Cardiac disease in pregnancy

Bridging gaps: The urgent call for cardio-obstetrics as a subspecialty in India

Cardiovascular disease complicates 1-4% of pregnancies. Women with heart disease going through pregnancy are on the increase. While global maternal deaths during pregnancy are decreasing, India remains a significant contributor to maternal deaths in the world. Cardiovascular disease during pregnancy is the leading cause of maternal mortality in developed nations, and this trend is expected soon in India, with the ongoing obstetric transition. Research in developed nations indicates that a high proportion of maternal mortality related to heart disease is preventable. However, India lacks indigenous data, risk stratification tools, management guidelines, and a well-defined cardio-obstetric team concept for pregnant women with heart disease. There is a pressing need to establish national registries, develop risk stratification tools, develop and disseminate management guidelines, and create dedicated cardio-obstetric programs. This article provides a comprehensive overview of this requirement and offers solutions to bridge the existing gaps in India's maternal healthcare landscape.

Trends in cardiovascular complications of pregnancy: A nationwide inpatient sample analysis

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States. Physiologic stress of pregnancy can induce several hemodynamic changes that contribute to an increased risk of cardiac complications in the peripartum period. There are ongoing efforts to improve cardiovascular mortality in pregnant patients. Understanding trends in cardiovascular complications during pregnancy may provide insight into improving care for high-risk pregnancies.

METHODS

We retrospectively analyzed data from the National Inpatient Sample (NIS) Database and identified all inpatient hospitalizations for pregnancy and delivery. We then analyzed trends in the rates of cardiac complications in the pregnant patient.

RESULTS

There are concerning increases in trends of cardiac complications and comorbidities in pregnant people including: acute coronary syndrome, spontaneous coronary artery dissection, cardiogenic shock, pulmonary hypertension, chronic congestive heart failure, heart transplant, aortic syndromes, stroke, and pulmonary embolism. While the rates of STEMI have decreased, the incidence of peripartum cardiomyopathy has remained stable.

CONCLUSION

There are concerning increases in certain cardiac complications during pregnancy. This is likely due to increasing age at the time of pregnancy and associated comorbidities.

Experiences of a dedicated Heart and Maternal Health Service providing multidisciplinary care to pregnant women with cardiac disease in a tertiary centre in Namibia

Objectives

Methods

Results

Conclusions

Targeting Myadm to Intervene Pulmonary Hypertension on Rats Before Pregnancy Alleviates the Effect on Their Offspring's Cardiac-Cerebral Systems

Pregnancy with pulmonary hypertension (PH) seriously threatens the life and safety of mothers and infants. Here, the long-term effect of maternal PH on the postpartum growth of rat offspring was focused for the first time, as well as explored the role of Myadm in PH rats before pregnancy based upon the previous findings. Patients with PH are prone to hypoxemia, leading to insufficient placental structure and function, which affects the organ function of fetuses, followed by evidence that differently expressed genes (DEGs) existed in the heart of maternal PH newborn rats and enriched in pathways related to cardiac and nerve development on human infants with similar birth outcome: low birth weight (LBW). LBW was one of the possible birth outcomes of pregnancy with PH, especially severe PH, accompanied by evidence that offspring derived from mothers with PH presented lower birth weights and slower growth rates than those derived from normal control mothers in a rat model. Besides, maternal PH rat offspring showed cardiac remodeling and a significant elevation of the expression levels of hypoxia- and inflammation-related markers in the cerebral cortex at both 10 and 14 weeks of age, respectively. What is more, the previous studies found that the overexpression of Myadm could result in the remodeling of the pulmonary artery. And targeting Myadm to intervene PH before pregnancy could alleviate sustained low weight growth in maternal PH rat offspring, and the pathological changes of the cardiac–cerebral system caused by maternal PH, including enlarged right heart cavity, loss of cardiomyocytes, abnormal heart index, as well as cerebral cortex hypoxia and the inflammatory state as they grew up to a certain extent. The findings show the pathological significance of maternal PH on offspring growth and the cardiac–cerebral development in a rat model, as well as point out the potential treatment target, which may provide a further reference for pregnancy outcomes in women with PH and healthy development of offspring to some extent.

Predictors of maternal and neonatal complications in women with severe valvular heart disease during pregnancy in Tunisia: a retrospective cohort study

Background

Severe valvular heart disease, especially stenosis, is a contraindication for conception according to the World Health Organization. This is still encountered in countries with a high rheumatic fever prevalence. The objective of this study was to determine predictors of maternal cardiac, obstetric and neonatal complications in pregnant women with severe valve disease.

