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Baschat AA, Darwin K, Vaught AJ. Hypertensive Disorders of Pregnancy and the Cardiovascular System: Causes, Consequences, Therapy, and Prevention. Am J Perinatol 2024; 41:1298-1310. [PMID: 36894160 DOI: 10.1055/a-2051-2127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Hypertensive disorders of pregnancy continue to be significant contributors to adverse perinatal outcome and maternal mortality, as well as inducing life-long cardiovascular health impacts that are proportional to the severity and frequency of pregnancy complications. The placenta is the interface between the mother and fetus and its failure to undergo vascular maturation in tandem with maternal cardiovascular adaptation by the end of the first trimester predisposes to hypertensive disorders and fetal growth restriction. While primary failure of trophoblastic invasion with incomplete maternal spiral artery remodeling has been considered central to the pathogenesis of preeclampsia, cardiovascular risk factors associated with abnormal first trimester maternal blood pressure and cardiovascular adaptation produce identical placental pathology leading to hypertensive pregnancy disorders. Outside pregnancy blood pressure treatment thresholds are identified with the goal to prevent immediate risks from severe hypertension >160/100 mm Hg and long-term health impacts that arise from elevated blood pressures as low as 120/80 mm Hg. Until recently, the trend for less aggressive blood pressure management during pregnancy was driven by fear of inducing placental malperfusion without a clear clinical benefit. However, placental perfusion is not dependent on maternal perfusion pressure during the first trimester and risk-appropriate blood pressure normalization may provide the opportunity to protect from the placental maldevelopment that predisposes to hypertensive disorders of pregnancy. Recent randomized trials set the stage for more aggressive risk-appropriate blood pressure management that may offer a greater potential for prevention for hypertensive disorders of pregnancy. KEY POINTS: · Optimal management of maternal blood pressure to prevent preeclampsia and its risks is undefined.. · Early gestational rheological damage to the intervillous space predisposes to preeclampsia and FGR.. · First trimester blood pressure management may need to aim for normotension to prevent preeclampsia..
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Affiliation(s)
| | - Kristin Darwin
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Arthur J Vaught
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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Halpern DG, Penfield CA, Feinberg JL, Small AJ. Reproductive Health in Congenital Heart Disease: Preconception, Pregnancy, and Postpartum. J Cardiovasc Dev Dis 2023; 10:jcdd10050186. [PMID: 37233153 DOI: 10.3390/jcdd10050186] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
The prevalence of congenital heart disease (CHD) in pregnancy is rising due to the improved survival of patients with CHD into childbearing age. The profound physiological changes that occur during pregnancy may worsen or unmask CHD, affecting both mother and fetus. Successful management of CHD during pregnancy requires knowledge of both the physiological changes of pregnancy and the potential complications of congenital heart lesions. Care of the CHD patient should be based on a multidisciplinary team approach beginning with preconception counseling and continuing into conception, pregnancy, and postpartum periods. This review summarizes the published data, available guidelines and recommendations for the care of CHD during pregnancy.
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Affiliation(s)
- Dan G Halpern
- NYU Adult Congenital Heart Disease Program, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Christina A Penfield
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Jodi L Feinberg
- NYU Adult Congenital Heart Disease Program, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Adam J Small
- NYU Adult Congenital Heart Disease Program, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
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3
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Ma JL, Luo F, Yan L. Neonatal Outcomes in Pregnant Women With Repaired and Unrepaired Congenital Heart Disease in Zhejiang, China. Indian Pediatr 2023. [DOI: 10.1007/s13312-023-2809-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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4
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Goldstein SA, Savu A, Islam S, Ward CC, Krasuski RA, Grotegut CA, Newby LK, Hornberger LK, Windram J, Kaul P. Risk Factors and Outcomes Associated With Hypertensive Disorders of Pregnancy in Maternal Congenital Heart Disease. JACC. ADVANCES 2022; 1:100036. [PMID: 38939317 PMCID: PMC11198567 DOI: 10.1016/j.jacadv.2022.100036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 06/29/2024]
Abstract
Background Among women with congenital heart disease (CHD), risk factors for hypertensive disorders of pregnancy (HDP) and the association of HDP with adverse outcomes are unknown. Objectives The purpose of this study was to identify risk factors for HDP among women with and without CHD and to assess the association of HDP with adverse events. Methods This retrospective cohort study included the first live birth for each woman who was pregnant in Alberta, Canada, between January 1, 2005, and December 31, 2018. The prevalence of HDP among women with and without CHD was compared. Multivariable models were used to determine the independent associations between maternal characteristics and HDP and to assess the strength of associations between HDP and CHD with adverse events. Results Of the total birth events, 0.6% (N = 2,575) occurred in women with CHD. HDP were more common among women with CHD (11.2% vs 8.1%, P < 0.0001). Chronic hypertension and diabetes mellitus were strongly associated with HDP among women with CHD (adjusted odds ratio [aOR]: 4.56; 95% confidence interval [CI]: 2.95-7.03; and aOR: 3.33; 95% CI: 1.48-7.49, respectively). Coarctation of the aorta was the only CHD lesion independently associated with increased risk for HDP (aOR: 1.76; 95% CI: 1.02-3.02). HDP, as opposed to CHD, was more strongly associated with having a complicated delivery admission, preterm delivery, and small for gestational age infant. Conclusions HDP were more common among women with CHD. The strongest risk factors for HDP among women with CHD were acquired. The presence of HDP, rather than CHD, was more strongly associated with certain adverse outcomes.
