2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy

Analysis of the clinical characteristics and outcomes of pregnant women with different degrees of pulmonary hypertension

OBJECTIVES

To investigate the clinical situation and pregnancy outcome of pregnant women with pulmonary arterial hypertension (PAH).

METHODS

A retrospective analysis was conducted on 125 pregnant women with varying degrees of PAH who were treated in the Department of Obstetrics and Gynecology of the First Affiliated Hospital of the University of Science and Technology between January 2016 and January 2023. The patients were divided into the mild group (58 cases), the moderate group (42 cases), and the severe group (25 cases) based on the pulmonary artery systolic blood pressure (PASBP) measurements. Mild was considered as PASBP 30-49 mmHg, moderate as PASBP 50-79 mmHg, and severe as PASBP ≥80 mmHg. The clinical data, cardiac function grade, etiology, and pregnancy outcome of the pregnant women with different degrees of severity of PASBP were analyzed.

RESULTS

Out of the 125 cases, the primary cause of PAH was congenital heart disease in 46 cases, followed by idiopathic heart disease in 32 cases, preeclampsia in 30 cases, rheumatic heart disease in 10 cases, and perinatal cardiomyopathy in 7 cases. A significant correlation was observed between the severity of PAH and the cardiac function grade, indicating that higher PASBP levels were associated with worse cardiac function (New York Heart Association functional classification system) (p < .05). Most deliveries were conducted via cesarean section, predominantly under intraspinal anesthesia. It was found that as the severity of PAH increased, there was a corresponding escalation in the incidence of adverse outcomes, including preterm birth, neonatal asphyxia, the need for intensive-care-unit transfer for both mothers and newborns, maternal death, perinatal death, extended postoperative hospital stay, and increased hospital expenses (p < .05).

CONCLUSIONS

The higher the pulmonary artery pressure, the worse the prognosis and outcome in pregnant patients with severe PAH.

Impact of smoking on cardiovascular health: Mechanisms, epidemiology and specific concerns regarding congenital heart disease

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Efficacy and safety of bromocriptine in peripartum cardiomyopathy: A systematic review and meta-analysis

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a rare but potentially serious pregnancy complication. The use of bromocriptine in addition to standard treatment has been recommended; however, the evidence supporting its efficacy remains limited.

METHODS

A systematic search was conducted across 4 databases including PubMed, Embase, Web of Science, and Cochrane CENTRAL, from inception to September 13, 2024, without language restrictions. The inclusion criteria were studies that compared the efficacy of bromocriptine in addition to standard treatment versus standard treatment alone in PPCM patients and reported outcomes on LVEF, LV function recovery, all-cause mortality, rehospitalization, New York Heart Association (NYHA) class III/IV, major adverse cardiac events (MACE), and thromboembolism.

RESULTS

There were 11 studies included in this meta-analysis, involving 1706 participants. Bromocriptine was associated with a greater ΔLVEF (Post-Pretreatment LVEF) compared to the control group, with a mean difference (MD) of 10.03 % (95 %CI 3.88 % to 16.17 %), p < 0.01. Subgroup analysis demonstrated that bromocriptine was associated with increased ΔLVEF compared to the control group only in the subgroup with baseline LVEF<30. Bromocriptine was associated with a significantly higher post-treatment LVEF compared to standard treatment alone, with an MD of 8.50 % (95 %CI 3.39 % to 13.61 %), p < 0.01. Additionally, subgroup analysis showed that bromocriptine was associated with higher post-treatment LVEF regardless of study design and baseline LVEF. There was no significant difference in LV function recovery, all-cause mortality, rehospitalization, NYHA class III/IV, MACE, and thromboembolism.

CONCLUSIONS

Bromocriptine is associated with greater ΔLVEF improvement and higher post-treatment LVEF compared to standard treatment alone in PPCM.

Development of the European Society of Hypertension guidelines for the management of arterial hypertension: comparison of the helpfulness of ESH 2013, 2018, and 2023 guidelines

OBJECTIVE

Over the last decade, the European Society of Hypertension (ESH) published several guidelines (GLs) for the Management of Arterial Hypertension (2013, 2018, and 2023). We hypothesized that the GL has been improved because of the publications of new evidence. Thus, we aimed to examine the development of ESH guidelines (ESH GLs) by comparing their helpfulness regarding the diagnosis and treatment of hypertension.

METHODS

A novel mathematical analysis was used to compare ESH GLs. Not only the frequency of Classes of Recommendations (CLASS) and the Levels of Evidence (LEVEL) were examined but a newly developed certainty index (CI) was calculated. This CI allows the CLASS and LEVEL to be assessed together, providing a less biased assessment of GLs, than examining the CLASS and LEVEL independently or related to each other.

RESULTS

The number of recommendations showed continuous and significant increases from 2013 ( N  = 110) to 2018 ( N  = 169), and 2023 ( N  = 269). Examining the frequency of CLASS and/or LEVEL led to biased results, showing both improvements and/or worsening comparing years. However, based on the new analysis, a continuous improvement was shown in the percentage of certainty from 2013 to 2023 (2013: 60.5%, 2018: 72.1%, 2023: 75.3%). Accordingly, the CI was also significantly increased from 2013 (CI: 0.21), to 2018 (CI: 0.44), and to 2023 (CI: 0.51).

CONCLUSION

The analysis shows that compared to previous GLs, the structure of the ESH 2023 GL has been rearranged and simplified. The higher number of Recommendations indicates a continuously accumulating knowledge regarding the mechanisms, clinical findings, and epidemiology of hypertension. Moreover, the ESH 2023 GL shows a higher degree of certainty and CI, corresponding to a higher level of helpfulness of the ESH 2023 GL for healthcare professionals to diagnose, prevent, and treat hypertension.

Outcome of Pregnancy in Women with Congenitally Corrected Transposition of the Great Arteries: A Systematic Review

Congenitally corrected transposition of the great arteries (ccTGA or L-TGA) presents potentially challenging cardiac physiology in the pregnant state. While women with ccTGA often live into childbearing age, little is known about the maternal and fetal outcomes of pregnancy in this rare and heterogenous patient population. We performed a systematic review of the literature over the last 25 years to further investigate these outcomes. A total of 107 women who had 178 pregnancies were analyzed. Maternal outcomes demonstrated: mortality (0.6%), hospitalization (24.5%), heart failure (9.6%) and arrythmia (11.2%). Fetal outcomes included live birth (83.6 %), premature deliveries (10.2%), cesarian section (44.6%), and congenital heart disease identified in offspring (1.9%). Overall mortality was low but high rates of hospitalization highlight the importance of monitoring for potential morbidity and complication in this patient population. While this is the largest review to date on maternal and fetal outcomes in pregnancy in women with ccTGA, future studies are warranted to augment our understanding of cardiovascular and obstetrical outcomes in this population.