Methods

This is an observational retrospective cohort study of all pregnant women with severe heart valvulopathy who gave birth between 2010 and 2017.

Results

We included 60 pregnancies in 54 women. Cardiac complications occurred during 37 pregnancies (61%). In multivariate analysis, parity (aOR =2.41, 95% CI[1.12–5.16]), revelation of valvulopathy during pregnancy (aOR = 6.34; 95% CI[1.26–31.77]), severe mitral stenosis (aOR = 6.98, 95% CI[1.14–41.05],) and systolic pulmonary arterial pressure (aOR =1.08, 95% CI[1.01–1.14]) were associated with cardiac complications. Obstetrical complications were noted during 19 pregnancies (31.8%). These complications were associated with nulliparity (aOR = 5.22; 95% CI[1.15–23.6]), multiple valve disease (aOR = 5.26, 95% CI[1.19–23.2]), systolic pulmonary arterial pressure (aOR =1.04, 95% CI[1.002–1.09]), and treatment with vitamin K antagonists (aOR = 8.71, 95% CI[1.98–38.2]). Neonatal complications were noted in 39.3% of newborns (n = 61) and these were associated with occurrence of obstetric complications (aOR = 16.47, 95% CI[3.2–84.3]) and revelation of valvulopathy during pregnancy (aOR = 7.33, 95% CI[1.4–36.1]).

Conclusions

Revelation of valvular heart disease during pregnancy is a predictor of not only cardiac but also neonatal complications. Valvular heart disease screening during pre-conceptional counseling is thus crucial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04259-6.

Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis

Purpose

Associations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy.

Methods

Medline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I² statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529).

Findings

The search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54–5.33), and perinatal death (6 studies, RR 3.23, 1.92–5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02–4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02–5.95).

Interpretation

RHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Real-world in-hospital outcomes and potential predictors of heart failure in primigravid women with heart disease in Southwestern China

Background

Little is known about the status of maternal, obstetric, and neonatal complications and the potential predictors of developing heart failure (HF) in mothers with underlying heart disease (HD) in Southwestern China.

Methods

The eligible records from the YiduCloud database from December 1, 2010 to December 31, 2019 were screened. The maternal clinical characteristics and the in-hospital outcomes were collected and compared in primigravid women with and without HD. The HD subtypes analyzed included valvular HD (VHD), cardiomyopathy, adult congenital HD (ACHD), pulmonary hypertension (PH), and other cardiac conditions.

Results

Among 45,067 primigravid women, 508 (1.1%) had HD, in which 207 (41%) had ACHD, 66 (13%) had VHD, 84 (17%) had cardiomyopathy, 7 (1%) had PH, and 144 (28%) had other cardiac diseases. The maternal cardiac events and the neonatal complications occurred in 28% and 23.3%, respectively, of women with HD and were predominant in the PH group. In multivariable regression, HF was associated with the New York Heart Association (NYHA) class ≥3 (OR = 15.9, 95% confidence interval [CI] = 2.5–99.7; P = 0.003), heart rate ≥ 100 bpm (OR = 3.8, 95% CI = 1.1–13.5; P = 0.036), ejection fraction ≤60% (OR = 6.4, 95% CI = 2.0–21.0; P = 0.002) and left ventricular end-diastolic diameter ≥ 50 mm (OR = 3.4, 95% CI = 1.1–11.2; P = 0.041) at the beginning of pregnancy.

Conclusions

Maternal and neonatal complications are higher in primigravid women with HD particularly in the PH group compared with primigravid women without HD. Women with HD should be guided on the potential predictors for HF and closely monitored during pregnancy to reduce maternal and neonatal complications.

Maternal mortality due to cardiac disease in low- and middle-income countries

Objectives

To assess the frequency of maternal death (MD) due to cardiac disease in low‐ and middle‐income countries (LMIC).

Methods

Systematic review searching Medline, EMBASE, Web of Science, Cochrane Library, Emcare, LILACS, African Index Medicus, IMEMR, IndMED, WPRIM, IMSEAR up to 01/Nov/2017. Maternal mortality reports from LMIC reviewing all MD in a given geographical area were included. Hospital‐based reports or those solely based on verbal autopsies were excluded. Numbers of MD and cardiac‐related deaths were extracted. We calculated cardiac disease MMR (cMMR, cardiac‐related MD/100 000 live births) and proportion of cardiac‐related MDs among all MDs. Frequency of cardiac MD was compared with the MMR of the country.

