Severe cardiac disease in pregnancy, part II: impact of congenital and acquired cardiac diseases during pregnancy

A bibliometric review of peripartum cardiomyopathy compared to other cardiomyopathies using artificial intelligence and machine learning

As developments in artificial intelligence and machine learning become more widespread in healthcare, their potential to transform clinical outcomes also increases. Peripartum cardiomyopathy is a rare and poorly-characterised condition that presents as heart failure in the last trimester prior to delivery or within 5-6 months postpartum. The lack of a definitive understanding of the molecular causes and clinical progress of this condition suggests that bibliometrics will be well-suited to creating new insights into this serious clinical problem. We examine similarities and differences between peripartum and its closely related familial dilated cardiomyopathy and idiopathic dilated cardiomyopathy. Using PubMed as the source of bibliometric data, we apply artificial intelligence-supported natural language processing to compare extracted data and genes association with these cardiomyopathies. Gene data were enhanced with additional metadata from third-party datasets and then analysed for their impact and specificity for peripartum cardiomyopathy. Artificial intelligence identified 14 genes that distinguished peripartum from both dilated and familial dilated cardiomyopathy. They are as follows: CTSD, RLN2, MMP23B*, SLC17A5, ST2*, PTHLH, CFH*, CFI, GPT, MR1, Rln1, SRI, STAT5A* and THBD. We then used the Human Protein Atlas website that uses affinity-purified rabbit polyclonal antibodies to identify genes that are expressed at the protein level (bold), or as RNA transcripts (*) in healthy human left ventricles. Additional analysis focussed on the full set of peripartum genes on linkage and specificity to cardiomyopathy yielded a different set of thirteen genes (bold font indicates those expressed in cardiomyocytes: PRL, RLN2, PLN, ST2, CTSD, F2, ACE, STAT3, TTN, SPP1, LGALS3, miR-146a, GNB3, SRI). This type of analysis can highlight new avenues for research, aimed at improving genomics-driven peripartum cardiomyopathy diagnosis as well as potential pathological and clinical sub-classification. We expect that this will allow for future improvements in identification, treatment and management of this condition. The first step in the application of these bibliometric-based artificial intelligence methods is to understand the current knowledge, and it is the aim of this paper to show how this might be achieved.

Fetomaternal outcome of pregnancy with Mitral stenosis

Objective:

To evaluate the frequency of fetomaternal outcome of pregnancy with Mitral stenosis admitted in Civil Hospital Karachi.

Methods:

It was a two years descriptive study done in the Department of Obstetrics and Gynaecology Civil Hospital Karachi. All pregnant women with a known or newly diagnosed Mitral stenosis on echocardiography were included in the study. History was taken regarding age, parity, gestational age (calculated by ultrasound) and complaints. Mode of delivery and Maternal mortality noted. Foetal outcome was analyzed by birth weight and Apgar score.

Results:

A total of 101 patients meeting the inclusion criteria were enrolled in the study. The ages of the women ranged between 20-29 years (69%) and 81% were multigravidas. Vaginal delivery occurred in 67 (66.3%) women and 78.3% were term pregnancies. Preterm deliveries were 21.8% and 27.7% newborns were low birth weight. APGAR score <7 was found in 14.9% of neonates and 9 babies had intrauterine death. Low ejection fraction<55% was diagnosed in 20(13.9%) women and Maternal mortality was found in two cases.

Conclusion:

Heart disease in pregnancy is associated with significant morbidity, it should be carefully managed in a tertiary care hospital to obtain optimum maternal and foetal outcome.

Cardiomyopathy During Pregnancy

Cardiomyopathy is an acquired cardiac disorder that, although rare, accounts for a rising proportion of reported pregnancy-related deaths in the United States. During pregnancy, cardiomyopathy may be divided into 2 groups. The first group is peripartum cardiomyopathy; the second group is stratified according to 3 classically defined pathophysiologic presentations: hypertrophic, dilated, or restrictive. Within this second group, the cardiomyopathy can be either idiopathic or due to a specific identified cause. This disorder poses significant risks of morbidity and/or mortality to the pregnant woman and fetus/neonate. This article describes types of cardiomyopathy during pregnancy, perinatal risks, and general management principles with a focus on intrapartum care. Hemodynamic and oxygen transport data are presented to illustrate interpretation of patient assessment findings and the effects of interventions for abnormal maternal and fetal findings.

