A Growing Problem: Maternal Death and Peripartum Complications Are Higher in Women With Grown-Up Congenital Heart Disease

Navigating Pregnancy in Congenital Heart Disease: A Comprehensive Review of Maternal Outcomes

Congenital heart disease (CHD) affects approximately 0.5-1% of the population, with advancements in cardiovascular care enabling 97% of these individuals to survive to adulthood. Pregnancy in women with CHD presents with unique challenges due to increased hemodynamic demands and associated risks. This review provides a comprehensive analysis of maternal outcomes in women with CHD, focusing on the physiological changes during pregnancy, classification of CHD types, and their specific consequences. The review highlights significant complications within this population, such as arrhythmias, heart failure, thromboembolic events, and aortic dissection, emphasizing the need for multidisciplinary management and individualized care. Despite considerable advancements, gaps in research persist, particularly in neonatal risk prediction and long-term maternal outcomes. Future directions prioritize the refinement of risk stratification models and leveraging emerging technologies to enhance care for this complex population.

Maternal and neonatal outcomes in women with congenital heart disease: A nationwide population-based study

BACKGROUND

We evaluated the outcomes of pregnancy in women with congenital heart disease (CHD) and their offspring in Taiwan. We also investigated how different severity levels may influence the outcomes.

METHODS

We used data (2009-2017) from the Birth Certificate Application database in Taiwan, which is linked to the National Health Insurance Research Database and Taiwan Maternal and Child Health Database. We identified 2990 women with CHD who had 4227 births. Based on the CHD subtypes, patients were further divided into "severe CHD" and "simple CHD" groups.

RESULTS

Women with CHD have a significant risk of stillbirth. In maternal cardiac events, they had the highest risk of heart failure, followed by arrhythmia. The severity of CHD had a significant effect on the outcomes as well. The neonatal birth event that mothers with CHD have the highest risk of is preterm birth at < 32 weeks of gestation. The prominent difference in neonatal morbidities between mothers with severe and simple CHD is recurrent CHD in the offspring. The offspring of the severe CHD group had a higher risk of severe CHD, whereas those of the simple CHD group had a higher risk of simple CHD.

CONCLUSION

During pregnancy, the monitoring of heart function and cardiac rhythm could be more intensive in mothers with CHD. In addition to accurately assessing fetal growth and development during antenatal care, mothers with severe CHD should be provided with careful fetal heart structure assessment and genetic testing along with counseling.

Fetomaternal outcomes in pregnant women with congenital heart disease: a comparative analysis from an apex institute

OBJECTIVE

With advancements in cardiac surgical interventions during infancy and childhood, the incidence of maternal congenital heart disease (CHD) is increasing. This retrospective study compared fetal and cardiac outcomes in women with and without CHD, along with a sub-analysis between cyanotic versus non-cyanotic defects and operated versus non-operated cases.

METHODS

A 10-year data were retrospectively collected from pregnant women with CHD and a 1:1 ratio of pregnant women without any heart disease. Adverse fetal and cardiac outcomes were noted in both groups. Statistical significance was set at P<0.05.

RESULTS

A total of 86 pregnant women with CHD were studied, with atrial septal defects (29.06%) being the most common. Out of 86 participants, 27 (31.39%) had cyanotic CHD. Around 55% of cases were already operated on for their cardiac defects. Among cardiovascular complications, 5.8% suffered from heart failure, 7.0% had pulmonary arterial hypertension, 8.1% presented in New York Heart Association functional class IV, 9.3% had a need for intensive care unit admission, and one experienced maternal mortality. Adverse fetal outcomes, including operative vaginal delivery, mean duration of hospital stay, fetal growth restriction, preterm birth (<37 weeks), low birth weight (<2,500 g), 5-minute APGAR score <7, and neonatal intensive care unit admissions, were significantly higher in women with CHD than in women without heart disease.

CONCLUSION

Women with CHD have a higher risk of adverse fetal and cardiac outcomes. The outcome can be improved with proper pre-conceptional optimization of the cardiac condition, good antenatal care, and multidisciplinary team management.

Length of hospital stay after delivery among Danish women with congenital heart disease: a register-based cohort study

Background

The literature about the impact of congenital heart disease (CHD) on the length of hospital stay after delivery is limited, and nonexisting in a country with free and equal access to healthcare. We aimed to examine the hypothesis that Danish women with CHD have a longer hospital stay after delivery compared to women without CHD. Secondarily, we aimed to examine the hypothesis that cesarean section modifies the association.