Results

Forty‐seven reports were included, which reported on 38,486 maternal deaths in LMIC. Reported cMMR ranged from 0/100 000 live births (Moldova, Ghana) to 31.9/100 000 (Zimbabwe). The proportion of cardiac‐related MD ranged from 0% (Moldova, Ghana) to 24.8% (Sri Lanka). In countries with a higher MMR, cMMR was also higher. However, the proportion of cardiac‐related MD was higher in countries with a lower MMR.

Conclusions

The burden of cardiac‐related mortality is difficult to assess due limited availability of mortality reports. The proportion of cardiac deaths among all MD appeared to be higher in countries with a lower MMR. This is in line with what has been called ‘obstetric transition’: pre‐existing medical diseases including cardiac disease are becoming relatively more important where the MMR falls.

Standardizing clinical care measures of rheumatic heart disease in pregnancy: A qualitative synthesis

BACKGROUND

Rheumatic heart disease (RHD) is a preventable cardiac condition that escalates risk in pregnancy. Models of care informed by evidence-based clinical guidelines are essential to optimal health outcomes. There are no published reviews that systematically explore approaches to care provision for pregnant women with RHD and examine reported measures. The review objective was to improve understanding of how attributes of care for these women are reported and how they align with guidelines.

METHODS

A search of 13 databases was supported by hand-searching. Papers that met inclusion criteria were appraised using CASP/JBI checklists. A content analysis of extracted data from the findings sections of included papers was undertaken, informed by attributes of quality care identified previously from existing guidelines.

RESULTS

The 43 included studies were predominantly conducted in tertiary care centers of low-income and middle-income countries. Cardiac guidelines were referred to in 25 of 43 studies. Poorer outcomes were associated with higher risk scores (detailed in 36 of 41 quantitative studies). Indicators associated with increased risk include anticoagulation during pregnancy (28 of 41 reported) and late booking (gestation documented in 15 of 41 studies). Limited access to cardiac interventions was discussed (19 of 43) in the context of poorer outcomes. Conversely, early assessment and access to regular multidisciplinary care were emphasized in promoting optimal outcomes for women and their babies.

CONCLUSIONS

Despite often complex care requirements in challenging environments, pregnancy provides an opportunity to strengthen health system responses and address whole-of-life health for women with RHD. A standard set of core indicators is proposed to more accurately benchmark care pathways, outcomes, and burden.

Oxygen and lack of oxygen in fetal and placental development, feto-placental coupling, and congenital heart defects

Low oxygen concentration (hypoxia) is part of normal embryonic development, yet the situation is complex. Oxygen (O₂ ) is a janus gas with low levels signaling through hypoxia-inducible transcription factor (HIF) that are required for development of fetal and placental vasculature and fetal red blood cells. This results in coupling of fetus and mother around midgestation as a functional feto-placental unit (FPU) for O₂ transport, which is required for continued growth and development of the fetus. Defects in these processes may leave the developing fetus vulnerable to O₂ deprivation or other stressors during this critical midgestational transition when common septal and conotruncal heart defects (CHDs) are likely to arise. Recent human epidemiological and case-control studies support an association between placental dysfunction, manifest as early onset pre-eclampsia (PE) and increased serum bio-markers, and CHD. Animal studies support this association, in particular those using gene inactivation in the mouse. Sophisticated methods for gene inactivation, cell fate mapping, and a quantitative bio-reporter of O₂ concentration support the premise that hypoxic stress at critical stages of development leads to CHD. The secondary heart field contributing to the cardiac outlet is a key target, with activation of the un-folded protein response and abrogation of FGF signaling or precocious activation of a cardiomyocyte transcriptional program for differentiation, suggested as mechanisms. These studies provide a strong foundation for further study of feto-placental coupling and hypoxic stress in the genesis of human CHD.

Brain natriuretic peptide in pregnant women with heart disease

Background

Plasma brain natriuretic peptide levels were prospectively studied in pregnant women with heart disease.

Methods

Fifty pregnant women with heart disease and 25 controls were evaluated at 24 weeks or under, 30-32 weeks, 34 weeks or more of gestation, and 6 weeks postpartum. Adverse maternal cardiac events were hospitalization for worsening heart failure, stroke, and death.