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Affiliation(s)
- Sarah A. Goldstein
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Anamaria Savu
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Sunjidatul Islam
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Cary C. Ward
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Richard A. Krasuski
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Chad A. Grotegut
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Wake Forest Baptist Health, Winston Salem, North Carolina, USA
| | - L. Kristin Newby
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa K. Hornberger
- Fetal & Neonatal Cardiology Program, Pediatric Cardiology, Women’s & Children’s Health Research Institute & Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Department of Obstetrics & Gynecology, Women’s & Children’s Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan Windram
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Mendelson MA. Pregnancy in women with left-to-right cardiac shunts: Any risk? INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Hardee I, Wright L, McCracken C, Lawson E, Oster ME. Maternal and Neonatal Outcomes of Pregnancies in Women With Congenital Heart Disease: A Meta-Analysis. J Am Heart Assoc 2021; 10:e017834. [PMID: 33821681 PMCID: PMC8174159 DOI: 10.1161/jaha.120.017834] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background With advances in the treatment of congenital heart disease (CHD), more women with CHD survive childhood to reach reproductive age. The objective of this study was to evaluate the maternal and neonatal outcomes of pregnancies among women with CHD in the modern era. Methods and Results We conducted a meta‐analysis of peer‐reviewed literature published January 2007 through June 2019. Studies were included if they reported on maternal or fetal mortality and provided data by CHD lesion. Meta‐analysis was performed using random effect regression modeling using Comprehensive Meta‐Analysis (v3). CHD lesions were categorized as mild, moderate, and severe to allow for pooling of data across studies. Of 2200 articles returned by our search, 32 met inclusion criteria for this study. Overall, the rate of neonatal mortality was 1%, 3.1%, and 3.5% in mild, moderate, and severe lesions, respectively. There were too few maternal deaths in any group to pool data. The rates of maternal and neonatal morbidity among women with CHD increase with severity of lesion. Specifically, rates of maternal arrhythmia and heart failure, cesarean section, preterm birth, and small for gestational age neonate are all markedly increased as severity of maternal CHD increases. Conclusions In the modern era, pregnancy in women with CHD typically has a successful outcome in both mother and child. However, as maternal CHD severity increases, so too does the risk of numerous morbidities and neonatal mortality. These findings may help in counseling women with CHD who plan to become pregnant, especially women with severe lesions.
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Affiliation(s)
- Isabel Hardee
- Department of Pediatrics University of Colorado School of Medicine Denver CO
| | - Lydia Wright
- Department of Pediatrics Emory University School of Medicine, Children's Healthcare of Atlanta Atlanta GA
| | - Courtney McCracken
- Department of Pediatrics Emory University School of Medicine, Children's Healthcare of Atlanta Atlanta GA
| | - Emily Lawson
- Woodruff Health Sciences Center Library Emory University Atlanta GA
| | - Matthew E Oster
- Department of Pediatrics Emory University School of Medicine, Children's Healthcare of Atlanta Atlanta GA
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Abstract
Women with congenital heart disease are pursuing pregnancy in increasing numbers. Counseling about genetic transmission, medication management, maternal and fetal risks, and maternal longevity should be initiated well before pregnancy is considered. Although preconception medical and surgical optimization as well as coordinated multidisciplinary care throughout pregnancy decrease maternal and fetal risks, the rate of complications remains increased compared with the general population. Lesion-specific risk stratification and care throughout pregnancy further improve outcomes and decrease unnecessary interventions.
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Affiliation(s)
- Katherine B Salciccioli
- Adult Congenital Heart Disease, Department of Internal Medicine, University of Michigan, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109-4204, USA
| | - Timothy B Cotts
- Adult Congenital Heart Disease, Department of Internal Medicine, University of Michigan, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109-4204, USA; Adult Congenital Heart Disease, Department of Pediatrics, University of Michigan, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109-4204, USA.