Pregnancy with a prosthetic heart valve, thrombosis, and bleeding: the ESC EORP Registry of Pregnancy and Cardiac disease III

BACKGROUND AND AIMS

Pregnancy in women with a prosthetic heart valve is considered high risk, primarily due to the need for effective anticoagulation. However, data on the relationship between anticoagulation practices and pregnancy outcomes are very limited.

METHODS

The Registry of Pregnancy and Cardiac disease is a global registry that prospectively enrolled pregnancies in women with a prosthetic heart valve between January 2018 and April 2023. Detailed data on anticoagulation, including dosage and monitoring, and cardiovascular, pregnancy, and perinatal outcomes were collected.

RESULTS

In total, 613 pregnancies were included of which 411 pregnancies were in women with a mechanical valve and 202 were in women with a biological valve. The chance of an uncomplicated pregnancy with a live birth in women with a mechanical valve was 54%, compared with 79% in women with a biological valve (P < .001). Thromboembolic and haemorrhagic complications most frequently occurred when low-molecular weight heparin (LMWH)-based regimens were used. Valve thrombosis occurred in 24 (6%) women, and a prosthetic valve in mitral position was associated with valve thrombosis (odds ratio 3.3; 95% confidence interval 1.9-8.0). A thromboembolic event occurred in 12 (10%) women with anti-Xa monitoring and in 9 (21%) women without (P = .060). Foetal death occurred in 20% of all pregnancies.

CONCLUSIONS

More favourable outcomes were found in women with a biological valve compared with a mechanical valve. In women with a mechanical valve, the use of LMWH was associated with an increased risk of thromboembolic complications. A mitral prosthetic valve was identified as a predictor for valve thrombosis. The benefit could not be confirmed nor refuted, in terms of reduced thromboembolic events, from using anti-Xa level monitoring in women on LMWH.

Real-world family planning and pregnancy practices in women with homozygous familial hypercholesterolemia

BACKGROUND AND AIMS

Homozygous familial hypercholesterolemia (HoFH) is characterized by extremely high plasma low-density lipoprotein cholesterol (LDL-C) levels and high premature atherosclerotic cardiovascular disease risk. During pregnancy LDL-C levels increase, while limited therapeutic options are available. This international study documented current approaches of healthcare professionals (HCPs) to family planning, pregnancy, and breastfeeding in HoFH.

METHODS

An online HCP survey was distributed among the HoFH International Clinical Collaborators (HICC, NCT04815005). Responses were analyzed according to HCPs' gender, medical specialty, country income status, and world region.

RESULTS

In total, 87 HCPs (39.1 % women) from 48 countries participated (64.4 % practicing in high-income countries). Most HCPs (79.3 %) always discuss family planning with patients with HoFH. Most (72.4 %) recommend contraception, with intrauterine devices (50.8 %) and oral contraceptives (49.2 %) being most commonly recommended. One in three HCPs would advise against pregnancy if ASCVD risks were deemed too high. Except for lipoprotein apheresis and colesevelam, most HCPs would recommend discontinuing LLT during the conception, pregnancy, and breastfeeding periods. However, approximately 30 % advise continuation or reinitiation of statins and/or ezetimibe during pregnancy and breastfeeding despite labelled restrictions on use during pregnancy and breastfeeding. Nearly half (48.3 %) of HCPs would recommend that women with HoFH shorten the breastfeeding period to resume LLT earlier, with HCPs from high-income countries significantly more likely to do so (51.8 % vs. 41.9 %; p = 0.008).

CONCLUSIONS

This study highlights significant variability in the management of HoFH in women of childbearing age, especially concerning LLT use during conception, pregnancy, and breastfeeding. The findings underscore the need for further research to establish global evidence-based guidelines tailored to individual needs, to improve cardiovascular risk management and reproductive health outcomes for women with HoFH worldwide.

Prevalence and predictive risk factors of hypertensive disorders in pregnant women at high risk for gestational diabetes. The PREeclampsia in DIabetiC gestaTION (PREDICTION) study

PURPOSE

Women with gestational diabetes (GDM) have increased risk of hypertensive disorders in pregnancy (HDP). However, knowledge remains limited for women with high-risk metabolic profiles, regardless of GDM diagnosis. This study aimed to evaluate the prevalence of HDP among women at high risk for GDM, while simultaneously identifying potential predictive clinical risk factors of HDP.

METHODS

Pregnant women who performed a 75-gr Oral Glucose Tolerance Test for the selective screening (based on pre-pregnancy risk factors) of GDM were prospectively enrolled (October 2019-June 2022). The development of HDPwas assessed. Logistic regression and ROC-curve analysis were used to identify predictive risk factors for HDP.

RESULTS

Of the 398 women enrolled (53.5% with GDM), 30 (8%) developed HDP. Women developing HDP had more frequently a family history of type 2 diabetes, a personal history of GDM or preeclampsia, and showed higher pregestational BMI and first-trimester fasting plasma glucose. Moreover, at GDM screening, they had higher fasting and 1-hour glucose levels, and higher systolic and diastolic blood pressure. At logistic regression, systolic and diastolic blood pressure were the strongest risk factors for HDP. The risk increased for systolic blood pressure ≥ 127 mmHg (61% sensitivity, 86% specificity, PPV:27%, NPV:86%) and diastolic blood pressure ≥ 82 mmHg (57% sensitivity, 92% specificity, PPV:38%, NPV:96%).

CONCLUSION

Women at high risk for GDM with poor metabolic profile have higher prevalence of HDP. Systolic and diastolic blood pressure at the time of GDM screening may identify women with higher risk of developing HDP, regardless of GDM diagnosis.

Prognostic impact of hypertension and diabetes in patients with cardiac amyloidosis

BACKGROUND

Hypertension and diabetes may increase the risk of adverse events in the general population and patients with cardiomyopathies, however, their role in patients with cardiac amyloidosis (CA) is still unclarified.

AIMS

to evaluate the effect on phenotype and clinical outcomes of hypertension and diabetes in patients with CA.

METHODS

Data from 5 Italian Amyloidosis Referral Centres were used to describe clinical characteristics and outcomes of patients with CA based on the presence of a history of hypertension and diabetes.

RESULTS

The study includes 887 patients with CA (311 light chain CA, 87 hereditary transthyretin CA, 489 wild-type transthyretin CA). Median age was 75 years (67-81), and 692 (78 %) were men. Five hundred-seven (57 %) patients had hypertension, 127 (14 %) had diabetes. In multivariable linear regression analysis, hypertension was associated with an increased interventricular septal thickness (coefficient 0.63,95 % CI 0.2-1.06), and augmented E/e' ratio (1.92,95 % CI 0.55-3.29). On Cox regression, diabetes was independently associated with death and heart failure hospitalizations (HR 1.45,95 % CI 1.05-1.99, p = 0.02).

CONCLUSIONS

Patients with hypertension present a more severe phenotype with increased LV wall thickness and more severe diastolic dysfunction compared to non-hypertensive. The presence of diabetes in this cohort is associated with an increased risk of adverse outcomes.