Results

Thirty-eight (76%) women had rheumatic heart disease. Plasma brain natriuretic peptide levels were (in cases and controls) 118.3 ± 46.5 pg/ml and 66.3 ± 15.9 pg/ml (at 24 weeks or under), 124.8 ± 30.4 pg/ml and 68.4 ± 16.5 pg/ml (30-32 weeks), 135.8 ± 34.9 pg/ml and 68.6 ± 15.6 pg/ml (34 weeks or more), and 110.1 ± 21.9 pg/ml and 65.0 ± 16.1 pg/ml (6 weeks postpartum) (p = .0001). Eighteen women had adverse events. Of these, only 1 had a level less than 100 pg/ml, 12 were between 100 and 200 pg/ml, and 5 more than 200 pg/ml.

Conclusions

Plasma brain natriuretic peptide levels were higher in women with heart disease at all periods of gestation as well as six weeks postpartum. No woman with a plasma brain natriuretic peptide levels of 98 pg/ml or less had an adverse event.

Clinical analyses of 383 cases with maternal cardiac diseases

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.

Validation of modified World Health Organization classification for pregnant women with heart disease in a tertiary care center in southern Thailand

Purpose

To validate the modified World Health Organization (WHO) classification in pregnant women with congenital and acquired heart diseases.

Patients and methods

The database of pregnant women with heart disease, who delivered at Songklanagarind Hospital between January 1995 and December 2016, was retrieved from the Statistical Unit, Department of Obstetrics and Gynecology, along with the Hospital Information System of Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University. Each patient was retrospectively classified according to the modified WHO classification of maternal cardiovascular risk. Comparison of maternal and fetal outcomes among the modified WHO classes were analyzed using the chi-square test or Fisher’s exact test and one-way ANOVA test. A p-value of <0.05 was considered statistically significant.

Results

A total of 331 cases were studied: 157 cases with congenital heart disease and 174 cases with acquired heart disease. There were 48, 173, 32 and 78 cases in the modified WHO class I, II, III and IV, respectively. Congestive heart failure was the most common complication. The overall maternal mortality rate was 3.6%, all of which were in the modified WHO class IV. Maternal cardiovascular events occurred in 24.2% of cases, increasing rates with higher modified WHO class: 4.2%, 15.0%, 25.0% and 56.4% in class I, II, III and IV, respectively (p<0.001). Adverse fetal outcomes including preterm delivery, low birth weight, small for gestational age and neonatal intensive care unit admission were also significantly increased in class III and IV (p<0.05).

Conclusion

The modified WHO classification is useful not only for obtaining a cardiovascular risk assessment in pregnant women with heart disease but also for predicting adverse fetal outcomes. It must, therefore, be implemented into routine care service at all levels of health care systems.

Factors associated with maternal mortality at advanced maternal age: a population-based case-control study

OBJECTIVE

This study aimed to examine the factors associated with maternal mortality among women aged ≥35 years.

DESIGN

Unmatched population based case-control study.

SETTING

United Kingdom.

POPULATION

Between 2009 and 2012, 105 cases of maternal deaths aged ≥35 years were extracted from the surveillance database of the MBRRACE-UK confidential enquiries into maternal deaths in the UK. In addition, 766 controls aged ≥35 years were identified from the UK Obstetric Surveillance System (2005-2012).

METHODS

Risk factors known to be associated with maternal mortality and morbidity and for which data were available were examined for their association with maternal mortality among women ≥35 years using logistic regression analysis.

MAIN OUTCOME MEASURES

Odds ratios and 95% confidence intervals associated with maternal death.

RESULTS

Five factors were found to be significantly associated with increased odds of death among women aged ≥35 years: smoking during pregnancy (adjusted odds ratio (aOR) 2.06, 95% CI 1.13-3.75), inadequate use of antenatal care (aOR 23.62, 95% CI 8.79-63.45), medical co-morbidities (aOR 5.92, 95% CI 3.56-9.86) and previous pregnancy problems (aOR 2.06, 95% CI 1.23-3.45). The odds associated with death increased by 12% per year increase in age (aOR 1.12, 95% CI 1.02-1.22).

CONCLUSION

Age was associated with maternal mortality even after adjusting for other known risk factors. Importantly, this study showed an association between maternal mortality and smoking among women aged 35 years or older. It emphasises the importance of public health action to reduce smoking levels and address trends in rising maternal age.

TWEETABLE ABSTRACT

Smoking is a risk factor for maternal death for those aged over 35 years.