Methods

The study was a national cohort study using Danish nationwide registers in 1997–2014. Maternal CHD was categorized as simple, moderate, or complex CHD. The comparison group consisted of women without CHD. Outcome of interest was length of hospital stay after delivery registered in complete days. Mode of delivery was categorized as cesarean section or vaginal delivery. Data was analyzed using a generalized linear model with a Poisson distribution.

Results

We included 939,678 births among 551,119 women. Women without CHD were on average admitted to the hospital for 3.6 (SD 3.7) days, whereas women with simple, moderate, and complex CHD were admitted for 3.9 (SD 4.4), 4.0 (SD 3.8) and 5.1 (SD 6.7) days, respectively. The adjusted length of hospital stay after delivery was 12% (relative ratio (RR) = 1.12, 95% confidence interval (CI) 1.07–1.18), 14% (RR = 1.14, 95% CI: 1.07–1.21), and 45% (RR = 1.45, 95% CI: 1.24–1.70) longer among women with simple, moderate, and complex CHD, respectively, compared to women without CHD. The association between maternal CHD and length of hospital stay was not modified by mode of delivery (p-value of interaction = 0.62). Women who gave birth by cesarean section were on average admitted to the hospital for 2.7 days longer compared to women with vaginal delivery.

Conclusion

The hospital stay after delivery was significantly longer among women with CHD as compared to women without CHD. Further, higher complexity of CHD was associated with longer length of stay. Cesarean section did not modify the association.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04286-3.

Delivering Coordinated Cardio-Obstetric Care from Preconception through Postpartum

Coordinated preconception through postpartum cardio-obstetrics care is necessary to optimize both maternal and fetal health. Maternal mortality in the United States is increasing, largely driven by increasing cardiovascular (CV) disease burden during pregnancy and needs to be addressed emergently. Both for women with congenital and acquired heart disease, CV complications during pregnancy are associated with increased future risk of CV disease. Comprehensive cardio-obstetrics care is a powerful way of ensuring that women's CV risks before and during pregnancy are appropriately identified and treated and that they remain engaged in CV care long term to prevent future CV complications.

Maternal and Neonatal Outcomes of Pregnancies in Women With Congenital Heart Disease: A Meta-Analysis

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.

Patent Ductus Arteriosus in Pregnancy: Cardio-Obstetrics Management in a Late Presentation

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Congenital heart disease may be first diagnosed during pregnancy.

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PDA with significant left-to-right shunting can cause peripartum cardiac decompensation.

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Multidisciplinary management of congenital heart disease in pregnancy is recommended.

Congenital Heart Disease and Risk of Cardiovascular Disease: A Meta-Analysis of Cohort Studies

Background Despite remarkable success in the surgical and medical management of congenital heart disease ( CHD ), some survivors still experience cardiovascular complications over the long term. The goal of this study was to evaluate the association between CHD and risk of cardiovascular disease ( CVD ) by conducting a meta-analysis of cohort studies. Methods and Results A systematic literature search of several databases was conducted through April 2018 to identify studies reporting the risk of CVD , stroke, heart failure, and coronary artery heart disease in CHD survivors. The quality of individual studies was assessed using the Newcastle-Ottawa scale. The overall risk estimates were pooled using fixed-effects meta-analysis. Subgroup analyses were performed to explore possible sources of heterogeneity. Nine cohort studies comprising 684 200 participants were included. The overall combined relative risks for people with CHD compared with the controls were 3.12 (95% CI, 3.01-3.24) for CVD , 2.46 (95% CI, 2.30-2.63) for stroke, 5.89 (95% CI, 5.58-6.21) for heart failure, and 1.50 (95% CI, 1.40-1.61) for coronary artery heart disease. Significant heterogeneity was detected across studies regarding these risk estimates. Heterogeneity in the risk estimate of CVD was explained by geographic region, type of study design, sample source, age composition, and controlled confounders. Conclusions This meta-analysis of cohort studies of CHD found an association of increased risk of CVD in later life, although we cannot determine whether this association is confounded by a risk factor profile of CVD among CHD survivors or whether CHD is an independent risk factor.