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Romeo JLR, Papageorgiou G, Takkenberg JJM, Roos-Hesselink JW, van Leeuwen WJ, Cornette JMJ, Rizopoulos D, Bogers AJJC, Mokhles MM. Influence of pregnancy on long-term durability of allografts in right ventricular outflow tract. J Thorac Cardiovasc Surg 2019; 159:1508-1516.e1. [PMID: 31706555 DOI: 10.1016/j.jtcvs.2019.08.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 08/25/2019] [Accepted: 08/26/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND There is very limited published evidence about the influence of pregnancy on allograft durability in right ventricular outflow tract position. We present the first study using mixed and joint modeling. METHODS This retrospective study compared clinical and valve related outcomes of all consecutive female hospital survivors in their fertile life phase (18-50 years) based on pregnancy. Serial echocardiographic measurements of pulmonary gradient and regurgitation were analyzed for their association with valve replacement using joint models for longitudinal and time-to-event data. Occurrence of first pregnancy was included as a time-dependent intermediate event in both the longitudinal and survival analyses of the joint model to assess its impact on the hemodynamic and clinical outcome. RESULTS In total, 196 consecutive women in their fertile life-phase with an allograft were included. Complete information of 176 (90%) allografts in 165 women was available, including 1395 echocardiograms. Of these women, 51 (30.9%) women had 84 completed pregnancies at an average age of 29.1 ± 3.9 (SD) years; 8.1 ± 6.1 years since allograft implantation. Tetralogy of Fallot was the most common diagnosis in both groups. After a mean follow-up of 15.2 years (range 0.1-30), 7 (13.7%) parous women underwent valve replacement versus 20 (17.5%) nulliparous women. During this follow-up, the mean allograft gradient in parous (24.2 mm Hg) and nulliparous (21.0 mm Hg) women was comparable (P = .225). A 1-mm Hg increase in pulmonary gradient increased the instantaneous risk of pulmonary valve replacement (PVR) by a ratio of 1.051 (P < .001), regardless of pregnancy. Similarly, development of moderate or severe regurgitation increased the risk of PVR (P = .038), regardless of pregnancy. Pregnancy was not associated with a change in the allograft gradient (P = .258), regurgitation grade (P = .774), or hazard of PVR (P = .796) during follow-up. CONCLUSIONS Pregnancy is not associated with impaired allograft durability in women with good cardiac health.
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Affiliation(s)
- Jamie L R Romeo
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Grigorios Papageorgiou
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Johanna J M Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jolien W Roos-Hesselink
- Department of Congenital Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Wouter J van Leeuwen
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jerome M J Cornette
- Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M Mostafa Mokhles
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Outcomes of Pregnancy After Right Ventricular Outflow Tract Reconstruction With an Allograft Conduit. J Am Coll Cardiol 2019; 71:2656-2665. [PMID: 29880126 DOI: 10.1016/j.jacc.2018.03.522] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 02/26/2018] [Accepted: 03/06/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is no published evidence on pregnancy after right ventricular outflow tract (RVOT) reconstruction with an allograft. OBJECTIVES The aim of this study was to describe pregnancy outcomes in women with allografts in the RVOT position. METHODS A retrospective cohort study of consecutive female patients who received allografts in the RVOT position was conducted. All patients between 18 and 50 years of age were screened for cardiac, obstetric, and fetal outcomes of completed (≥20 weeks' gestation) pregnancies. RESULTS In total, 196 women met the inclusion criteria, of whom 56 had 89 completed pregnancies. Information could be retrieved in 84 cases (94.4%). Mean maternal age was 29.6 ± 4.3 years, with 80 patients (95.2%) in New York Heart Association functional class I or II. The most common diagnosis was tetralogy of Fallot. All women survived pregnancy. There were 2 cases (2.4%) of heart failure (arrhythmic and diastolic dysfunction), 1 case (1.2%) of infection (chorioamnionitis), and 3 cases (3.6%) of pre-eclampsia. No other cardiac or obstetric events were reported. All children were born alive at a median gestational age of 38.4 weeks (interquartile range: 36.9 to 39.6 weeks), with a median birthweight of 2,930 g (interquartile range: 2,535 to 3,385 g). Seventeen (20.2%) were small for gestational age, and 20 (23.8%) were premature. Neonatal death was reported in 2 children (2.5%). Preconception pulmonary regurgitation was associated with an increased probability of pre-term labor (odds ratio: 2.610; 95% confidence interval: 1.318 to 5.172). Compared with the general Dutch population, pre-term delivery (25.0% vs. 7.4%, p < 0.001) and children small for gestational age (20.2% vs. 10.0%, p = 0.002) were more common. CONCLUSIONS Women in good cardiac health after RVOT reconstruction with allografts can safely experience pregnancy and labor. The higher incidence of pre-term delivery and children small for gestational age warrants special attention.