Non-communicable diseases during pregnancy in low and middle income countries

Apart from the risks of obstetric complications like haemorrhage and eclampsia, a large number of medical conditions affect pregnancy and result in adverse outcomes for both the mother and offspring. Non-communicable diseases in pregnancy are becoming increasingly important in contributing to death and poor health. Changes in the patterns and distribution of these conditions mean that we need new perspectives and ways of dealing with these challenges for the future. This article reviews the burden of ill-health due to non-communicable diseases during pregnancy in low and middle income countries and presents some paradigms relevant to public health and health system needs of the future.

Surgery for rheumatic mitral valve disease in sub-saharan African countries: why valve repair is still the best surgical option

Rheumatic valve disease, a consequence of acute rheumatic fever, remains endemic in developing countries in the sub-Saharan region where it is the leading cause of heart failure and cardiovascular death, involving predominantly a young population. The involvement of the mitral valve is pathognomonic and mitral surgery has become the lone therapeutic option for the majority of these patients. However, controversies exist on the choice between valve repair or prosthetic valve replacement. Although the advantages of mitral valve repair over prosthetic valve replacement in degenerative mitral disease are well established, this has not been the case for rheumatic lesions, where the use of prosthetic valves, specifically mechanical devices, even in poorly compliant populations remains very common. These patients deserve more accurate evaluation in the choice of the surgical strategy which strongly impacts the post-operative outcomes. This report discusses the factors supporting mitral repair surgery in rheumatic disease, according to the patients' characteristics and the effectiveness of the current repair techniques compared to prosthetic valve replacement in developing countries.

Pregnancy in women with cardiovascular disease in the guidelines era: an Italian single-center experience

AIMS

The aim of the present study is to determine pregnancy outcome with regard to the risk class and the modality way of referral to our joint Cardiac Obstetric Clinic.

METHODS

This is a prospective observational study. Patients referred to our clinic between 2011 and 2014 were included. Reason and timing for referral were recorded. Two groups were identified: women who were known to have cardiac disease before referral (group I) and women who were not (group II). Pregnancies were managed as recommended by the ESC Guidelines. Cardiac events were defined as death, heart failure requiring treatment, documented tachyarrhythmias, thromboembolic events and need for urgent endovascular procedures or surgery.

RESULTS

Of the 110 pregnancies, 51 (47%) were in group I and 57 (53%) in group II. Congenital (44%) and valvular (27%) diseases were the most frequent diagnosis. Thirty-two percent of patients were in WHO risk classes III-IV. Thirty percent were referred for symptoms, 70% for risk assessment. Women in group II were evaluated later in pregnancy than those in group I (25.6 ± 9 vs. 21.4 ± 9; P < 0.01). Cardiovascular events occurred in 15 (13.6%) pregnancies and were more common in WHO risk classes III-IV (11, P < 0.001), in group II (12, P= 0.02) and in patients referred for symptoms (11, P < 0.001). Stillbirths occurred only in classes III-IV (three pregnant, 2.7%).

CONCLUSION

There was no maternal or neonatal mortality and an overall acceptable incidence of cardiovascular events but a relevant percentage of pregnant were first referred late and/or for the onset of symptoms. Events were more frequent in these patients. Further efforts are needed to optimize referral to specialized centers.

Percutaneous mitral commisurotomy during pregnancy - A report of two cases performed in a United Kingdom tertiary centre and a review of the literature

We report two cases of severe mitral stenosis where percutaneous mitral commisurotomy was performed within pregnancy. The first case involves an emergency procedure for a new diagnosis of severe mitral stenosis in a woman presenting with pulmonary oedema at 27 weeks' gestation. The second case is of a woman known to have mitral stenosis who underwent a semi-elective procedure for deterioration in symptoms. This procedure is not commonly performed in the United Kingdom because of low incidence of rheumatic heart disease. In addition, percutaneous mitral commisurotomy during pregnancy is rarely performed in the United Kingdom because of the improved healthcare system where majority of the women with moderate to severe mitral stenosis (even asymptomatic) will undergo planned interventions (percutaneous mitral commisurotomy or mitral valve surgery) before contemplating pregnancy. These cases highlight both the acute and chronic presentations of mitral stenosis and the impact pregnancy has on this condition. In addition, these cases show the importance of retaining skills in performing percutaneous mitral commisurotomy within our United Kingdom cardiologists.

Maternal Cardiac Output and Fetal Doppler Predict Adverse Neonatal Outcomes in Pregnant Women With Heart Disease

BACKGROUND

The mechanistic basis of the proposed relationship between maternal cardiac output and neonatal complications in pregnant women with heart disease has not been well elucidated.