Adverse Pregnancy Conditions Among Privately Insured Women With and Without Congenital Heart Defects

Background In women with congenital heart defects (CHD), changes in blood volume, heart rate, respiration, and edema during pregnancy may lead to increased risk of adverse outcomes and conditions. The American Heart Association recommends providers of pregnant women with CHD assess cardiac health and discuss risks and benefits of cardiac-related medications. We described receipt of American Heart Association-recommended cardiac evaluations, filled potentially teratogenic or fetotoxic (Food and Drug Administration pregnancy category D/X) cardiac-related prescriptions, and adverse conditions among pregnant women with CHD compared with those without CHD. Methods and Results Using 2007 to 2014 US healthcare claims data, we ascertained a retrospective cohort of women with and without CHD aged 15 to 44 years with private insurance covering prescriptions during pregnancy. CHD was defined as ≥1 inpatient code or ≥2 outpatient CHD diagnosis codes >30 days apart documented outside of pregnancy and categorized as severe or nonsevere. Log-linear regression, accounting for multiple pregnancies per woman, generated adjusted prevalence ratios (aPRs) for associations between the presence/severity of CHD and stillbirth, preterm birth, and adverse conditions from the last menstrual period to 90 days postpartum. We identified 2056 women with CHD (2334 pregnancies) and 1 374 982 women without (1 524 077 pregnancies). During the last menstrual period to 90 days postpartum, 56% of women with CHD had comprehensive echocardiograms and, during pregnancy, 4% filled potentially teratogenic or fetotoxic cardiac-related prescriptions. Women with CHD, compared with those without, experienced more adverse conditions overall (aPR, 1.9 [95% CI, 1.7-2.1]) and, specifically, obstetric (aPR, 1.3 [95% CI, 1.2-1.4]) and cardiac conditions (aPR, 10.2 [95% CI, 9.1-11.4]), stillbirth (aPR, 1.6 [95% CI, 1.1-2.4]), and preterm delivery (aPR, 1.6 [95% CI, 1.4-1.8]). More women with severe CHD, compared with nonsevere, experienced adverse conditions overall (aPR, 1.5 [95% CI, 1.2-1.9]). Conclusions Women with CHD have elevated prevalence of adverse cardiac and obstetric conditions during pregnancy; 4 in 100 used potentially teratogenic or fetotoxic medications, and only half received an American Heart Association-recommended comprehensive echocardiogram.

Contraceptive methods of privately insured US women with congenital heart defects

BACKGROUND

The American Heart Association recommends women with congenital heart defects (CHD) receive contraceptive counseling early in their reproductive years, but little is known about contraceptive method use among women with CHD. We describe recent female sterilization and reversible prescription contraceptive method use by presence of CHD and CHD severity in 2014.

METHODS

Using IBM MarketScan Commercial Databases, we included women aged 15 to 44 years with prescription drug coverage in 2014 who were enrolled ≥11 months annually in employer-sponsored health plans between 2011 and 2014. CHD, CHD severity, contraceptive methods, and obstetrics-gynecology and cardiology provider encounters were identified using billing codes. We used log-binomial regression to calculate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to compare contraceptive method use overall and by effectiveness tier by CHD presence and, for women with CHD, severity.

RESULTS

Recent sterilization or current reversible prescription contraceptive method use varied slightly among women with (39.2%) and without (37.3%) CHD, aPR = 1.04, 95% CI [1.01-1.07]. Women with CHD were more likely to use any Tier I method (12.9%) than women without CHD (9.3%), aPR = 1.41, 95% CI [1.33-1.50]. Women with severe, compared to non-severe, CHD were less likely to use any method, aPR = 0.85, 95% CI [0.78-0.92], or Tier I method, aPR = 0.84, 95% CI [0.70-0.99]. Approximately 60% of women with obstetrics-gynecology and <40% with cardiology encounters used any included method.

CONCLUSIONS

There may be missed opportunities for providers to improve uptake of safe, effective contraceptive methods for women with CHD who wish to avoid pregnancy.

Maternal Comorbidities and Complications of Delivery in Pregnant Women With Congenital Heart Disease

BACKGROUND

Pregnant women with congenital heart defects (CHDs) may be at increased risk for adverse events during delivery.

OBJECTIVES

This study sought to compare comorbidities and adverse cardiovascular, obstetric, and fetal events during delivery between pregnant women with and without CHDs in the United States.

METHODS

Comorbidities and adverse delivery events in women with and without CHDs were compared in 22,881,691 deliveries identified in the 2008 to 2013 National Inpatient Sample using multivariable logistic regression. Among those with CHDs, associations by CHD severity and presence of pulmonary hypertension (PH) were examined.