Hospital-based incidence of maternal heart failure during pregnancy in Nigeria

Purpose

To determine the incidence of heart failure during pregnancy and incriminated cardiac lesions, as well as maternal and fetal outcomes in Ladoke Akintola University of Technology Teaching Hospital (LTH), Osogbo, Southwest Nigeria.

Methods

This study was a retrospective, descriptive review of all cases of heart failure during pregnancy based on data retrieved from the medical records of LTH over a 7-year period from January 2004 to December 2010. Analysis of these data was carried out using SPSS 17. Ethical clearance was obtained from the Ethical Committee of LTH.

Results

A total of 4523 patients delivered babies over the 7-year period, ten (2.2/1000) of which had cardiac decompensation. All patients were not registered at LTH for antenatal care (unbooked), with 70% of them aged 18–24 years. Fifty percent were primigravidae and the majority of them presented with symptoms in the second and third trimester. There were two cases of maternal deaths recorded and three cases of fetal/perinatal mortality. Only one case of congenital heart disease (pulmonary stenosis) and no cases of rheumatic heart disease were found.

Conclusion

The data suggests that heart failure during pregnancy is uncommon in Southwest Nigeria. However, it occurs more often in young, unbooked primigravid women. Efforts should be aimed at encouraging early booking for antenatal care and a full cardiovascular evaluation to prevent associated maternal and fetal/perinatal morbidity and mortality.

Labor complicated by mitral stenosis

A case where a 28-year-old woman presented in labor complicated by mitral stenosis is described. Mitral stenosis is the most commonly encountered valvular lesion in pregnancy.

A retrospective survey of adverse maternal and neonatal outcomes for parturients with congenital heart disease

BACKGROUND

Parturients with congenital heart disease are at increased risk of maternal cardiac and neonatal complications. There is a paucity of literature regarding the relationship of complications with the type of anesthesia or mode of delivery.

METHODS

We retrospectively reviewed all parturients with congenital heart disease undergoing delivery over a 7-year period at Tokyo Women's Medical University, Maternal and Perinatal Center to identify maternal cardiac and neonatal complications occurring during the peripartum period.

RESULTS

Of 151 pregnancies in 128 women with congenital heart disease, there were 84 vaginal and 67 cesarean deliveries. Cesarean deliveries were performed with either neuraxial (n=51) or general (n=16) anesthesia. There were no maternal deaths and two neonatal deaths (one vaginal; one cesarean delivery). The incidence of maternal cardiac events was 1 in 84 (1%) for vaginal deliveries and 10 in 67 (15%) for cesarean deliveries. Neonatal complications occurred in 11 of 84 (13%) pregnancies with vaginal delivery and 25 of 67 (37%) pregnancies with cesarean delivery. Twenty-three elective cesarean deliveries occurred for maternal cardiac problems and were associated with a significant incidence of maternal cardiac (35%) and neonatal (65%) complications. The incidence of maternal cardiac events during delivery, when stratified by severity of cardiac disease, was similar to a previously derived cardiac risk index for pregnant women with cardiac disease.

CONCLUSION

Despite a low overall incidence of maternal and neonatal mortality, pregnancy in women with congenital heart disease was associated with significant maternal cardiac and neonatal complications. Elective cesarean delivery with neuraxial anesthesia was a common approach for high-risk parturients with congenital heart disease; however, the benefit of this mode of delivery and anesthetic technique could not be ascertained.

