Obstetric outcomes in pregnant women with congenital heart disease
Introduction
Increasing numbers of women with congenital heart disease (CHD) are surviving into their childbearing years. Prior studies evaluating pregnancy outcomes in these women have focused on adverse maternal cardiac events [1], [2], [3] with few studies evaluating obstetric outcomes [4]. In addition, the majority of these studies assess the relationship between pregnancy outcomes and diagnostic categories of CHD rather than baseline hemodynamic characteristics [5], [6], [7], [8]. Multiple studies have suggested that actual hemodynamics are more important than congenital diagnoses in predicting outcome, likely due to the variable outcomes of corrective cardiac surgery [1], [3].
We have previously published data on adverse maternal cardiac events and neonatal outcomes in women with CHD and evaluated predictors of those adverse outcomes [1]. The focus of the current study is to provide a detailed analysis of obstetric outcomes and further investigate what baseline hemodynamic risk factors predict sustaining an adverse obstetric outcome. A secondary goal was to assess the impact of routinely avoiding Valsalva in the second stage of labor and assisting expulsion with forceps or vacuum. The cardiovascular changes of pregnancy place women with CHD at unique risk for adverse cardiac events, particularly during the active phase of labor through the immediate post-partum period when significant fluid shifts and increased myocardial demand occur [9], [10]. Many authorities recommend a passive second stage of labor and assisted delivery to avoid the reduction in preload and increase in cardiac oxygen requirements that occur with maternal Valsalva and exertion [11], [12]. It is unclear how this practice impacts obstetric outcomes such as chorioamnionitis, rate of cesarean delivery and post-partum hemorrhage (PPH).
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Materials and methods
The study cohort consisted of all women with CHD followed by the Boston Adult Congenital Heart service and delivering at Brigham and Women's Hospital between January 1998 and December 2005. Our prior analysis reported primarily on maternal cardiac outcomes in this same cohort of women, but was limited to those delivering by September 2004 [1]. Women with acquired heart disease, primary arrhythmia diagnoses without underlying congenital defects, and isolated mitral valve prolapse were excluded.
Baseline characteristics
During the study period, 65 women with congenital heart disease with a total of 112 pregnancies met inclusion criteria. This represents an additional twelve women and twenty-two pregnancies from our original cohort that was used to evaluate maternal cardiac outcomes [1]. Updated congenital heart lesions and maternal baseline characteristics in our cohort are summarized in Table 1, Table 2, respectively. 48% of pregnancies were considered planned. The median gestational age at the first prenatal
Discussion
Recent studies have demonstrated that a composite scoring index of risk factors can be utilized to predict risk of sustaining an adverse cardiac event during pregnancy in women with CHD [1], [3]. This can be a valuable tool to assist clinicians in managing pregnant patients or counseling those contemplating pregnancy. However, there have been no studies that have similarly attempted to determine predictors of adverse obstetric outcomes in this patient population.
Our multivariate analysis did
Acknowledgements
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [37].
References (37)
- et al.
Outcome of pregnancy in women with congenital heart disease
J Am Coll Cardiol
(2007) - et al.
Coarctation of the aorta: outcome of pregnancy
J Am Coll Cardiol
(2001) - et al.
Human neutrophil collagenase (matrix metalloproteinase 8) in parturition, premature rupture of membranes, and intrauterine infection
Am J Obstet Gynecol
(2000) - et al.
Increased matrix metalloproteinase activity and reduced tissue inhibitor of metalloproteinase-1 levels in amniotic fluid from pregnancies complicated by premature rupture of membranes
Am J Obstet Gynecol
(1996) - et al.
Smooth muscle cells of the media in the dilatative pathology of ascending thoracic aorta: morphology, immunoreactivity for osteopontin, matrix metalloproteinases and their inhibitors
Hum Pathol
(2001) - et al.
Matrix metalloproteinase expression in nonrheumatic aortic stenosis
Cardiovasc Pathol
(2000) Preterm premature rupture of membranes
Obstet Gynecol
(2003)- et al.
Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial
Obstet Gynecol
(2002) - et al.
Forceps-assisted vaginal delivery
Obstet Gynecol Clin North Am
(1999) - et al.
The incidence of congenital heart disease
J Am Coll Cardiol.
(2002)
The effect of valvular heart disease on maternal and fetal outcome of pregnancy
J Am Coll Cardiol
Atenolol and fetal growth in pregnancies complicated by hypertension
Am J Hypertens
Effect of atenolol on birthweight
Am J Cardiol
Uterine and fetal hemodynamics and fetal cardiac function after atenolol and pindolol infusion. A randomized study
Eur J Obstet Gynecol Reprod Biol
Ethical authorship and publishing
Int J Cardiol
Pregnancy outcomes in women with congenital heart disease
Circulation
Pregnancy in patients with heart disease: experience with 1,000 cases
Clin Cardiol
Prospective multicenter study of pregnancy outcomes in women with heart disease
Circulation
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