RESULTS

There were 17,729 deliveries to women with CHDs (77.5 of 100,000 deliveries). These women had longer lengths of stay and higher total charges than women without CHDs. They had greater odds of comorbidities, including PH (adjusted odds ratio [aOR]: 193.8; 95% confidence interval [CI]: 157.7 to 238.0), congestive heart failure (aOR: 49.1; 95% CI: 37.4 to 64.3), and coronary artery disease (aOR: 31.7; 95% CI: 21.4 to 47.0). Greater odds of adverse events were observed, including heart failure (aOR: 22.6; 95% CI: 20.5 to 37.3), arrhythmias (aOR: 12.4; 95% CI: 11.0 to 14.0), thromboembolic events (aOR: 2.4; 95% CI: 2.0 to 2.9), pre-eclampsia (aOR: 1.5; 95% CI: 1.3 to 1.7), and placenta previa (aOR: 1.5; 95% CI: 1.2 to 1.8). Cesarean section, induction, and operative vaginal delivery were more common, whereas fetal distress was less common. Among adverse events in women with CHDs, PH was associated with heart failure, hypertension in pregnancy, pre-eclampsia, and pre-term delivery; there were no differences in most adverse events by CHD severity.

CONCLUSIONS

Pregnant women with CHDs were more likely to have comorbidities and experience adverse events during delivery. These women require additional monitoring and care.

Neonatal Risk in Children of Women With Congenital Heart Disease: A Cohort Study With Focus on Socioeconomic Status

Background

We hypothesized that women with congenital heart disease (CHD) are at increased risk of giving birth preterm, including very and moderately preterm and giving birth to infants small for gestational age (SGA). We aimed to investigate this in a nation‐wide study with focus on the potential modifying effect of socioeconomic status.

Methods and Results

We performed a cohort study using Danish nation‐wide registers between 1997 and 2014. The exposure, maternal CHD, was subdivided into simple, moderate and complex based on severity of defects. Outcomes were preterm birth and SGA. Cox regression was used to estimate hazard ratios (HR). A total of 933 149 births including 3745 births among women with CHD were studied. The risk of giving birth preterm and SGA were higher among women with CHD as compared with women without CHD; for example, adjusted hazard ratios of preterm birth according to severity: simple 1.33 (95% CI, 1.11–1.59), moderate 1.45 (95% CI, 1.14–1.83) and complex 3.26 (95% CI, 2.41–4.40). Same pattern was seen for very and moderately preterm births and SGA. Education was a strong predictor of both preterm birth and SGA but did not modify the association between maternal congenital heart disease and preterm birth (P=0.38) or SGA (P=0.99).

Conclusions

Women with CHD were at increased risk of preterm birth both, moderately and very preterm, as well as giving birth to infants SGA. Education was a strong predictor of both preterm birth and SGA but the association between CHD and risk of preterm birth and SGA was independent of educational level.

Secular trends in pregnancy rates, delivery outcomes, and related health care utilization among women with congenital heart disease

BACKGROUND

The number of women with congenital heart disease (CHD) of reproductive age is increasing, yet a description of trends in pregnancy and delivery outcomes in this population is lacking.

OBJECTIVE

To assess secular trends in pregnancy rates, delivery outcomes, and related health care utilization in the adult female CHD population in Quebec, Canada.

METHODS

The Quebec CHD database was used to construct a cohort with all women with CHD aged 18-45 years between 1992 and 2004. Pregnancy and delivery rates were determined yearly and compared to the general population. Secular trends in pregnancy and delivery rates were assessed with linear regression. The cesarean delivery rate in the CHD population was compared to the general population. Predictors of cesarean section were determined with multivariable logistic regression. Cox regression, adjusted for comorbidities, was used to analyze the impact of cesarean sections on 1-year health care use following delivery.

RESULTS

About 14 878 women were included. A total of 10 809 pregnancies were identified in 5641 women, of whom 4551 (80%) and 2528 (45%) experienced at least one delivery and/or abortion, respectively. Absolute yearly numbers and rates of pregnancies and deliveries increased during the study period (P < .05). The increment in cesarean section rates was more pronounced among women with CHD than among the general population. Gestational diabetes (OR 1.50, 95% CI [1.13, 1.99]), gestational hypertension (OR 1.81, 95% CI [1.27, 2.57]), and preeclampsia (OR 1.59, 95% CI [1.11, 2.8]) were independent predictors of cesarean delivery. Cesarean sections were associated with postpartum cardiac-hospitalization within 1 year following delivery (HR = 2.35, 95% CI [1.05, 5.28]).

CONCLUSIONS

Yearly numbers and rates of pregnancies and deliveries in adult females with CHD rose significantly during the study period. Cesarean sections led to increased health care utilization. Further research is required to determine causes of high cesarean section rates in this patient population.