Systematic review of pregnancy in women with inherited cardiomyopathies

Pregnancy exposes women with inherited cardiomyopathies to increased risk for heart failure and arrhythmias. In this paper, we review the clinical course and management of pregnant women with the following inherited cardiomyopathies: hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, left ventricular non-compaction cardiomyopathy, and restrictive cardiomyopathy. We also discuss peripartum cardiomyopathy. Pregnancy is generally well tolerated in asymptomatic patients with inherited cardiomyopathies. However, worsening of the clinical condition can occur during pregnancy, despite intensive medical treatment. If prior cardiac events, poor functional class (New York Heart Association class III or IV), or advanced left ventricular systolic dysfunction are present, the risk of maternal cardiac complications during pregnancy are markedly increased. The postpartum condition is generally no worse than the antepartum condition, but no long-term follow-up studies have been reported. Preconception evaluation and counselling are important aspects of managing women with inherited cardiomyopathies. Genetic counselling and DNA testing should be offered to all women following the diagnosis of an inherited cardiomyopathy.

Ischemic Stroke during Pregnancy and Puerperium

Ischemic stroke during pregnancy and puerperium represents a rare occurrence but it could be a serious and stressful event for mothers, infants, and also families. Whenever it does occur, many concerns arise about the safety of the mother and the fetus in relation to common diagnostic tests and therapies leading to a more conservative approach. The physiological adaptations in the cardiovascular system and in the coagulability that accompany the pregnant state, which are more significant around delivery and in the postpartum period, likely contribute to increasing the risk of an ischemic stroke. Most of the causes of an ischemic stroke in the young may also occur in pregnant patients. Despite this, there are specific conditions related to pregnancy which may be considered when assessing this particular group of patients such as pre-eclampsia-eclampsia, choriocarcinoma, peripartum cardiomiopathy, amniotic fluid embolization, and postpartum cerebral angiopathy. This article will consider several questions related to pregnancy-associated ischemic stroke, dwelling on epidemiological and specific etiological aspects, diagnostic issue concerning the use of neuroimaging, and the related potential risks to the embryo and fetus. Therapeutic issues surrounding the use of anticoagulant and antiplatelets agents will be discussed along with the few available reports regarding the use of thrombolytic therapy during pregnancy.

Role of echocardiography in the assessment and management of adult congenital heart disease in pregnancy

Congenital heart disease represent a large proportion of heart disease in pregnancy. With the exception of patients with Eisenmenger's syndrome, pulmonary vascular obstructive disease, and Marfan's syndrome with aortopathy, maternal death during pregnancy is rare in women with CHD but morbidity occurs such as heart failure, arrhythmias, and stroke. Echocardiography represents a milestone in diagnosis, understanding of pathophysiology, assessment of disease severity and patient monitoring in pregnant women with unoperated and post-operative congenital heart disease.

[Management of cardiac high risk pregnancy. Caesarean section in a primagravida with cyanotic cardiac defect]

A 37-year-old gravida I with cyanotic heart disease presented for caesarean section in the 31st week of gestation. Caesarean section was performed uneventfully with the patient under epidural anaesthesia accompanied by invasive monitoring. Postoperative echocardiography showed no change in the shunt fraction, volumes or the ventricular function. Every patient with complex comorbidities has to be managed according to individual prerequisites and the experiences and preferences of the team. For such high risk pregnancies regional anaesthesia seems to be a possible option although no clear evidence can be found in the literature.

The Anesthesiologist's Role in Adults with Congenital Heart Disease

Anesthesia for adults with congenital heart disease has many challenging physiologic considerations. Collaborative relationships of a multidisciplinary team including cardiology, cardiac surgery, anesthesiology, and intensive care are essential to ensure positive outcomes in this population for noncardiac and cardiac surgery.

Assessment and evaluation of the woman with cardiac disease during pregnancy

Maternal heart disease complicates 0.2 to 3% of pregnancies and is responsible for 10% to 25% of maternal deaths. Many healthy women manifest subtle signs of cardiac failure during uncomplicated pregnancy and birth. Classic symptoms of heart disease mimic common symptoms of late pregnancy, such as palpitations, shortness of breath with exertion, and occasional chest pain. A complete cardiovascular examination assists the healthcare team to fully assess and evaluate the pregnant woman with known heart disease. Detailed assessment of the woman throughout pregnancy may lead to initial discovery of heart disease. Compilation of these objective data with subjective functional capacities allows for risk stratification and assignment to a New York Heart Association functional classification.