METHODS AND RESULTS

Pregnant women with cardiac disease and healthy pregnant women (controls) were prospectively followed with maternal echocardiography and obstetrical ultrasound scans at baseline, third trimester, and postpartum. Fetal/neonatal complications (death, small-for-gestational-age or low birthweight, prematurity, respiratory distress syndrome, or intraventricular hemorrhage) comprised the primary study outcome. One hundred and twenty-seven women with cardiac disease and 45 healthy controls were enrolled. Neonatal events occurred in 28 pregnancies and were more frequent in the heart disease group as compared with controls (n=26/127 or 21% versus n=2/45 or 4%; P=0.01). Multiple complications in an infant were counted as a single outcome event. Neonatal complications in the heart disease group were small-for-gestational-age/low birthweight (n=18), prematurity (n=14), and intraventricular hemorrhage/respiratory distress syndrome (n=5). Preexisting obstetric risk factors (P=0.003), maternal cardiac output decline from baseline to third trimester (P=0.017), and third trimester umbilical artery Doppler abnormalities (P<0.001) independently predicted neonatal complications and were incorporated into a novel risk index in which 0, 1, and >1 predictor corresponded to expected complication rates of 5%, 30%, and 76%, respectively.

CONCLUSIONS

Decline in maternal cardiac output during pregnancy and abnormal umbilical artery Doppler flows independently predict neonatal complications. These findings will enhance the identification of higher risk pregnancies that would benefit from close antenatal surveillance.

Pregnancy with co-morbidities: Anesthetic aspects during operative intervention

The presence of co-morbidities during pregnancy can pose numerous challenges to the attending anesthesiologists during operative deliveries or during the provision of labor analgesia services. The presence of cardiac diseases, endocrinological disorders, respiratory diseases, renal pathologies, hepatic dysfunction, anemia, neurological and musculoskeletal disorders, connective tissue diseases and many others not only influence the obstetric outcome, but can significantly impact the anesthetic technique. The choice of anesthesia during the pregnancy depends upon the type of surgery, the period of gestation, the site of surgery, general condition of patient and so on. Whatever, the anesthetic technique is chosen the methodology should be based on evidentially supported literature and the clinical judgment of the attending anesthesiologist. The list of co-morbid diseases is unending. However, the present review describes the common co-morbidities encountered during pregnancy and their anesthetic management during operative deliveries.

The Evaluation of Applied Anaesthetic Techniques for Caesarean in Parturients with Cardiac Diseases: Retrospective Analysis

OBJECTIVE

In this study, the effects of anaesthetic technique on mother and newborn were investigated in a retrospective analysis of parturients with cardiac diseases undergoing Caesarean section between 2006-2012.

METHODS

Our hospital's medical information system records were analyzed, and we found 107 parturients with cardiac disease and were undergoing Caesarean section, and their demographic data and obstetric, anaesthetic, and neonatal record forms were inspected.

RESULTS

Fifty-three (49.5%) pregnant women received general anaesthesia, and 54 (50.5%) received regional anaesthesia (34 spinal, 19 epidural and 1 CSE) (p=0.05). Week of pregnancy was lower for the group of general anaesthesia (p=0.007). Among cardiac parturients, valvular lesion rates were higher (75.7%). The relationship between existing cardiac disease and anaesthetic management was not significant (p=0.28). However, we determined that parturients with higher NYHA (New York Heart Association) classifications had higher general anaesthesia rates. (p=0.001). A rate of 39% of 74 NYHA I patients were undergoing general anaesthesia; this rate was 64% for NYHA II and 100% for NYHA III. The patients with cardiac surgery or medical treatment history had higher general anaesthesia rates (p=0.009). Although the general anaesthesia group newborn weights were lower (p=0.03), there was no difference between groups for APGAR scores. With regard to postoperative complications and hospital stay, the groups were similar.

CONCLUSION

We determined that general and epidural rates in parturients with cardiac diseases were similar, general anaesthesia was preferred for parturients who had higher NYHA classifications and surgical or medical treatment history. We considered that general anaesthesia criteria should reduce the anaesthesia management of parturients with cardiac disease; epidural or CSE anaesthesia applications should increase according to the patient's physical state, haemodynamic parameters, and obstetric indications.

Congenital heart disease in pregnancy in a low-income country

OBJECTIVE

To assess maternal and perinatal outcomes among pregnant women with congenital heart disease (CHD) in a low-resource country.