Maternal and Fetal Outcomes of Admission for Delivery in Women With Congenital Heart Disease

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.

Association of Adult Congenital Heart Disease With Pregnancy, Maternal, and Neonatal Outcomes

IMPORTANCE

With the help of medical advances, more women with adult congenital heart disease (ACHD) are becoming pregnant. Adverse maternal, obstetric, and neonatal events occur more frequently in women with ACHD than in the general obstetric population. Adult congenital heart disease is heterogeneous, yet few studies have assessed whether maternal and neonatal outcomes differ across ACHD subtypes.

OBJECTIVE

To assess the association of ACHD and its subtypes with pregnancy, maternal, and neonatal outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the Discharge Abstract Database, which contains information on all hospitalizations in Canada (except Quebec) from fiscal years 2001-2002 through 2014-2015. Discharge Abstract Database information was linked with maternal and infant hospital records across Canada. All women who gave birth in hospitals during the study period were included in the study. Data were analyzed from December 18, 2017, to March 22, 2019.

EXPOSURES

Women with ACHD were identified using diagnostic and procedural codes. Subtypes of ACHD were classified using the Anatomic and Clinical Classification of Congenital Heart Defects scheme.

MAIN OUTCOMES AND MEASURES

Primary outcomes were defined a priori and included severe maternal morbidity (measured using the Maternal Morbidity Outcomes Indicator), neonatal morbidity and mortality (measured using the Neonatal Adverse Outcomes Indicator), ischemic placental disease, preterm birth, congenital anomalies, and small-for-gestational-age births. Absolute and relative rates of each outcome were calculated overall and by ACHD subtype. Logistic regression using generalized estimating equations assessed crude and adjusted odds ratios (aORs) for each outcome in women with ACHD compared with women without ACHD after adjustment for comorbidities, mode of delivery, and study year.

RESULTS

The 2114 women with ACHD included in the analysis (mean [SD] age, 29.4 [5.7] years) had significantly higher odds of maternal morbidity (aOR, 2.7; 95% CI, 2.2-3.4) and neonatal morbidity and mortality (aOR, 1.8; 95% CI, 1.6-2.1) compared with women without ACHD (n = 2 682 451). Substantial variation was observed between women with different subtypes of ACHD. For example, the aORs of preterm birth (<37 weeks) varied from 0.4 (95% CI, 0.4-0.5) for women with anomalies of atrioventricular junctions and valves to 4.7 (95% CI, 2.9-7.5) for women with complex anomalies of atrioventricular connections.

CONCLUSIONS AND RELEVANCE

These results suggest that women with different subtypes of ACHD are not uniformly at risk for adverse maternal and neonatal outcomes. Although some women with ACHD can potentially expect healthy pregnancies, it appears that clinical care should be modified to address the heightened risks of certain ACHD subtypes.

Transition to Adult Congenital Heart Disease Care: A Review

The population of adults with congenital heart disease (ACHD) has grown due to recent advances in surgical procedures. The survival rate to adulthood is now more than 95%. This review identifies current recommendations and status of ACHD management and treatment in the United States by examining comprehensive guidelines for management and transition and comparing them to the current state of the science. Successful transition from pediatric to adult care begins during the adolescent years, and prepares patients for management at an ACHD regional center utilizing multidisciplinary teams of ACHD specialists. Advocacy and research needs for the ACHD population persist.

Medical and Obstetric Outcomes Among Pregnant Women With Congenital Heart Disease

OBJECTIVE

To estimate nationwide trends in the prevalence of maternal congenital heart disease (CHD) and determine whether women with CHD are more likely than women without maternal CHD to have medical and obstetric complications.

METHODS

The 2000-2010 Nationwide Inpatient Sample was queried for International Classification of Diseases, 9th Revision, Clinical Modification codes to identify delivery hospitalizations of women with and without CHD. Trends in the prevalence of CHD were determined and then rates of complications were reported for CHD per 10,000 delivery hospitalizations. For Nationwide Inpatient Sample 2008-2010, logistic regression was used to examine associations between CHD and complications.