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Hayward RM, Foster E, Tseng ZH. Maternal and Fetal Outcomes of Admission for Delivery in Women With Congenital Heart Disease. JAMA Cardiol 2019; 2:664-671. [PMID: 28403428 DOI: 10.1001/jamacardio.2017.0283] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Women with congenital heart disease (CHD) may be at increased risk for adverse events during pregnancy and delivery. Objective To compare delivery outcomes between women with and without CHD. Design, Setting, and Participants This retrospective study of inpatient delivery admissions in the Healthcare Cost and Utilization Project's California State Inpatient Database compared maternal and fetal outcomes between women with and without CHD by using multivariate logistic regression. Female patients with codes for delivery from the International Classification of Diseases, Ninth Revision, from January 1, 2005, through December 31, 2011, were included. The association of CHD with readmission was assessed to 7 years after delivery. Cardiovascular morbidity and mortality were hypothesized to be higher among women with CHD. Data were analyzed from April 4, 2014, through January 23, 2017. Exposures Noncomplex and complex CHD. Main Outcomes and Measures Maternal outcomes included in-hospital arrhythmias, eclampsia or preeclampsia, congestive heart failure (CHF), length of stay, preterm labor, anemia complicating pregnancy, placental abnormalities, infection during labor, maternal readmission at 1 year, and in-hospital mortality. Fetal outcomes included growth restriction, distress, and death. Results Among 3 642 041 identified delivery admissions, 3189 women had noncomplex CHD (mean [SD] age, 28.6 [7.6] years) and 262 had complex CHD (mean [SD] age, 26.5 [6.8] years). Women with CHD were more likely to undergo cesarean delivery (1357 [39.3%] vs 1 164 509 women without CHD [32.0%]; P < .001). Incident CHF, atrial arrhythmias, ventricular arrhythmias, and maternal mortality were uncommon during hospitalization, with each occurring in fewer than 10 women with noncomplex or complex CHD (<0.5% each). After multivariate adjustment, noncomplex CHD (odds ratio [OR], 9.7; 95% CI, 4.7-20.0) and complex CHD (OR, 56.6; 95% CI, 17.6-182.5) were associated with greater odds of incident CHF. Similar odds were found for atrial arrhythmias in noncomplex (OR, 8.2; 95% CI, 3.0-22.7) and complex (OR, 31.8; 95% CI, 4.3-236.3) CHD, for fetal growth restriction in noncomplex (OR, 1.6; 95% CI, 1.3-2.0) and complex (OR, 3.5; 95% CI, 2.1-6.1) CHD, and for hospital readmission in both CHD groups combined (OR, 3.6; 95% CI, 3.3-4.0). Complex CHD was associated with greater adjusted odds of serious ventricular arrhythmias (OR, 31.8; 95% CI, 4.3-236.3) and maternal in-hospital mortality (OR, 79.1; 95% CI, 23.9-261.8). Conclusions and Relevance In this study of hospital admissions for delivery in California, CHD was associated with incident CHF, atrial arrhythmias, and fetal growth restriction and complex CHD was associated with ventricular arrhythmias and maternal in-hospital mortality, although these outcomes were rare, even in women with complex CHD. These findings may guide monitoring decisions and risk assessment for pregnant women with CHD at the time of delivery.
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Affiliation(s)
- Robert M Hayward
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Francisco2now with Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Memorial Medical Center, Worcester
| | - Elyse Foster
- Division of Cardiology, Department of Medicine, University of California, San Francisco
| | - Zian H Tseng
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Francisco
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Foeller ME, Foeller TM, Druzin M. Maternal Congenital Heart Disease in Pregnancy. Obstet Gynecol Clin North Am 2018; 45:267-280. [PMID: 29747730 DOI: 10.1016/j.ogc.2018.01.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Congenital heart disease comprises most maternal cardiac diseases in pregnancy and is an important cause of maternal, fetal, and neonatal morbidity and mortality worldwide. Pregnancy is often considered a high-risk state for individuals with structural heart disease as a consequence of a limited ability to adapt to the major hemodynamic changes associated with pregnancy. Preconception counseling and evaluation are of utmost importance, as pregnancy is contraindicated in certain cardiac conditions. Pregnancy can be safely accomplished in most individuals with careful risk assessment before conception and multidisciplinary care throughout pregnancy and the postpartum period.