METHODS

A prospective, observational study was conducted at a teaching hospital in Kolkata, India, between January 1, 2008, and December 31, 2010. All pregnant women with CHD were followed up from first prenatal visit to discharge. Both maternal and perinatal outcomes were analyzed.

RESULTS

Of 174 pregnant women with heart disease, 27 (16%) had CHD. Mean age was 23.5±3.6 years. Four (15%) patients were diagnosed with CHD during the index pregnancy. Nine (33%) women had undergone surgical correction before conception. Cesarean delivery was performed in 12 (44%) women. Fifteen (56%) neonates weighed less than 2500 g, and 4 (15%) were born preterm. Mean birth weight was slightly higher in women with corrected heart lesions than in those with uncorrected ones (2593±480 g vs 2294±620 g; P=0.22). Three (11%) neonates died, but no stillbirths occurred. One (4%) woman died after delivery owing to atonic postpartum hemorrhage.

CONCLUSION

Delayed diagnosis, lack of treatment, and unplanned pregnancy are major challenges for women with CHD, which need to be addressed to improve maternal and neonatal outcomes in low-resource countries.

Surgery for rheumatic valve disease in pregnancy: what about the newborn?

BACKGROUND

Valvular heart disease constitutes the majority of all causes of cardiac disease in pregnancy. The significant physiological haemodynamic changes of pregnancy may cause serious cardiac problems leading to severe maternal and foetal morbidity and mortality. In this study, we evaluate the effect of maternal rheumatic valvular disease requiring definitive operation concurrent with caesarian delivery on maternal and foetal outcome.

METHODS

Between 2003 and 2010, a total of nine pregnant women and nine live births were examined. Immediately after caesarean section, the newborns were examined by the neonatologist and transferred to the neonatal intensive care unit. All the mothers were followed routinely with clinical and echocardiographic examinations.

RESULTS

The age at the time of delivery ranged between 21 and 36 years (median 31 years). Postoperative period of mothers was uneventful and mean hospital stay was 7.56±3.97 days. Birth weight for the newborns was ranged between 1370 and 2900g. Six of the newborns were premature (≤37 weeks). Four newborns were small for gestational age (SGA). There was no mortality in newborns. Hospital stay for the newborns ranged between four and 54 days.

CONCLUSIONS

Careful follow-up of pregnancies with valvular heart diseases and determining the optimal time of cardiac intervention are the essential issues. We suggest that careful follow-up of both mother and foetus until at least the 28th gestational week, following which combined caesarian section and cardiac surgery can be performed.

Fetomaternal outcome among women with mitral stenosis after balloon mitral valvotomy

OBJECTIVE

To compare pregnancy outcomes among patients with non-operated mitral stenosis and those who had balloon mitral valvotomy before pregnancy.

METHODS

In a study at a tertiary-care referral hospital in Kolkata, India, 48 women with mitral stenosis who delivered between July 2007 and June 2008 were separated into 2 groups according to whether they had cardiac surgery before pregnancy. Eighteen women in the test group had balloon mitral valvotomy before pregnancy, whereas 30 women in the control group had no cardiac surgery. Fetomaternal outcomes were compared between the 2 groups.

RESULTS

In the control group, significantly more patients had palpitations (P=0.032) and severe dyspnea (P=0.017) than in the test group. The incidence of preterm labor in the test group (1/18) was lower than that in the control group (10/30) (P=0.035). However, the groups did not differ in mode of delivery, mean birth weight, or neonatal complications.

CONCLUSION

Balloon mitral valvotomy improved maternal symptoms and should be done to prevent maternal morbidity and to reduce the incidence and complications of preterm labor.

Anaesthetic Management of Parturient with Acute Atrial Fibrillation for Emergency Caesarean Section

A 31-year-antenatal lady with critical mitral stenosis presented for emergency caesarean section with fetal distress. She had acute onset atrial fibrillation. She was given a combined spinal epidural (CSE) anaesthesia and her arrhythmia was successfully managed after delivery of the baby with intravenous calcium channel blocker. Mitral stenosis is the most common valvular heart disease complicating pregnancy in developing countries. The physiological changes during pregnancy may exacerbate their cardiac symptoms. They may present with complications like congestive cardiac failure, atrial fibrillation, or pulmonary thromboembolism during the antenatal, intrapartum, or postpartum period. Here we discuss the management of parturient woman with high maternal and fetal risk presenting for emergency caesarean. The merits of regional anaesthesia and the importance of invasive monitoring are also discussed.