Pregnancy-Associated Takotsubo Syndrome: A Narrative Review of the Literature

Takotsubo syndrome (TTS) is a clinical syndrome defined most typically by transient systolic dysfunction and dilatation of the apex of the left ventricle or other regional areas in the documented absence of obstructive coronary artery disease. Although more commonly presented in postmenopausal women, there are reports in the literature of TTS during the peripartum and postpartum periods. Early TTS diagnosis in pregnancy is of great importance in improving both maternal and fetal mortality. Although TTS involves many pathogenetic pathways, the imbalance between declining estrogen and arising sympathetic nervous system tone plays an important role. This review aims to provide recent published evidence of TTS in pregnancy and delve into the epidemiology of TTS in pregnancy, the pathophysiological mechanisms involved, the prognosis of TTS for the mother and the fetus, and its therapeutic multi-disciplinary management.

Heart failure in low-income and middle-income countries

Heart failure (HF) is a complex syndrome which leads to significant morbidity and mortality, poor quality of life and extremely high costs to healthcare systems worldwide. Although progress in the management of HF in high-income countries is leading to an overall reduction in the incidence and mortality of HF, there is a starkly different scenario in low- and middle-income countries (LMICs). There is a substantial lack of data on HF in LMICs, as well as a scarcity of diagnostic tools, limited availability and affordability of healthcare and high burdens of cardiovascular risk factors and communicable diseases. Patients in this setting present with more advanced HF at much younger ages and are, more often, women. In this review, we aim to comprehensively describe the burden of HF from an LMIC perspective, based on the more recent available data. We summarise the major causes of HF that are endemic in these regions, including hypertension, cardiomyopathy, rheumatic heart disease, HIV-associated heart disease and endomyocardial fibrosis. Finally, we discuss the challenges faced by the least developed health systems and highlight interventions that may prove to be more efficient in changing the paradigm of HF of the more vulnerable populations.

Special considerations in assisted reproductive technology for patients with cardiovascular disease

Many individuals with cardiovascular disease can benefit from the availability of assisted reproductive technologies (ARTs) for family building. Its use for this population may be because of underlying infertility, a need for fertility preservation before disease worsening or heart transplant, a genetic cardiac condition they believe to avoid passing to offspring, or the need to use a gestational surrogate in the setting of cardiovascular contraindications to pregnancy. Cardiovascular disease exists on a spectrum, from mild and common diseases that pose minimal threat to maternal health during pregnancy to severe and rare diseases with a high risk of morbidity and maternal mortality if ART or pregnancy is pursued. In this review, we characterize the varying cardiovascular diseases from the lens of the reproductive-aged patient undergoing ART. We classify the necessary steps in the pre-ART evaluation from the multidisciplinary team, discuss risk stratification before ART treatment and possible subsequent pregnancy, and offer specific evidence-based guidance on the care of these patients during the in vitro fertilization and embryo transfer cycles.

Cardio-obstetrics in the Cardiac Intensive Care Unit: An Introductory Guide

The care of the cardio-obstetric population in the cardiac intensive care unit is challenging due to limited data in this patient population. Optimal care requires a broad multidisciplinary team of experts such that both maternal and fetal health are fully supported. A deep understanding of the interplay between the hemodynamics of pregnancy and the clinical manifestations of varied cardiac disease states is essential. The assessment, diagnostic testing, and treatment of patients who are pregnant require special consideration, especially as teams consider pharmacological and invasive therapies. Complex ethical decisions often arise and therapies may be limited by federal and state policy, which adds an additional layer of complexity. This review serves as an introductory guide to cardio-obstetric care in the cardiac intensive care unit.

Investigating the association of albuminuria with the incidence of preeclampsia and its predictive capabilities: a systematic review and meta-analysis

BACKGROUND

Preeclampsia (PE) is a severe hypertensive disorder affecting approximately 6.7% of pregnancies worldwide. Identifying reliable biomarkers for early prediction could significantly reduce the incidence of PE and facilitate closer monitoring and timely management. This study aims to investigate the association between albuminuria in early pregnancy and the subsequent development of PE, and to explore its predictive abilities.

METHODS

A systematic search was conducted across PubMed, Embase, and Web of Science on July 15, 2024, for studies published between January 1, 1990, and June 30, 2024. Quality assessments were performed using the Joanna Briggs Institute Critical Appraisal and Risk of Bias in Non-randomized Studies - of Exposures Checklists. Random-effects models in STATA were used to conduct meta-analyses comparing urine albumin and albumin-to-creatinine ratio levels in patients who later developed PE versus those who did not. The incidence of PE was also compared between patients with and without albuminuria in early pregnancy. The predictive ability of albuminuria for PE was assessed using META-DISC software.

RESULTS

A total of 26 studies comprising 7,640 pregnant women were systematically reviewed. Of these, 17 studies met the quality criteria for inclusion in the meta-analyses. Our findings indicate that urine albumin (Hedges's g = 0.48 [95% confidence interval (CI): 0.16-0.80]; p-value < 0.001) and albumin-to-creatinine ratio (Hedges's g = 0.48 [95% CI: 0.16-0.80]; p-value = 0.003) were significantly higher in the early stages of pregnancy in patients who later developed PE compared to those who did not. The incidence of PE was higher in patients with early-diagnosed albuminuria (log odds ratio = 2.56 [95% CI: 1.75-3.38]; p-value < 0.001). The pooled sensitivity and specificity for albuminuria in predicting PE were 56% [95% CI: 48-64%] and 87% [95% CI: 85-89%], respectively.

CONCLUSIONS

Elevated maternal urine albumin and albumin-to-creatinine ratio in early pregnancy are associated with a higher risk of developing PE. While these biomarkers show promise for early identification of at-risk patients, the relatively low sensitivity suggests that albuminuria alone may not be a robust predictor of PE, which underscores the need for future research in this regard.

TRIAL REGISTRATION

Review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the code CRD42024575772.

Volume challenge in women with congenital heart disease during reproductive age and pregnancy outcomes

BACKGROUND

Thanks to medical improvements in the care for patients with congenital heart disease (CHD), women with CHD reach reproductive age. Pregnancy is not without risk due to the cardiovascular changes that occur. University Hospitals Leuven use a standardised protocol, including a catheterisation and volume challenge, to assess these women before pregnancy. This protocol has never been evaluated.

OBJECTIVE

The primary aim was to evaluate this volume challenge protocol. The second objective was to investigate whether hemodynamic data obtained during cardiac catheterisation were associated with maternal and/or neonatal outcome.

METHODS

A single-centre, retrospective study was conducted. Primarily, changes in catheterisation measurements were evaluated. Second, correlation statistics investigated associations between catheterisation data and outcome.