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Affiliation(s)
- Megan E Foeller
- Obstetrics and Gynecology, Stanford University, Stanford Hospital, 300 Pasteur Drive, Room G302, 5317, Stanford, CA 94305-5317, USA.
| | - Timothy M Foeller
- Internal Medicine, Stanford Health Care-ValleyCare, 5555 West Positas Boulevard, 1 West Hospitalist Room 1, Pleasanton, CA 94588, USA
| | - Maurice Druzin
- Obstetrics and Gynecology, Stanford University, Stanford Hospital, 300 Pasteur Drive, Room G302, 5317, Stanford, CA 94305-5317, USA
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12
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Phillips S, Pirics M. Congenital Heart Disease and Reproductive Risk: An Overview for Obstetricians, Cardiologists, and Primary Care Providers. Methodist Debakey Cardiovasc J 2018; 13:238-242. [PMID: 29744016 DOI: 10.14797/mdcj-13-4-238] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Patients with congenital heart disease have improved survival rates, and most patients are now expected to survive into adulthood. This improved survival has resulted in increasing numbers of women with congenital heart disease who are of childbearing age. This patient population requires specialized advice on contraception and pregnancy risk. Understanding the unique challenges this population presents is key to providing appropriate care.
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Aydin E, Ozyuncu O, Kasapoglu D, Orgul G, Ozer N, Yurdakok M, Beksac MS. Clinical analyses of 383 cases with maternal cardiac diseases. J Perinat Med 2018. [PMID: 28622145 DOI: 10.1515/jpm-2017-0023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AIM To evaluate the pregnancy outcomes of women with heart disease. MATERIALS AND METHODS In this retrospective study, 383 pregnant women with cardiac diseases were examined. The cases were classified according to the World Health Organization (WHO) classification. The distribution of the cases according to class, congenital heart diseases, mean birthweight, mean gestational week at delivery, type of delivery [cesarean section (CS) or vaginal delivery], and cardivascular events (during pregnancy and puerperium) were evaluated. RESULTS Of the 383 patients, 25 were in Class I; 39, Class II; 255, Class II or III; 31, Class III; and 33, Class IV cardiac diseases. The neonatal birth weights were significantly lower in Class III than in Classes II, and II or III. The preterm delivery rate was higher in Class III than in the other classes. Delivery was performed by CS due to cardiac indications in the high-risk classes, however, only obstetric indications were considered in the low-risk classes. Only one case of maternal death occurred during the postpartum period, in a patient with Eisenmenger's syndrome. DISCUSSION Cardiovascular diseases are an important cause of mortality and morbidity in pregnancy. The adverse impact of cardiovascular disorders on pregnancy outcomes should be the main concern during the management of these women.
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Affiliation(s)
- Emine Aydin
- Hacettepe University Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, 06100, Sıhhiye, Ankara, Turkey, Phone: +90 312 305 2477, Fax: +90 312 305 2315
| | - Ozgur Ozyuncu
- Hacettepe University, Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Perinatology, Ankara, Turkey
| | | | - Gokcen Orgul
- Hacettepe University, Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Perinatology, Ankara, Turkey
| | - Necla Ozer
- Hacettepe University Faculty of Medicine, Department of Cardiology, Ankara, Turkey
| | - Murat Yurdakok
- Hacettepe University Faculty of Medicine, Department of Child Health and Diseases, Neonatology Unit, Ankara, Turkey
| | - M Sinan Beksac
- Hacettepe University, Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Perinatology, Ankara, Turkey
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14
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Abstract
The prevalence of pregnant women with cardiovascular heart disease is increasing. Transthoracic echocardiography is safe during pregnancy, and it is an important diagnostic tool in pregnant women with established heart disease in order to monitor ventricular and valvular anatomy and function. In addition, it can be used to delineate cardiac anatomy in complex congenital heart disease and help stratify maternal risk during pregnancy. This review will focus on the use of echocardiography in the diagnosis and management of pregnant women with common congenital lesions and with prosthetic valves.
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Affiliation(s)
- Meena Narayanan
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Uri Elkayam
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tasneem Z Naqvi
- Division of Cardiology, Department of Medicine, College of Medicine, Mayo Clinic, CK27, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
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15
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Abstract
OPINION STATEMENT Advances in cardiac surgical interventions in infancy and childhood have led to an increased number of women with congenital heart disease of childbearing age. For these women, individualized preconception counseling and pregnancy planning should be a vital component of their medical management, and presentation for obstetric care may even be an opportunity to re-establish cardiovascular care for patients who have been lost to follow-up. These patients have unique cardiovascular anatomy and physiology, which is dependent upon the surgical intervention they may have undergone during childhood or adolescence. These factors are associated with a variety of long-term complications, and the normal hemodynamic changes of pregnancy may unmask cardiac dysfunction and pose significant risk. Among three published risk assessment algorithms, the World Health Organization classification is the most sensitive in predicting maternal cardiovascular events in this population. Women with simple congenital heart defects generally tolerate pregnancy well and can be cared for in the community with careful monitoring. Conversely, women with complex congenital defects, with or without surgical repair and/or residual defects, should be managed in tertiary care centers under a multidisciplinary team of physicians experienced in adult congenital heart disease and high-risk obstetrics, who collaboratively participate in pregnancy planning, management, and care through childbirth and postpartum. Women who are cyanotic with oxygen saturation less than 85%, have significant pulmonary arterial hypertension of any cause, or have systemic ventricular dysfunction should be counseled to avoid pregnancy due to a very high risk of maternal and fetal mortality.
