

We try to give a brief and comprehensive review on this topic.