RESULTS

Twenty-five women, with nine different CHDs were eligible for inclusion and underwent a catheterisation with volume challenge. Significant changes in pre- and post-volume challenge measurements were observed in the mean averaged systemic venous pressure (ASVP) (p < 0.001), diastolic and mean pulmonary artery pressures (p < 0.001), and the pulmonary capillary wedge pressure (p < 0.001). A negative correlation was observed between the pre-test ASVP and the neonatal gestational age at delivery (p = 0.002). Another negative correlation was found between the post-test cardiac index (CI) and gestational age at delivery (p = 0.049) and birthweight (p = 0.018).

CONCLUSION

The results suggest that higher ASVP is associated with lower gestational age at delivery. Remarkably, higher CI was related with lower gestational age and birthweight. However, our data do not support that a systematic volume challenge in women with CHD can be considered as a reliable prediction test.

Pregnancy and Delivery Outcomes in Vascular Ehlers-Danlos Syndrome: A Retrospective Multicentre Cohort Study

OBJECTIVE

We aim to increase knowledge on pregnancy and delivery risks in vascular Ehlers-Danlos Syndrome (vEDS). Our outcomes can contribute to establishing future guidelines for pregnancy and delivery management in women with vEDS.

DESIGN

Retrospective multicentre cohort study.

SETTING

Women with vEDS due to pathogenic/likely pathogenic (P/LP) COL3A1 variants are at increased risk for arterial dissection and pregnancy-related complications during pregnancy and delivery.

POPULATION

Women with a P/LP COL3A1 variant were included from 2019 until 2021.

METHODS

Genetic and clinical data was collected through retrospective analysis.

MAIN OUTCOME MEASURES

Description of the genotype and pregnancy-related outcomes.

RESULTS

We collected information about 121 pregnancies of 43 women with vEDS, including nine women with a haploinsufficient variant. Neither uterine rupture nor life-threatening or fatal vascular events occurred in the perinatal period. The miscarriage rate was 19% (23/121) and 19.1% of the live births were preterm (18/94). Miscarriages were significantly more frequent in women with a glycine substitution in COL3A1 compared to other COL3A1 variant types (19/23, 82.6%, p = 0.018). Thirty-four women had a vaginal birth (79.1%), including 1/7 with known vEDS. Eight deliveries were complicated by severe perineal tears, and six by postpartum haemorrhage.

CONCLUSIONS

No pregnancy-related deaths, arterial dissections or uterine ruptures occurred in our cohort. Since no life-threatening events occurred during pregnancy and delivery, discouragement of pregnancy in all women with vEDS in current guidelines might be too strict. Based on these data, we propose a shared decision-making process.

Understanding Thoracic Aortic Disease in Women

Multifaceted disparities exist between men and women with thoracic aortic aneurysm and dissection. Despite a higher prevalence of thoracic aortic aneurysm and dissection among men, women experience disproportionately accelerated aneurysmal expansion, greater risks of rupture or dissection, and acute aortic syndromes that occur at relatively smaller diameters. In the context of acute type A aortic dissection, they also experience more complications, increased out-of-hospital mortality, delays in presentation and diagnosis, and worse postoperative survival. These gaps are largely driven by sex differences in vascular aging and remodeling, which include arterial stiffening associated with the hormonal changes that occur during menopause. Furthermore, the increased risk of acute type A aortic dissection during pregnancy in women with thoracic aortic disease necessitates a multidisciplinary approach to peripartum counseling and surveillance. Despite significant recent improvements in early postoperative outcomes, other disparities persist, emphasizing the need for sex-specific research, patient counseling, routine monitoring, and surgical thresholds to bridge the gap in outcomes of thoracic aortic care between sexes. Elucidating the underlying mechanisms of aortic aging and its difference between men and women, as well as moving toward personalized management protocols, will give rise to improved outcomes in the treatment of thoracic aortopathy.

Bromocriptine treatment and outcomes in peripartum cardiomyopathy: the EORP PPCM registry

BACKGROUND AND AIMS

Peripartum cardiomyopathy (PPCM) remains a serious threat to maternal health around the world. While bromocriptine, in addition to standard treatment for heart failure, presents a promising pathophysiology-based disease-specific treatment option in PPCM, the evidence regarding its efficacy remains limited. This study aimed to determine whether bromocriptine treatment is associated with improved maternal outcomes in PPCM.

METHODS

Peripartum cardiomyopathy patients from the EORP PPCM registry with available follow-up were included. The main exposure of this exploratory non-randomized analysis was bromocriptine treatment, and the main outcome was a composite endpoint of maternal outcome [death or hospital readmission within the first 6 months after diagnosis, or persistent severe left ventricular dysfunction (left ventricular ejection fraction < 35%) at 6-month follow-up]. Inverse probability weighting was used to minimize the effects of confounding by indication. Multiple imputation was used to account for the missing data.

RESULTS

Among the 552 patients with PPCM, 85 were treated with bromocriptine (15%). The primary endpoint was available in 491 patients (89%) and occurred in 18 out of 82 patients treated with bromocriptine in addition to standard of care (22%) and in 136 out of 409 patients treated with standard of care (33%) (P = .044). In complete case analysis, bromocriptine treatment was associated with reduced adverse maternal outcome [odds ratio (OR) 0.29, 95% confidence interval (CI) 0.10-0.83, P = .021]. This association remained after applying multiple imputation and methods to correct for confounding by indication (inverse probability weighted model on imputed data: OR 0.47, 95% CI 0.31-0.70, P < 0.001). Thromboembolic events were observed in 6.0% of the patients in the bromocriptine group vs. 5.6% in the standard of care group (P = .900).

CONCLUSIONS

Among women with PPCM, bromocriptine treatment in addition to standard of care was associated with better maternal outcomes after 6 months.

Pregnancies in women after peri-partum cardiomyopathy: the global European Society of Cardiology EuroObservational Research Programme Peri-Partum Cardiomyopathy Registry

BACKGROUND AND AIMS

The risk of heart failure progression or mortality in patients with peri-partum cardiomyopathy (PPCM) during subsequent pregnancies (SSPs) is a significant concern for patients, their families, and healthcare providers. However, there is limited contemporary, prospective data on SSP outcomes in PPCM patients from diverse ethnic and sociodemographic groups. This study aimed to assess maternal and neonatal outcomes in PPCM patients undergoing SSPs.

METHODS

This is a sub-study on PPCM and SSPs of the global European Society of Cardiology PPCM Registry that recruited patients from 2012 to 2023. Maternal and neonatal outcomes were reported.