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Affiliation(s)
- Evin Yucel
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Doreen DeFaria Yeh
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA. .,Adult Congenital Heart Disease Program, Massachusetts General Hospital, Division of Cardiology, Harvard Medical School, Boston, MA, USA.
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Bianca I, Geraci G, Gulizia MM, Egidy Assenza G, Barone C, Campisi M, Alaimo A, Adorisio R, Comoglio F, Favilli S, Agnoletti G, Carmina MG, Chessa M, Sarubbi B, Mongiovì M, Russo MG, Bianca S, Canzone G, Bonvicini M, Viora E, Poli M. Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Pediatric Cardiology (SICP), and Italian Society of Gynaecologists and Obstetrics (SIGO): pregnancy and congenital heart diseases. Eur Heart J Suppl 2017; 19:D256-D292. [PMID: 28751846 PMCID: PMC5526477 DOI: 10.1093/eurheartj/sux032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The success of cardiac surgery over the past 50 years has increased numbers and median age of survivors with congenital heart disease (CHD). Adults now represent two-thirds of patients with CHD; in the USA alone the number is estimated to exceed 1 million. In this population, many affected women reach reproductive age and wish to have children. While in many CHD patients pregnancy can be accomplished successfully, some special situations with complex anatomy, iatrogenic or residual pathology are associated with an increased risk of severe maternal and fetal complications. Pre-conception counselling allows women to come to truly informed choices. Risk stratification tools can also help high-risk women to eventually renounce to pregnancy and to adopt safe contraception options. Once pregnant, women identified as intermediate or high risk should receive multidisciplinary care involving a cardiologist, an obstetrician and an anesthesiologist with specific expertise in managing this peculiar medical challenge. This document is intended to provide cardiologists working in hospitals where an Obstetrics and Gynecology Department is available with a streamlined and practical tool, useful for them to select the best management strategies to deal with a woman affected by CHD who desires to plan pregnancy or is already pregnant.
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Affiliation(s)
- Innocenzo Bianca
- Pediatric Cardiology Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Giovanna Geraci
- Cardiology Department, PO Cervello, Az. Osp. Riuniti Villa Sofia-Cervello, Via Trabucco, 180, 90146 Palermo, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione ‘Garibaldi’, Catania, Italy
| | - Gabriele Egidy Assenza
- Pediatric Cardiology and Adult Congenital Heart Program, Azienda Ospedaliera-Universitaria Sant’Orsola-Malpighi, Bologna, Itlay
| | - Chiara Barone
- Genetics Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Marcello Campisi
- Pediatric Cardiology Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Annalisa Alaimo
- Pediatric Cardiology Department, PO Di Cristina, ARNAS Civico, Palermo, Italy
| | - Rachele Adorisio
- Pediatric Cardiology Department, Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Francesca Comoglio
- SCDU 2, Dipartimento di Scienze Chirurgiche (Surgical Sciences Department), Università di Torino, Italy
| | - Silvia Favilli
- Pediatric Cardiology Department, Azienda-Ospedalliero-Universitaria Meyer, Firenze, Italy
| | - Gabriella Agnoletti
- Pediatric Cardiology Department, Ospedale Regina Margherita, Città della Salute e della Scienza, Torino, Italy
| | - Maria Gabriella Carmina
- Cardiology Department, PO Cervello, Az. Osp. Riuniti Villa Sofia-Cervello, Via Trabucco, 180, 90146 Palermo, Italy
| | - Massimo Chessa
- Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato Milanese San Donato Milanese (MI), Italy
| | - Berardo Sarubbi
- Pediatric Cardiology and Cardiology SUN, Seconda Università di Napoli, AORN dei Colli, Ospedale Monaldi, Napoli, Italy
| | - Maurizio Mongiovì
- Pediatric Cardiology Department, PO Di Cristina, ARNAS Civico, Palermo, Italy
| | - Maria Giovanna Russo
- Pediatric Cardiology and Cardiology SUN, Seconda Università di Napoli, AORN dei Colli, Ospedale Monaldi, Napoli, Italy
| | - Sebastiano Bianca
- Genetics Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Giuseppe Canzone
- Women and Children Health Department, Ospedale S. Cimino, Termini Imerese (PA), Italy
| | - Marco Bonvicini
- Pediatric Cardiology and Adult Congenital Heart Program, Azienda Ospedaliera-Universitaria Sant’Orsola-Malpighi, Bologna, Itlay
| | - Elsa Viora
- Echography and Prenatal Diagnosis Centre, Obstetrics and Gynaecology Department, Città della Salute e della Scienza di Torino, Italy
| | - Marco Poli
- Intensive Cardiac Therapy Department, Ospedale Sandro Pertini, Roma, Italy
