Prediction of complications in pregnant women with cardiac diseases referred to a tertiary center

Abstract

Background

Prediction of adverse maternal and neonatal events in women with heart disease is not well established. We aimed to assess cardiac, obstetrical and neonatal complications in pregnant women with heart disease referred to our tertiary care center and validate a previously proposed risk index.

Methods

We included 227 women with cardiac disease followed for 312 pregnancies at our tertiary center from 1992 to 2007. Cardiac risk was assessed using the previously proposed Cardiac Disease in Pregnancy (CARPREG) score and its association with maternal and neonatal outcomes was determined.

Results

Maternal cardiac lesions were predominantly congenital (81.4%). CARPREG risk was low (score = 0) in 66.3% and intermediate (score = 1) in 33.7% pregnancies. Maternal cardiac events complicated 7.4% pregnancies, with pulmonary edema occurring most frequently (3.8%). An intermediate score was associated with a higher rate of cardiac events (19.0% vs. 1.4%, odds ratio [OR] 15.6, 95% confidence interval (95%CI) 4.5–54.4, p < 0.0001). Adverse events occurred in 27.5% neonates. Preterm deliveries occurred in 16.7% pregnancies, more commonly in patients with intermediate scores (OR 2.4, 95%CI 1.2–4.6, p = 0.01). The sensitivity and negative predictive values of a low score were respectively 87% and 99% for total cardiac events and both 100% for primary cardiac events including pulmonary edema and sustained arrhythmia.

Conclusion

The CARPREG risk index has a high sensitivity and negative predictive value with regards to cardiac complications in pregnant women with heart disease. It may, therefore, be routinely used to improve the assessment of cardiac risk before and during pregnancy.

Introduction

With recent advances in pediatric cardiology and cardiac surgery, the number of women with congenital heart disease (CHD) of childbearing age continues to rise, resulting in an increase in the number of pregnant women with cardiac disease [1]. Pregnancy is associated with hemodynamic changes (increased blood volume and cardiac output, decreased peripheral vascular resistance) and rapid modifications of intravascular volume and pressure during labor and delivery. These changes may be poorly tolerated and precipitate cardiac decompensation or lead to neonatal adverse outcomes [2], [3], [4]. Cardiac diseases represent a wide spectrum of lesions and the impact of pregnancy differs according to the type and severity of heart disease. Several studies showed that women with heart disease are at increased risk for maternal cardiac and neonatal complications [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. However, the prediction of risk is not well established and specific guidelines in the assessment of these women during pregnancy are scarce [15]. Several authors aimed to predict complications for specific cardiac lesions [16], [17], [18], [19], while others rather proposed to assess the risk according to the cardiac functional status [5], [6], [9], [11], [12], [14], [20]. In a cohort of women with various forms of heart disease, Siu et al. proposed a risk index to predict the likelihood of cardiac complications [6], which was subsequently validated in a population exclusively with congenital heart disease [9].

We aimed to assess cardiac, obstetric and neonatal complications in pregnant women with cardiac disease referred to our tertiary care center and to validate this proposed risk index.