RESULTS

From 332 patients with PPCM, there were 98 SSPs among 73 women. Of these, 25 (26%) SSPs ended prematurely due to therapeutic termination (20/25), miscarriage (4/25), and stillbirth (1/25). The median follow-up from the end of the SSP was 198 days (inter-quartile range 160-240). Left ventricular ejection fraction (LVEF) was persistently reduced to <50% prior to the SSP in 26% of patients, with only 6% having an LVEF <40%. Patient characteristics were similar, irrespective of SSP baseline LVEF. Clinical worsening [composite of all-cause death, cardiovascular rehospitalization, or decline in LVEF ≥10% (percentage points) and to <50%] occurred in 20% SSPs, with 2% all-cause maternal mortality. Signs/symptoms of heart failure and worsening of New York Heart Association class occurred in 26% and 22% of SSPs, respectively. At follow-up, the mean LVEF was 50% (±12%), and in 69% of SSPs, the LVEF was ≥50%. African women had similar outcome as the other ethnic groups. Pre-term delivery occurred in 24% of SSPs, 20% of babies were of low birth weight, and there was 3% all-cause neonatal mortality. Compared with women with SSP baseline LVEF <50%, fewer women with LVEF ≥50% were on heart failure pharmacotherapies prior to the SSP, and in this group of women, there was a significant decline in LVEF.

CONCLUSIONS

Maternal morbidity and mortality rates were lower than anticipated. Baseline LVEF <50% was not associated with an increased frequency of adverse maternal outcomes, and no further decline in LVEF was observed in this group. In contrast, women with SSPs and a baseline LVEF ≥50% experienced a decline in LVEF, potentially attributable to reduced use of heart failure pharmacotherapy during pregnancy and the post-partum period. Therapeutic termination was performed in approximately a fifth of cases. The findings suggest that reclassification of a SSP with persisting mild left ventricular impairment from modified World Health Organization (mWHO) Class IV (contraindicated) to mWHO III may be considered, while remaining under the care of an experienced medical team and with appropriate pharmacological management.

Mitral Transcatheter Edge-to-Edge Repair in a Pregnant Woman: Procedure and Pregnancy Outcomes

Secondary mitral regurgitation (MR) associated with left ventricular dysfunction carries a high risk of acute heart failure during pregnancy because of associated hemodynamic changes. Mitral transcatheter edge-to-edge repair (TEER) is currently recommended for symptomatic patients with secondary MR; however, no evidence exists on the use of this therapy in pregnancy. We present a case of secondary MR in a pregnant woman with dilated cardiomyopathy. She was successfully treated with TEER with minimal use of fluoroscopy (35 seconds). This is the first case to our knowledge of mitral TEER during pregnancy described in the literature, suggesting feasibility and safety of this procedure.

RAAS inhibitors in pregnancy, breastfeeding and women of childbearing potential: a review of national and international clinical practice guidelines

Globally prevalent conditions such as hypertension, heart failure, ischaemic heart disease (IHD) and chronic kidney disease (CKD) are frequently and effectively treated with blockers of the renin-angiotensin-aldosterone system (RAAS) as a first line treatment in the UK and worldwide. RAAS blockers are prohibited in pregnancy due to their adverse fetal effects. We reviewed clinical guidelines from the National Institute of Health and Care Excellence (NICE) on the management of cardiovascular and kidney disease with RAAS blockers in pregnancy, with other UK, European and American guidance as comparators. Whilst guidelines agree on the strict avoidance of RAAS blockers in pregnancy, nuanced considerations regarding prescription in women of childbearing potential, contraception, timing of RAAS blocker withdrawal and breastfeeding are not consistently addressed in clinical guidelines. We call for consistent wording and more explicit advice on RAAS blocker prescription in women of childbearing potential, in pregnancy and in the postpartum period in future iterations of clinical guidelines.

Anticoagulant therapy in pregnant women with mechanical and bioprosthetic heart valves

OBJECTIVE

The aim of the present study was to review maternal and fetal outcomes in pregnant women with prosthetic heart valves.

METHODS

A retrospective record review of pregnant women with prosthetic heart valves on anticoagulation was performed at the Specialist Cardiac Antenatal Clinic, Johannesburg South Africa from 2015 to 2023.

RESULTS

Fifty pregnancies with mechanical heart valves and three with tissue valves, on anticoagulation for comorbid atrial fibrillation were identified. The majority were of African ethnicity at a mean age of 33 ± 6 years. Anti-Xa adjusted enoxaparin was commenced at 10.5 ± 5.6 weeks' gestation until delivery in 48 (90.6%) pregnancies and warfarin was continued in five (9.4%) pregnancies. The live birth rates on enoxaparin and warfarin were 56.3% (95% confidence interval [CI]: 42.3-69.3) and 20.0% (95% CI: 2.0-64.0), respectively. There were 12 (22.6%) miscarriages at a mean of 11.3 ± 3.7 weeks' gestation, four (7.5%) intrauterine fetal deaths on warfarin and two (3.8%) warfarin embryopathy/fetopathy. The rates of antepartum/secondary postpartum bleeding and primary postpartum bleeding were 29.4% (95% CI: 18.6-43.1) and 5.9% (95% CI: 1.4-16.9), respectively. Maternal complications included anemia (n = 11, 20.8%), arrhythmia (n = 2, 3.8%), heart failure (n = 2, 3.8%) and paravalvular leak (n = 2, 3.8%). There was one (1.9%) mitral valve thrombosis and one (1.9%) stuck valve in pregnancies who defaulted warfarin prior to pregnancy. There were no maternal deaths.

CONCLUSION

Multidisciplinary management of pregnant women with prosthetic heart valves with anti-Xa adjusted low molecular weight heparin throughout pregnancy represents an effective anticoagulation option for low-middle-income countries.

Peripartum cardiomyopathy in the twenty-first century: a review of the pathophysiology and clinical trials for novel disease-specific therapeutics

Peripartum cardiomyopathy is an idiopathic and nonischemic systolic dysfunction with onset toward the end of pregnancy and up to 5 months postpartum. Its clinical phenotype overlaps with pregnancy-associated cardiomyopathy rendering both a continuum of the same disease. Incidence varies geographically and is highest in areas where risk factors are prevalent. The understanding of its pathophysiology is constantly evolving, but a proposed two-hit model of dysfunctional vasculogenesis and genetic predisposition exacerbated by the hemodynamic stressors of pregnancy is widely accepted. The catalysis of the cleavage of prolactin into an anti-angiogenic fragment provoked by unbalanced oxidative stress forms the bedrock of its pathogenesis. Furthermore, miRNA signaling, placenta-produced factors, and a potential underlying genetic susceptibility convene to disrupt cardiac and endothelial metabolic homeostasis. The role of anti-adrenergic and anti-sarcomeric antibodies, nutritional deficiency, and mutated viral cardiotropes are understudied. There are limited randomized controlled trials for disease-specific drugs; however, most trials are targeted at the D2 receptor agonist bromocriptine. Positive primary endpoints in a large German clinical trial led to its approved use in Europe, but the U.S.A. still renders it experimental with ongoing trials evaluating its long-term efficacy and safety. Despite its popularity since the 1900s, multiple gaps in evidence regarding long-term management after myocardial recovery, management of subsequent pregnancies, optimal anticoagulation strategy, and alternative pathophysiological pathways remain unknown.