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Martins LC, Freire CMV, Capuruçu CAB, Nunes MDCP, Rezende CADL. Risk Prediction of Cardiovascular Complications in Pregnant Women With Heart Disease. Arq Bras Cardiol 2016; 106:289-96. [PMID: 26959402 PMCID: PMC4845701 DOI: 10.5935/abc.20160028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 10/26/2015] [Accepted: 11/06/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Heart disease in pregnancy is the leading cause of non- obstetric maternal death. Few Brazilian studies have assessed the impact of heart disease during pregnancy. OBJECTIVE To determine the risk factors associated with cardiovascular and neonatal complications. METHODS We evaluated 132 pregnant women with heart disease at a High-Risk Pregnancy outpatient clinic, from January 2005 to July 2010. Variables that could influence the maternal-fetal outcome were selected: age, parity, smoking, etiology and severity of the disease, previous cardiac complications, cyanosis, New York Heart Association (NYHA) functional class > II, left ventricular dysfunction/obstruction, arrhythmia, drug treatment change, time of prenatal care beginning and number of prenatal visits. The maternal-fetal risk index, Cardiac Disease in Pregnancy (CARPREG), was retrospectively calculated at the beginning of prenatal care, and patients were stratified in its three risk categories. RESULTS Rheumatic heart disease was the most prevalent (62.12%). The most frequent complications were heart failure (11.36%) and arrhythmias (6.82%). Factors associated with cardiovascular complications on multivariate analysis were: drug treatment change (p = 0.009), previous cardiac complications (p = 0.013) and NYHA class III on the first prenatal visit (p = 0.041). The cardiovascular complication rates were 15.22% in CARPREG 0, 16.42% in CARPREG 1, and 42.11% in CARPREG > 1, differing from those estimated by the original index: 5%, 27% and 75%, respectively. This sample had 26.36% of prematurity. CONCLUSION The cardiovascular complication risk factors in this population were drug treatment change, previous cardiac complications and NYHA class III at the beginning of prenatal care. The CARPREG index used in this sample composed mainly of patients with rheumatic heart disease overestimated the number of events in pregnant women classified as CARPREG 1 and > 1, and underestimated it in low-risk patients (CARPREG 0).
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Affiliation(s)
- Luciana Carvalho Martins
- Universidade Federal de Minas Gerais - UFMG, Belo
Horizonte, MG - Brazil
- Maternidade Odete Valadares - Fundação
Hospitalar do Estado de Minas Gerais, Belo Horizonte, MG - Brazil
| | - Claudia Maria Vilas Freire
- Universidade Federal de Minas Gerais - UFMG, Belo
Horizonte, MG - Brazil
- Maternidade Odete Valadares - Fundação
Hospitalar do Estado de Minas Gerais, Belo Horizonte, MG - Brazil
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Abstract
Most women with known congenital heart disease can have successful pregnancy, labor, and delivery. Preconception assessment is essential in understanding anatomy, repairs, and current physiology, all of which can influence risk in pregnancy. With that foundation, a multidisciplinary cardio-obstetric team can predict and prepare for complications that may occur with superimposed hemodynamic changes of pregnancy. Individuals with Eisenmenger syndrome, pulmonary hypertension, cyanosis, significant left heart obstruction, ventricular dysfunction, or prior major cardiac event are among the highest risk for complications.
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Abstract
Adults with congenital heart disease now form the largest group of women with cardiac disease becoming pregnant in the developed world. This is both a mark of impressive steps forward in the management of congenital heart disease and also a challenge to the medical community to develop systems of care that will best serve these women and their babies. Each woman with congenital heart disease presents a unique pattern of challenges for the cardiologist, obstetrician, and anesthesiologist, and their care should be tailored to deal with their individual circumstances. As this population of patients continues to grow, we must continue to learn and improve our diagnostic tools and management strategies to refine their care. This review intends to focus on reviewing the outcomes in this set of patients and also an approach to the assessment and the management of these patients, primarily for an audience of obstetricians, pediatricians, and anesthesiologists.
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Affiliation(s)
- Shaline Rao
- Division of Cardiology, Columbia University Medical Center, New York, NY
| | - Jonathan N Ginns
- Division of Cardiology, Columbia University Medical Center, New York, NY.