RESULTS

From 2000 to 2010, there was a significant linear increase in the prevalence of CHD from 6.4 to 9.0 per 10,000 delivery hospitalizations (P<.001). Multivariable logistic regression demonstrated that all selected medical complications, including mortality (17.8 compared with 0.7/10,000 deliveries, adjusted odds ratio [OR] 22.10, 95% confidence interval [CI] 13.96-34.97), mechanical ventilation (91.9 compared with 6.9/10,000, adjusted OR 9.94, 95% CI 7.99-12.37), and a composite cardiovascular outcome (614 compared with 34.3/10,000, adjusted OR 10.54, 95% CI 9.55-11.64) were more likely to occur among delivery hospitalizations with maternal CHD than without. Obstetric complications were also common among women with CHD. Delivery hospitalizations with maternal CHD that also included codes for pulmonary circulatory disorders had higher rates of medical complications compared with hospitalizations with maternal CHD without pulmonary circulatory disorders.

CONCLUSION

The number of delivery hospitalizations with maternal CHD in the United States is increasing, and although we were not able to determine whether correction of the cardiac lesion affected outcomes, these hospitalizations have a high burden of medical and obstetric complications.

LEVEL OF EVIDENCE

II.

Cardiac arrest during hospitalization for delivery in the United States, 1998-2011

BACKGROUND

The objective of this analysis was to evaluate the frequency, distribution of potential etiologies, and survival rates of maternal cardiopulmonary arrest during the hospitalization for delivery in the United States.

METHODS

By using data from the Nationwide Inpatient Sample during the years 1998 through 2011, the authors obtained weighted estimates of the number of U.S. hospitalizations for delivery complicated by maternal cardiac arrest. Clinical and demographic risk factors, potential etiologies, and outcomes were identified and compared in women with and without cardiac arrest. The authors tested for temporal trends in the occurrence and survival associated with maternal arrest.

RESULTS

Cardiac arrest complicated 1 in 12,000 or 8.5 per 100,000 hospitalizations for delivery (99% CI, 7.7 to 9.3 per 100,000). The most common potential etiologies of arrest included hemorrhage, heart failure, amniotic fluid embolism, and sepsis. Among patients with cardiac arrest, 58.9% of patients (99% CI, 54.8 to 63.0%) survived to hospital discharge.

CONCLUSIONS

Approximately 1 in 12,000 hospitalizations for delivery is complicated by cardiac arrest, most frequently due to hemorrhage, heart failure, amniotic fluid embolism, or sepsis. Survival depends on the underlying etiology of arrest.

Effect of transverse aortic constriction on cardiac structure, function and gene expression in pregnant rats

Background

There is an increased risk of heart failure and pulmonary edema in pregnancies complicated by hypertensive disorders. However, in a previous study we found that pregnancy protects against fibrosis and preserves angiogenesis in a rat model of angiotensin II induced cardiac hypertrophy. In this study we test the hypothesis that pregnancy protects against negative effects of increased afterload.

Methods

Pregnant (gestational day 5.5–8.5) and non-pregnant Wistar rats were randomized to transverse aortic constriction (TAC) or sham surgery. After 14.2±0.14 days echocardiography was performed. Aortic blood pressure and left ventricular (LV) pressure-volume loops were obtained using a conductance catheter. LV collagen content and cardiomyocyte circumference were measured. Myocardial gene expression was assessed by real-time polymerase chain reaction.

Results

Heart weight was increased by TAC (p<0.001) but not by pregnancy. Cardiac myocyte circumference was larger in pregnant compared to non-pregnant rats independent of TAC (p = 0.01), however TAC per se did not affect this parameter. Collagen content in LV myocardium was not affected by pregnancy or TAC. TAC increased stroke work more in pregnant rats (34.1±2.4 vs 17.5±2.4 mmHg/mL, p<0.001) than in non-pregnant (28.2±1.7 vs 20.9±1.5 mmHg/mL, p = 0.06). However, it did not lead to overt heart failure in any group. In pregnant rats, α-MHC gene expression was reduced by TAC. Increased in the expression of β-MHC gene was higher in pregnant (5-fold) compared to non-pregnant rats (2-fold) after TAC (p = 0.001). Nine out of the 19 genes related to cardiac remodeling were affected by pregnancy independent of TAC.

Conclusions

This study did not support the hypothesis that pregnancy is cardioprotective against the negative effects of increased afterload. Some differences in cardiac structure, function and gene expression between pregnant and non-pregnant rats following TAC indicated that afterload increase is less tolerated in pregnancy.

Perioperative Outcomes of Major Noncardiac Surgery in Adults with Congenital Heart Disease

Background:

An increasing number of patients with congenital heart disease are surviving to adulthood. Consensus guidelines and expert opinion suggest that noncardiac surgery is a high-risk event, but few data describe perioperative outcomes in this population.