Cardiovascular-obstetric state-of-the-art review: pulmonary hypertension in pregnancy

ABSTRACT

Pulmonary hypertension in pregnancy has been associated with negative maternal and fetal outcomes over the past decades. With the emergence of novel treatment modalities, morbidity and mortality of women who have pulmonary hypertension in pregnancy have improved. In this review, we aim to explore the contemporary updates in the management of pre-capillary and post-capillary pulmonary hypertension in pregnancy.

Consent to advanced imaging in antenatal pulmonary embolism diagnostics: Prevalence, outcomes of nonconsent and opportunities to mitigate delayed diagnosis risk

BACKGROUND

Nonconsent to pulmonary vascular (or advanced) imaging for suspected pulmonary embolism (PE) in pregnancy can delay diagnosis and treatment, increasing risk of adverse outcomes. We sought to understand factors associated with consent and understand outcomes after nonconsent.

METHODS

This retrospective cohort study was undertaken across 21 community hospitals from October 1, 2021, through March 31, 2023. We included gravid patients undergoing diagnostics for suspected PE who were recommended advanced imaging. The primary outcome was verbal consent to advanced imaging. Diagnostic settings were nonobstetric (99% emergency departments [EDs]) and obstetrics (labor and delivery and outpatient clinics). Using quasi-Poisson regression, we calculated adjusted relative risks (aRRs) of consenting with 95% confidence intervals (CIs). We also reported symptom resolution and delayed imaging at follow-up and 90-day PE outcomes.

RESULTS

Imaging was recommended for 405 outpatients: median age was 30.5 years; 50% were in the third trimester. Evaluation was more common in nonobstetric (83%) than obstetric settings (17%). Overall, 314 (78%) agreed to imaging and 91 (22%) declined imaging. Consenting was more prevalent in obstetric settings compared with nonobstetric settings: 99% versus 73% (p < 0.001). When adjusted for demographic and clinical variables, including pretest probability, only obstetric setting was independently associated with consenting: aRR 1.26 (95% CI 1.09-1.44). Seventy-nine (87%) patients declining imaging had 30-day follow-up. Eight of 12 who reported persistent or worsening symptoms on follow-up were again recommended advanced imaging and consented. Imaging was negative. None who initially declined imaging were diagnosed with PE or died within 90 days.

CONCLUSIONS

One in five gravid patients suspected of PE declined advanced imaging, more commonly in nonobstetric (principally ED) settings than obstetric settings. Patients symptomatic on follow-up responded favorably to subsequent imaging recommendations without 90-day outcomes. Improving the communication and documentation of informed consent and securing close follow-up for nonconsenters may mitigate risks of missed and delayed PE diagnosis.

Evaluation of Cardiac Function in a Patient With Hypertrophic Cardiomyopathy Before and During Pregnancy to Predict Its Outcome: A Case Report

The risk of maternal and neonatal mortality in pregnant women with hypertrophic cardiomyopathy (HCM) is considered low, and prognostic methods have not yet been established. In this study, we evaluated several pregnancies in the same patient. In each case, we were able to assess the severity of the mother's cardiac disease and estimate the prognosis. By reviewing the severity of the disease over time and its actual course, we verified the kind of assessment that is important for predicting prognosis. We present the case of a patient who was diagnosed with HCM at 18 years of age and had her first spontaneous pregnancy at 25 years of age. The baby was born at 38 weeks and was healthy, but the mother's HCM worsened after the second trimester of pregnancy, and treatment in the intensive care unit was needed after delivery. After an implantable cardioverter-defibrillator (ICD) implantation, a second pregnancy was established. However, due to repeated arrhythmias requiring ICD activation, a termination of pregnancy was performed due to the risk of worsening maternal heart failure. After radical septal myectomy, a third pregnancy was achieved. In this case, the left ventricular outflow tract stenosis disappeared, the left ventricular outflow tract pressure gradient decreased, and the pregnancy progressed well with no maternal complications. The New York Heart Association (NYHA) and modified World Health Organization (WHO) scores before conceiving were not sufficient to predict pregnancy outcomes. Changes in the disease status during pregnancy were generally consistent with the Zwangerschap bij Aangeboren HARtAfwijkingen (ZAHARA) or pregnancy and congenital heart disease score, Cardiac Disease in Pregnancy Study II (CARPREG II) score, and modified WHO classification ratings, suggesting that they are suitable for assessing risk during pregnancy, and before and after delivery in patients with HCM.

Diagnosis and treatment of pulmonary embolism. Recommendations of the Thromboembolic Disease Group of the Spanish Society of Internal Medicine 2024

Pulmonary embolism (PE) is a disease with a rising incidence rate. This article presents the recommendations for the diagnosis and treatment of PE of the Thromboembolic Disease Group of the Spanish Society of Internal Medicine (SEMI). The main objective is to facilitate decision making to improve the diagnostic and therapeutic approach based on published evidence. The final justification of the document is to improve the comprehensive care of the patient with PE.

The contemporary cardio-obstetrics team: The path to improving maternal outcomes in high-risk patients

The field of Cardio-Obstetrics is focused on mitigating cardiovascular risk among pregnant and post-partum individuals. Due to the complexity of caring for pregnant people with acquired or congenital cardiac disease, patients with these conditions are increasingly managed in multidisciplinary Cardio-Obstetrics teams, which are now considered essential to optimize maternal care in high-risk patients. Cardio-Obstetrics teams are composed of multiple subspecialists and have at least 3 roles: (1) provide preconception counseling and risk stratification to patients with known cardiac disease, (2) organize prenatal and postpartum care for patients who develop or present with cardiac disease during pregnancy, and (3) plan for emergent care for patients whose pregnancy "unmasks" cardiac disease, whether acquired disease or an unknown ACHD. Here we describe our experience at Einstein/Montefiore to aid other institutions in developing their own programs.

Normal echocardiographic findings in healthy pregnant women: A narrative review of the literature

During pregnancy, significant physiological changes occur that result in cardiac remodeling and altered functional performance, though these are generally reversible postpartum. Pregnancy increases the cardiovascular system's demand, requiring substantial adaptations such as elevated cardiac output (CO), plasma volume, stroke volume (SV), and heart rate (HR), alongside a reduction in systemic vascular resistance (SVR) and mean arterial pressure. These adaptations, essential to meet the hemodynamic needs of both the mother and fetus, often differ from standard echocardiographic measurements used to evaluate cardiac function, making interpretation challenging. Accurate identification of normal echocardiographic parameters during pregnancy is crucial to establishing a baseline for detecting pathological changes. Deviations from these baselines, when recognized early, can assist in risk stratification and inform clinical management of conditions such as heart failure, arrhythmias, or valvular disease. However, many existing studies rely on cross-sectional designs, limiting their ability to provide comprehensive longitudinal insights. For pregnant women, the lack of standardized echocardiographic reference values represents a critical gap. The physiological changes unique to this population, including increased CO and ventricular dimensions, complicate the interpretation of echocardiographic studies using non-pregnant norms. This shortfall can hinder the identification of subclinical cardiovascular alterations, delaying timely intervention. The development of pregnancy-specific echocardiographic reference values is essential for advancing preventive and personalized care. Such tailored references would improve diagnostic accuracy, facilitating early detection and management of pregnancy-related cardiac changes and their potential pathological implications.