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Regitz-Zagrosek V, Gohlke-Bärwolf C, Iung B, Pieper PG. Management of cardiovascular diseases during pregnancy. Curr Probl Cardiol 2014; 39:85-151. [PMID: 24794710 DOI: 10.1016/j.cpcardiol.2014.02.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The prevalence of cardiovascular diseases (CVDs) in women of childbearing age is rising. The successes in medical and surgical treatment of congenital heart disease have led to an increasing number of women at childbearing age presenting with problems of treated congenital heart disease. Furthermore, in developing countries and in immigrants from these countries, rheumatic valvular heart disease still plays a significant role in young women. Increasing age of pregnant women and increasing prevalence of atherosclerotic risk factors have led to an increase in women with coronary artery disease at pregnancy. Successful management of pregnancy in women with CVDs requires early diagnosis, a thorough risk stratification, and appropriate management by a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, and primary care physicians. The following review is based on the recent European guidelines on the management of CVDs during pregnancy, which aim at providing concise and simple recommendations for these challenging problems.
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Gelson E, Johnson M. Effect of maternal heart disease on pregnancy outcomes. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.10.49] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ruys TPE, Roos-Hesselink JW, Hall R, Subirana-Domènech MT, Grando-Ting J, Estensen M, Crepaz R, Fesslova V, Gurvitz M, De Backer J, Johnson MR, Pieper PG. Heart failure in pregnant women with cardiac disease: data from the ROPAC. Heart 2013; 100:231-8. [DOI: 10.1136/heartjnl-2013-304888] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Abstract
Heart disease is a main cause of maternal mortality in the United States and the United Kingdom. Most deaths are from acquired conditions. However, due to the increased survival of children born with congenital heart disease (CHD) over the past 30 years, the population of adults with congenital heart disease in the U.S. now exceeds 1 million. Thus, there are now more adults with CHD than children with CHD. Many of these adult survivors of pediatric heart disease are of childbearing age and are considering pregnancy. This article reviews the literature concerning pregnancy and CHD.
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Affiliation(s)
- Wayne J Franklin
- Texas Adult Congenital Heart Disease Program, Texas Children's Hospital, Departments of Pediatrics and Medicine, Baylor College of Medicine, 6621 Fannin Street, 20th Floor West Tower, MC 19-345C, Houston, TX 77030, USA.
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24
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Abstract
Advances in the surgical palliation and correction of congenital heart lesions have improved survival and increased the number of patients living into adulthood. Although pregnancy outcomes will be favorable for most patients with congenital heart disease, the cardiovascular challenges associated with pregnancy and delivery are best managed with a multidisciplinary approach during the puerperium. This review addresses the prevalence, physiology, risk assessment, peripartum complications, and anesthetic management of the pregnant patient with underlying congenital heart disease.
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Affiliation(s)
- Amy J Ortman
- University of Kansas Medical Center, Kansas City, KS 66160-7415, USA.
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Guía de práctica clínica de la ESC para el tratamiento de las enfermedades cardiovasculares durante el embarazo. Rev Esp Cardiol 2012. [DOI: 10.1016/j.recesp.2011.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, Cifkova R, Ferreira R, Foidart JM, Gibbs JSR, Gohlke-Baerwolf C, Gorenek B, Iung B, Kirby M, Maas AHEM, Morais J, Nihoyannopoulos P, Pieper PG, Presbitero P, Roos-Hesselink JW, Schaufelberger M, Seeland U, Torracca L. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:3147-97. [PMID: 21873418 DOI: 10.1093/eurheartj/ehr218] [Citation(s) in RCA: 953] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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JOSEFSSON ANN, KERNELL KRISTINA, NIELSEN NIELSERIK, BLADH MARIE, SYDSJÖ GUNILLA. Reproductive patterns and pregnancy outcomes in women with congenital heart disease - a Swedish population-based study. Acta Obstet Gynecol Scand 2011; 90:659-65. [DOI: 10.1111/j.1600-0412.2011.01100.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Congenital heart diseases are the most common birth defects in humans, affecting approximately 0.8% of all live births. In the past, many of the more severe defects resulted in profound disability and death during childhood, and adult survival was exceptional. The past 4 decades have seen dramatic improvements in the survival and quality of life of patients with the more severe defects. As a result of these improvements, the challenges of caring for adults with congenital heart disease are only now being realized. Most women with congenital heart disease are now expected to reach childbearing age and maternal cardiac disease is the major cause of maternal morbidity and mortality. As such, appropriate pre-pregnancy counseling and management during pregnancy are fundamental components of the care of these patients. This article describes the circulatory changes that occur during normal pregnancy and delivery, addresses the risks posed during pregnancy by specific congenital lesions, and reviews the current data on pregnancy outcomes in patients with individual congenital defects.
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Vitarelli A, Capotosto L. Role of echocardiography in the assessment and management of adult congenital heart disease in pregnancy. Int J Cardiovasc Imaging 2010; 27:843-57. [PMID: 21082254 DOI: 10.1007/s10554-010-9750-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 11/08/2010] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Antonio Vitarelli
- Echocardiology Unit, Cardiac Department, Sapienza University, Via Lima 35, 00198, Rome, Italy.
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