Methods:

By using the Nationwide Inpatient Sample database (years 2002 through 2009), the authors compared patients with adult congenital heart disease (ACHD) who underwent noncardiac surgery with a non-ACHD comparison cohort matched on age, sex, race, year, elective or urgent or emergency procedure, van Walraven comborbidity score, and primary procedure code. Mortality and morbidity were compared between the two cohorts.

Results:

A study cohort consisting of 10,004 ACHD patients was compared with a matched comparison cohort of 37,581 patients. Inpatient mortality was greater in the ACHD cohort (407 of 10,004 [4.1%] vs. 1,355 of 37,581 [3.6%]; unadjusted odds ratio, 1.13; P = 0.031; adjusted odds ratio, 1.29; P &lt; 0.001). The composite endpoint of perioperative morbidity was also more commonly observed in the ACHD cohort (2,145 of 10.004 [21.4%] vs. 6,003 of 37,581 [16.0%]; odds ratio, 1.44; P &lt; 0.001). ACHD patients comprised an increasing proportion of all noncardiac surgical admissions over the study period (P value for trend is &lt;0.001), and noncardiac surgery represented an increasing proportion of all ACHD admissions (P value for trend is &lt;0.001).

Conclusions:

Compared with a matched control cohort, ACHD patients undergoing noncardiac surgery experienced increased perioperative morbidity and mortality. Within the limitations of a retrospective analysis of a large administrative dataset, this finding demonstrates that this is a vulnerable population and suggests that better efforts are needed to understand and improve the perioperative care they receive.

Cardiovascular disorders in pregnancy: diagnosis and management

Cardiovascular diseases (CVDs) are a major cause of complications in pregnancy worldwide and the number of patients who develop cardiac problems during pregnancy is increasing. This review summarises recent literature on the aetiology and the underlying pathophysiology, diagnostic tools, risk stratification and prognosis in women who develop heart failure during pregnancy and in the peri-partum phase as well as in patients with pre-existing cardiomyopathies undergoing pregnancy. We specifically highlight peri-partum cardiomyopathy, valvular disease and Marfan's syndrome. Furthermore, we provide overviews on established treatment concepts and novel therapeutic strategies for these different disease types, stressing the point that pregnancy-associated cardiac disease requires interdisciplinary concepts for diagnosis, management and treatment.

Is vaginal delivery or caesarean section the safer mode of delivery in patients with adult congenital heart disease?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is vaginal delivery or caesarean section (CS) the safer mode of delivery in patients with adult congenital heart disease? Of the 119 studies, 13 papers represented the best evidence on the topic. Recommendations are based on 29 262 patients. Those having undergone successful corrective or palliative cardiac surgery for congenital heart disease, in addition to patients with unoperated congenital heart disease are a high-risk obstetric population. Heart disease is a leading cause of maternal mortality in the USA and the UK. Traditionally, CS was regarded as the mode of delivery of choice for high-risk patients, but growing experience in this field has now made this advice appear controversial. Patients are stratified into high- and low-risk, depending on the degree of heart failure symptoms [New York Heart Association (NYHA) class]. All studies demonstrated adverse outcomes in ACHD patients compared with normal age-matched controls. This pertained to a higher overall risk of maternal cardiac death, neonatal death, preterm birth, fetal growth restriction and longer hospital stay. On univariate regression analysis, the variables that imparted the highest risk to mother and foetus, were right ventricular failure, pulmonary regurgitation and pulmonary hypertension (P < 0.001). Induction of labour was deemed safe and was not associated with higher CS rates. There was no increase in maternal or neonatal complications in patients who were NYHA class I and II at labour. Patients who were NYHA class III and IV at labour had higher complication rates with adverse feto-maternal outcomes (P < 0.0001) and longer intensive care unit and hospital stay (Spearman's correlation 0.326, P = 0.007). The largest cohort from the USA (26 973 ACHD births) demonstrated that ventricular septal defect was associated with the highest risk of maternal death and complications (P < 0.05). The data would indicate that patients NYHA class I and II symptoms are suitable for VD. For most NYHA III and IV patients a trail of labour is safe with expedited delivery under good analgesic control as dictated by obstetric needs. Due to high complication risks, CS may be indicated in a proportion of patients.

Maternal, perinatal, and postneonatal outcomes in women with chronic heart disease in Washington State

OBJECTIVE

To explore the association between the presence of maternal heart disease and maternal, perinatal, and infant outcomes.