Maternal heart failure: state-of-the-art review

Pregnancy is a period of substantial changes to the body's normal physiology, and the failure to adapt to these changes can lead to life-threatening pathology, particularly involving the cardiovascular system. In comparison to pre-pregnancy physiology, pregnant women have increased blood volume and physical demands which exert increased stress on the heart. This is important to consider in women with and without previously diagnosed cardiovascular disease, as the physiologic changes during pregnancy and postpartum can lead to sudden decompensation. The management of heart failure is particularly important as it remains the most common cardiovascular complication during pregnancy and is associated with substantial maternal and fetal morbidity and mortality. This is especially true in patients with pre-existing heart failure, who should receive counseling before conception and in certain cases be advised against pregnancy. For these reasons, healthcare professionals must be well-versed in the different strategies of diagnosis, management, treatment, and monitoring. This review will outline the pathophysiology, diagnostics, management, and general approach to heart failure in pregnant patients.

Hypertensive Disorders of Pregnancy: A Review of the Current Literature and Future Directions

Hypertensive disorders in pregnancy (HDPs) are a leading cause of maternal and fetal morbidity and mortality worldwide. The pathophysiology is complex and still poorly understood but thought to involve a combination of maternal modifiable and nonmodifiable risk factors and placental changes with resultant end-organ dysfunction. Treatment of HDP involves a combination of lifestyle modification and pharmacotherapy, with differing treatment thresholds across organizations. HDP can increase maternal risk for future cardiovascular disease and has shown disparities in racial prevalence and outcomes. Additional efforts are needed to minimize the risk for future cardiovascular disease and improve racial disparities in patients facing HDP.

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.

Assessing and Addressing Cardiovascular and Obstetric Risks in Patients Undergoing Assisted Reproductive Technology: A Scientific Statement From the American Heart Association

The use of assisted reproductive technology (ART) is growing, both to assist individuals with infertility and for fertility preservation. Individuals with cardiovascular disease (CVD), or risk factors for CVD, are increasingly using ART. Thus, knowing how to care for patients undergoing ART is important for the cardiovascular clinician. In this scientific statement, we review the ART process and known short-term and long-term risks associated with ART that can adversely affect patients with CVD. We review current knowledge on risks from ART for specific cardiac conditions and provide a suggested approach to evaluating and counseling patients with CVD contemplating ART as well as suggested management before and during the ART process. Individuals with CVD are at increased risk for pregnancy complications, and management of this unique population has been discussed previously. The focus of this scientific statement is on ART. Therefore, discussions on risk assessment, counseling, and management of individuals with CVD during pregnancy are limited, and established guidelines are referenced.

Pregnancy, aortic events, and neonatal and maternal outcomes

BACKGROUND AND AIMS

This study aimed to evaluate the association between pregnancy and aortic complications and determine related maternal and neonatal outcomes.

METHODS

Records of pregnancies and neonatal deliveries from the Taiwan National Health Insurance Research Database from 2000 to 2020 were retrieved. The incidence rate ratio (IRR) was calculated to evaluate the risk factors for aortic events. Survival analysis was conducted to compare maternal and neonatal mortality with and without aortic events.

RESULTS

A total of 4 785 266 pregnancies were identified among 2 833 271 childbearing women, and 2 852 449 delivered neonates. In the vulnerable and control periods, 57 and 20 aortic events occurred, resulting in incidence rates of 1.19 and 0.42 aortic events per 100 000 pregnancies, respectively. Pregnancy was established as a risk factor for aortic events (IRR: 2.86, P < .001). The 1-year maternal mortality rate was significantly higher in pregnancies with aortic events than in those without such events (19.3% vs. 0.05%, P < .001). Neonates whose mothers experienced aortic events had a higher late mortality (6.3% vs. 0.6%, P < .001).

CONCLUSIONS

The association between pregnancy and aortic events was established in this study. The results revealed that women are at risk of aortic events from the gestational period to 1-year postpartum. Maternal mortality was significantly higher in pregnancies with aortic events than in those without. A higher late mortality and more complications were noted for neonatal deliveries with maternal aortic events. Early awareness of pregnant women at risk of aortic events-especially those with concomitant hypertensive disorders of pregnancy, contributive family histories, or aortopathy-is crucial.

Heart disease in pregnancy and adverse outcomes: an umbrella review

Background

Heart disease in pregnancy encompasses both congenital heart disease and maternal-acquired heart disease, both of which are associated with an increased risk of various adverse outcomes for mothers and their offspring.

Objective

The objective of the study was to review and summarize the evidence regarding the association between heart disease in pregnancy and adverse outcomes in mothers and their offspring.

Data sources

A comprehensive search was conducted in Embase, PubMed, Web of Science, and the Cochrane Database of Systematic Reviews from inception to March 2024. The protocol for this review was registered in PROSPERO (CRD42024519144).

Study eligibility criteria

This review included systematic reviews and meta-analyses that examined the association between heart disease in pregnancy and adverse outcomes for mothers and their offspring.

Study appraisal and synthesis methods

Data were independently extracted by two reviewers. The quality of the systematic reviews and meta-analyses was assessed using the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR2), while Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to evaluate the strength of the evidence for each outcome.

Results

A total of 12 meta-analyses and systematic reviews were included, which documented 156 adverse outcomes for mothers and 65 adverse outcomes for offspring. Evidence was found for both primary and secondary adverse outcomes. Adverse outcomes for mothers were death, cardiac events (cardiac arrest, heart failure, surgery, arrhythmia, anesthesia or sedation, endocarditis, mitral regurgitation, myocardial infarction, NYHA III-IV, restenosis, syncope, and others), pulmonary events (respiratory failure, pulmonary edema, and respiratory support), embolism, cerebrovascular events, postpartum hemorrhage, arterial events, delivery mode, and hospital stay. Adverse outcomes for offspring were death, pregnancy loss, growth restriction, low birth weight, preterm birth, recurrence, and uncertainty. No publication bias was detected using Egger's test. The overall AMSTAR 2 confidence rating for the included meta-analyses and systematic reviews was moderate. The majority (55.3%) of the evidence evaluated by GRADE was of low quality, while the remaining outcomes were categorized as having "very low"-quality evidence.

Conclusion

Current evidence links heart disease during pregnancy to adverse maternal outcomes, including death and cardiac, pulmonary, and cerebrovascular events, as well as increased mortality risk for offspring. Many meta-analyses in this field have limitations that raise concerns about their validity, highlighting the need for high-quality prospective studies.