Pregnancy outcomes and relative risk factors among Chinese women with congenital heart disease

OBJECTIVE

To summarize pregnancy outcomes among a cohort of Chinese women with congenital heart disease (CHD) and to identify predictive risk factors for maternal, fetal, and neonatal complications.

METHODS

A retrospective analysis of 529 women with CHD who gave birth at the Shanghai Obstetrical Cardiology Intensive Care Center, Shanghai, China, between January 1, 1993, and September 30, 2010. Maternal, fetal, and neonatal complications were evaluated for these women.

RESULTS

Maternal cardiac complications were reported in 33 (6.2%) of the women, whereas fetal and neonatal complications were reported in 145 (27.4%). The factors found to be significantly predictive for maternal cardiac complications were cardiac events before pregnancy (odds ratio [OR] 36.811), New York Heart Association functional class greater than II (OR 27.702), oxygen saturation below 90% (OR 7.506), and left ventricular obstruction (aorta stenosis) (OR 2.408). Factors significantly predictive for fetal and neonatal complications were New York Heart Association functional class greater than II (OR 20.12), oxygen saturation below 90% (OR 3.78), and pulmonary arterial hypertension (systolic pressure ≥ 50 mm Hg) (OR 3.42).

CONCLUSION

Identification of maternal, fetal, and neonatal complications among women with CHD may guide medical intervention and therefore reduce pregnancy-associated risk for these patients.

The burden of antenatal heart disease in South Africa: a systematic review

Background

Maternal mortality in South Africa is rising, and heart conditions currently account for 41 per cent of indirect causes of deaths. Little is known about the burden of heart disease in pregnant South Africans.

Methods

We systematically reviewed the contemporary epidemiology and peripartum outcomes of heart disease in South African women attending antenatal care. Searches were performed in PubMed, ISI Web of Science, the EBSCO Africa-Wide database, the South African Union Catalogue, and the Current and Completed Research database (South Africa). References of included articles were also hand-searched. Studies reporting epidemiologic data on antenatal heart disease in South Africa were included. Data on morbidity and mortality were also collected.

Results

Seven studies were included in the systematic review. The prevalence of heart disease ranged from 123 to 943 per 100,000 deliveries, with a median prevalence of 616 per 100,000. Rheumatic valvular lesions were the commonest abnormalities, although cardiomyopathies were disproportionately high in comparison with other developing countries. Peripartum case-fatality rates were as high as 9.5 per cent in areas with limited access to care. The most frequent complications were pulmonary oedema, thromboembolism, and major bleeding with warfarin use. Perinatal mortality ranged from 8.9 to 23.8 per cent, whilst mitral lesions were associated with low birth weight. Meta-analysis could not be performed due to clinical and statistical heterogeneity of the included studies.

Conclusion

Approximately 0.6 per cent of pregnant South Africans have pre-existing cardiac abnormalities, with rheumatic lesions being the commonest. Maternal and perinatal morbidity and mortality continue to be very high. We conclude this review by summarising limitations of the current literature and recommending standard reporting criteria for future reports.

Severe heart disease complicating pregnancy does not preclude a favourable pregnancy outcome: 15 years' experience in a single centre

Heart disease (HD) in pregnancy remains a major cause of non-obstetric maternal and neonatal mortality and morbidity. This study describes the outcome in 164 pregnant women with HD (158 deliveries in women in New York Heart Association (NYHA) Classes 1 and 2; 17 in NYHA Classes 3 and 4) who received good antenatal care and benefitted from a specific protocol and experience of a dedicated staff. There were no maternal or neonatal deaths; 46 women were diagnosed peripartum. Based on a sub-division into NYHA categories, and when sub-divided by HD, there were no statistically significant differences between groups with regard to maternal age, gestational age at admission or at delivery, birth weight, 5 min Apgar scores, mode of delivery (caesarean delivery), senior obstetric/anaesthesiology staff in attendance or delivery during day/working hours. There was a higher incidence of pre-term deliveries in women with rheumatic heart disease and Marfan syndrome (p = 0.06) relative to others. Babies of women with coronary heart disease had prolonged postpartum course in the NICU (p = 0.0001) and longer total hospital stays for the mother. In conclusion, well-managed, motivated mothers with HD who benefit from comprehensive antenatal care, and are managed primarily by their obstetric and anaesthesia teams, can aspire to a good outcome for themselves and their babies.