METHODS

We conducted a population-based retrospective cohort study using Washington State birth certificates linked with hospital discharge records of mothers noted to have maternal congenital heart disease, ischemic heart disease, heart failure, or pulmonary hypertension. Women who gave birth between 1987 and 2009 (n=2,171) were compared with a sample of mothers without these conditions (n=21,710). We described characteristics of pregnant women with heart disease over time. Logistic regression estimated the association between chronic maternal heart disease and small-for-gestational-age (SGA) neonates as well as perinatal, postneonatal, and maternal death.

RESULTS

The proportion of births to women with reported heart disease increased 224% between the 1987 and 1994 and 2002 and 2009 calendar periods. Chronic maternal heart disease was associated with increased risk of SGA (62 additional SGA newborns per 1,000 births, 95% confidence interval [CI] 46-78; P<.001), perinatal death (14 additional deaths per 1,000 births, 95% CI 8-20; P<.001), postneonatal death (5 additional deaths per 1,000 births, 95% CI 2-9; P<.001), and maternal death (5 additional deaths per 1,000 births, 95% CI 2-9; P<.001).

CONCLUSION

The presence of chronic maternal heart disease is associated with elevated risk for poor maternal, perinatal, and postneonatal outcomes.

Long-acting reversible contraceptive methods for adolescents with chronic medical problems

Adolescents with chronic medical problems are just as at-risk for unintended pregnancy as their healthy counterparts, but pregnancy in these adolescents can carry greater health risks. The objective of this article is to provide an overview of the United States Medical Eligibility Criteria for Contraceptive Use, the concept of contraceptive effectiveness, and a risk-benefit algorithm. Together these tools provide an evidence-based and clinically sound method of providing contraception to adolescents with chronic medical problems. Three cases of adolescents with chronic medical problems are used to illustrate this approach. To best avoid the complicated problem of a teenager with a chronic medical problem becoming pregnant, LARC should be considered as first-line contraception. In most cases, LARC methods are safe to prescribe, and preferable to less effective methods.

Referral patterns and perceived barriers to adult congenital heart disease care: results of a survey of U.S. pediatric cardiologists

OBJECTIVES

This study sought to elucidate referral patterns and barriers to adult congenital heart disease (ACHD) care, as perceived by pediatric cardiologists (PCs).

BACKGROUND

Management guidelines recommend that care of adults with moderate/complex congenital heart disease be guided by clinicians trained in ACHD.

METHODS

A cross-sectional survey was distributed to randomly selected U.S. PCs.

RESULTS

Overall response rate was 48% (291 of 610); 88% (257 of 291) of respondents met inclusion criteria (outpatient care to patients >11 years of age). Participants were in practice for 18.2 ± 10.7 years; 70% were male, and 72% were affiliated with an academic institution; 79% stated that they provide care to adults (>18 years). The most commonly perceived patient characteristic prompting referral to ACHD care was adult comorbidities (83%). The most perceived barrier to ACHD care was emotional attachment of parents and patients to the PC (87% and 86%, respectively). Clinician attachment to the patient/family was indicated as a barrier by 70% of PCs and was more commonly identified by responders with an academic institutional affiliation (p = 0.001). A lack of qualified ACHD care providers was noted by 76% of PCs. Those affiliated with an academic institution were less likely to identify this barrier to ACHD care (p = 0.002).

CONCLUSIONS

Most PC respondents in the United States provide care to ACHD patients. Common triggers that prompt referral and perceived barriers to ACHD care were identified. These findings might assist ACHD programs in developing strategies to identify and retain patients, improve collaborative care, and address emotional needs during the transition and transfer process.

Cardiac risks and management of complications in pregnant women with congenital heart disease

There are a growing number of women with congenital heart disease reaching adulthood and contemplating and/or undergoing pregnancy. However, pregnancy imposes hemodynamic stress on the heart and this can result in maternal, fetal and neonatal complications. Most women with congenital heart disease do well during pregnancy, but some women with high-risk cardiac lesions will not tolerate the hemodynamic changes of pregnancy. Physicians must be aware of the potential risks for the mother both during and after pregnancy, the risks to the fetus and neonate, and the risks and benefits of medications and procedures used during pregnancy. For women with complex cardiac conditions, management during pregnancy benefits from multidisciplinary care involving cardiologists with expertise in pregnancy, obstetricians with expertise in maternal fetal medicine, neonatologists and obstetric anesthetists, among others. This review will focus on the cardiac risks faced by women with congenital heart disease; particularly those at high risk, and on management strategies to mitigate risk and address cardiac complications.