Pregnancy outcomes in women with mitral valve stenosis: 10-year experience of a tertiary care center

INTRODUCTION

Mitral stenosis (MS) is recognized as one of the most common cardiovascular diseases during pregnancy and can result in adverse outcomes including maternal and fetal mortality if not diagnosed and treated in a timely manner. This study aimed to investigate the pregnancy outcomes of women with MS who were treated at the cardio-obstetric clinic in Alzahra Hospital, Isfahan, from 2011 to 2020.

METHODS

A total of 81 pregnant women diagnosed with MS were selected for the study. Their demographic and clinical data, along with echocardiography information-including systolic pulmonary artery pressure (SPAP), severity of MS, and NYHA class-were monitored throughout pregnancy. Additionally, the maternal and fetal outcomes were examined.

RESULTS

Among the participants, 38.3% were diagnosed with progressive MS, 56.8% exhibited severe stenosis, and 4.9% presented with very severe stenosis. Prior to pregnancy, no cases were classified as NYHA class 3 or 4. However, during the first trimester, six patients (7.4%) were classified as NYHA class 3. In the second trimester, 23 patients (28.4%) were in class 3, and 1 patient (1.2%) was classified as class 4. In the third trimester, 24 cases (29.6%) were in class 3, and 14 cases (17.3%) were in class 4. Notably, significant changes in NYHA class were observed throughout pregnancy (P < 0.001). Furthermore, 16% of participants required percutaneous balloon mitral commissurotomy, highlighting the severity of their condition. Additionally, 2.5% experienced decompensated heart failure and another 2.5% developed arrhythmia after delivery. Unfortunately, there was one case (1.2%) of mortality due to complications from MS. The study also documented one stillbirth (1.2%), 11 cases (13.6%) of spontaneous abortion, 17 cases (21%) of induced abortion, six cases (7.4%) of birth anomalies, three cases (3.7%) of prematurity, and four cases (4.9%) of intrauterine growth restriction, underscoring the critical need for careful management.

CONCLUSION

The results of the study suggest that cardiac function in women diagnosed with MS typically declines during pregnancy. Furthermore, even with optimal treatments, certain complications may still arise.

Reproductive Health in Congenital Heart Disease

As more children with congenital heart disease (CHD) survive to adulthood, reproductive health care in this demographic is becoming increasingly important. While all women with CHD can have an increased risk of morbidity associated with contraception and pregnancy, these risks can range from those that are medically manageable to catastrophic sequalae that can affect quality of life. Clinicians should discuss reproductive health before puberty and should counsel for pregnancy, family planning, and contraception. Comprehensive counseling during adulthood should include risks during the peripartum period, fetal risk, and long-term cardiovascular sequalae, and should be done with a cardiologist experienced in CHD. [Pediatr Ann. 2025;54(2):e70-e73.].

Neonatal birthweight prediction using two- and three-dimensional estimated fetal weight among borderline small fetuses

PURPOSE

This study aimed (1) to determine the degree of correlation between 2D and 3D estimated fetal weight (EFW) and neonatal birth weight (BW) among borderline small fetuses and (2) to compare the accuracy and precision of 2D and 3D EFW in BW prediction.

METHODS

A retrospective cohort study evaluated fetuses who had an ultrasound performed between January 2017 and September 2021 at a tertiary maternal center. All singleton pregnancies with 3D EFW within 4 weeks of delivery were included. Fetuses with known structural or genetic abnormalities were excluded. Pearson's correlation coefficients were determined for both 2D and 3D EFW to BW then compared using Williams' test and Fisher r to z transformation, where applicable. Mean percent difference and standard deviation were used to assess the accuracy and precision, respectively, of 2D and 3D EFWs in BW prediction.

RESULTS

Two hundred forty-eight pregnancies were included. Ultrasound studies were performed with a median interval of 2 weeks (IQR 1, 3) between ultrasound and delivery. Both 2D and 3D estimated fetal weights showed a significant correlation with birth weight (r = 0.74 and r = 0.73, respectively), indicating similar accuracy between the two techniques.

CONCLUSION

Two-dimensional and three-dimensional EFWs performed similarly in the prediction of BW in borderline small fetuses.

Spontaneous Postpartum Pneumomediastinum (Hamman's Syndrome): A Case Report and Review of Chest Pain Management in the Immediate Postpartum Period

Spontaneous pneumomediastinum is a rare condition in the postpartum period, characterized by symptoms such as dyspnea, chest pain, subcutaneous neck edema, tachycardia, crepitus, dysphonia, and dysphagia. The Valsalva maneuver, commonly performed during the second stage of vaginal delivery, has been implicated as a key precipitating factor in the pathogenesis of this condition. We report the case of a 25-year-old woman (G1P1001, 39w5d), with a history of smoking, who developed postpartum dyspnea and chest pain 24 hours following an uncomplicated vaginal delivery. A comprehensive diagnostic workup, including a CT scan with intravenous contrast, confirmed severe pneumomediastinum. The patient was managed conservatively with analgesics, supplemental oxygen, and close clinical monitoring. A follow-up chest CT performed 24 hours later demonstrated interval improvement of the pneumomediastinum and an esophagogram excluded the presence of an esophageal tear or rupture. Although spontaneous pneumomediastinum is a rare obstetric complication of normal childbirth, it can present dramatically with chest pain, dyspnea, and hemodynamic instability. Diagnosis is established through a combination of history, clinical presentation, and radiographic findings. Management is conservative and includes analgesics, rest, supplemental oxygen therapy, and bronchodilators. Importantly, other potentially life-threatening causes of postpartum chest pain and dyspnea must be carefully ruled out to ensure timely and appropriate treatment.

Cardio-Oncology and Heart Failure: a Scientific Statement From the Heart Failure Society of America

Heart failure and cancer remain 2 of the leading causes of morbidity and mortality, and the 2 disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnoses and cancer survivors. Risk stratification, monitoring and management of cardiotoxicity are presented across stages A through D heart failure, with focused discussion on heart failure with preserved ejection fraction and special populations, such as survivors of childhood and young-adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary-team approach and critical collaboration among heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Perioperative Management of Patients with Preeclampsia: A Comprehensive Review

Preeclampsia is a common condition of pregnancy characterized by hypertension complicated by cerebral, cardiac, hepatic, renal, hematologic, and placental dysfunction. Patients with preeclampsia frequently undergo cesarean delivery, the most common major surgical procedure in the world. They represent a high-risk perioperative cohort suffering significant preventable morbidity and mortality. This review focuses on the anesthesiologist's role, through a perioperative lens, in reducing maternal complications through management of hypertension and strategies for preserving the function of the brain, heart, liver, kidney, hematologic and coagulation systems, and placenta in patients with preeclampsia undergoing cesarean delivery. Preeclampsia-specific resuscitation, individualized fluid administration, safe neuraxial and general anesthesia, and management of intraoperative bleeding are discussed along with strategies for postoperative analgesia, thromboprophylaxis, and antihypertensive agents in patients who breastfeed. This review discusses recently recognized postoperative deterioration in maternal mental health, the possibility of myocardial injury after cesarean delivery, and the need for long-term cardiometabolic follow-up.