The impact of cardiovascular diseases on maternal deaths in the Nordic countries

Prediction of cardiac events in pregnant women with cardiac diseases using modified WHO, CARPREG II, and ZAHARA risk assessments in southern Thailand

OBJECTIVE

This study aimed to compare the predictive performance of three cardiovascular risk assessment models-modified WHO (mWHO) classification, Cardiac Disease in Pregnancy II (CARPREG II), and Zwangerschap bij Aangeboren Hartafwijking (Pregnancy in Women with Congenital Heart Disease; ZAHARA)-in predicting cardiac events among pregnant women with cardiac diseases.

METHODS

A retrospective review of medical records was conducted for all pregnant women with cardiac diseases who delivered at Songklanagarind Hospital between January 1, 2011, and December 31, 2022. Pregnancies ending in termination or miscarriage before 24 weeks were excluded. The mWHO, CARPREG II, and ZAHARA classifications were applied to each patient, with ZAHARA used only for congenital cardiac diseases. The discriminative ability of each model was evaluated using the area under the receiver operating characteristic curve (AUC).

RESULTS

Among 333 pregnancies with cardiac diseases (163 congenital and 170 acquired), 100 (30.0%) experienced cardiac events. The AUCs for predicting cardiac events in all cases were 0.774 (95% confidence interval [CI] 0.719-0.826) for CARPREG II and 0.744 (95% CI 0.689-0.799) for mWHO. In acquired cardiac disease, the AUC for mWHO (0.700 [95% CI 0.621-0.779]) was higher than that for CARPREG II (0.677 [95% CI 0.596-0.758]). For congenital cardiac disease, CARPREG II exhibited the best predictive performance, followed by mWHO and ZAHARA, with AUC values of 0.768 (95% CI 0.658-0.877), 0.754 (95% CI 0.653-0.854), and 0.685 (95% CI 0.563-0.806), respectively.

CONCLUSION

CARPREG II demonstrated the highest predictive performance for cardiac events in pregnant women with all cardiac diseases, while ZAHARA exhibited the lowest predictive performance for congenital cardiac diseases.

Maternal demography, clinical characteristics, & outcomes at an obstetric intensive care unit of a tertiary-care teaching maternity hospital in the Kashmir Valley

Background & objectives Obstetric patients often need admission to intensive care units (ICUs). The data on these patients are scarce and heterogeneous. We studied the profile of obstetric patients admitted to our ICU. Methods The records of obstetric patients admitted to the ICU at the Government Lalla Ded Hospital, Srinagar, Jammu and Kashmir, India, dedicated to obstetrics and gynaecology patients, were analysed retrospectively from March 2022 to February 2023.This included demography, co-morbidities, pre-admission surgeries/procedures, clinical characteristics, and outcomes (death/discharge/transfer). Results Out of 525 obstetric ICU patients, the majority were admitted for obstetric causes (94.66%) and after surgery (84.38%), mostly (66.59%) after caesarean section (CS). Hypertension (35.23%) and anaemia (32.76%) were the most common co-morbidities. The majority were admitted for hypertensive disorders of pregnancy (HDP; 34.47%) or post-partum haemorrhage (PPH; 24.71%) or complications. Only two per cent of CS and one per cent of vaginal delivery (VD) patients needed ICU admission. The maternal ICU mortality rate was 6.53 per cent (0.15% of total deliveries). Only 6.66 per cent needed transfer to non-obstetric or multi-specialty care. Admission with heart disease [Hazard ratio; HR=8.26, 95% Confidence interval (CI)=0.01-67.17,P<0.05], after intra-uterine foetal death (IUFD; HR=5.17, 95% CI=1-26.75, P<0.05), or after laparotomy for ectopic pregnancy (EP; HR=50.2, CI=1.43-1766.87, P<0.05) and need for invasive mechanical ventilation (IMV; HR=35.5, CI=3.14-401.75, P<0.05) or inotropic support (IS; HR=12.06, CI=1.96-74.19, P<0.05) increased while admission after VD (HR=0.10, CI=0.01-0.73, P<0.05) decreased mortality risk. Interpretation & conclusions HDP and PPH were the most common maternal presentations in obstetric ICUs. Maternal mortality was low. Patients with heart diseases, IMV/IS requirement, and those admitted after IUFD or laparotomy for EP had increased, while patients admitted after VD had decreased mortality risk in the ICU.

Hypertensive disorders of pregnancy among women with cardiovascular disease in Norway: A historical cohort study

INTRODUCTION

Women with cardiovascular disease may be at increased risk of hypertensive disorders of pregnancy (HDP). We aimed to: (1) Investigate the occurrence of HDP in a cohort of pregnant women with cardiovascular disease and compare it with the occurrence in the general population. (2) Assess the association between maternal cardiovascular risk and risk of HDP.

MATERIAL AND METHODS

We reviewed clinical data on a cohort of 901 pregnancies among 708 women with cardiovascular disease who were followed at the National Unit for Pregnancy and Heart Disease and gave birth at Oslo University Hospital between 2003 and 2018. The exposure under study was maternal cardiovascular risk, classified as low, moderate, or high based on a modified classification by the World Health Organization. The main outcome of interest was HDP, which included pre-eclampsia and gestational hypertension. The proportion of HDP cases in the general population in the same period was extracted from the Medical Birth Registry of Norway. We used logistic regression to estimate crude and adjusted odds ratios (OR) of HDP, with associated 95% confidence intervals (CIs), for women with moderate- and high cardiovascular risk compared to women with low risk.

RESULTS

The occurrence of HDP in the study cohort was 12.1% (95% CI: 10.0%-14.4%) and varied between 8.7% (95% CI: 6.5%-11.3%) in the low-risk group, 15.7% (95% CI: 11.1%-21.4%) in the moderate-risk group, and 22.2% (95% CI: 15.1%-30.8%) in the high-risk group. By contrast, the nationwide occurrence of HDP was 5.1% (95% CI: 5.1%-5.2%). In the study cohort, the proportions of pregnancies with gestational hypertension and pre-eclampsia were similar (6.3% and 5.8%, respectively). Compared to pregnancies with low cardiovascular risk, the adjusted OR of HDP was 2.04 (95% CI: 1.21-3.44) in the moderate-risk group and 2.99 (95% CI: 1.73-5.18) in the high-risk group.

CONCLUSIONS

The occurrence of hypertensive disease of pregnancy in the study cohort was more than doubled compared to the general population in Norway. The risk of HDP increased with maternal cardiovascular risk group. We recommend taking into account maternal cardiovascular risk group when assessing risk and prophylaxis of HDP.

Early suppression policies protected pregnant women from COVID-19 in 2020: A population-based surveillance from the Nordic countries

INTRODUCTION

The Coronavirus 2019 Disease (COVID-19) pandemic reached the Nordic countries in March 2020. Public health interventions to limit viral transmission varied across different countries both in timing and in magnitude. Interventions indicated by an Oxford Stringency Index ≥50 were implemented early (March 13-17, 2020) in Denmark, Finland, Norway and Iceland, and on March 26, 2020 in Sweden. The aim of the current study was to assess the incidence of COVID-19-related admissions of pregnant women in the Nordic countries in relation to the different national public health strategies during the first year of the pandemic.

MATERIAL AND METHODS

This is a meta-analysis of population-based cohort studies in the five Nordic countries with national or regional surveillance in the Nordic Obstetric Surveillance System (NOSS) collaboration: national data from Denmark, Finland, Iceland and Norway, and regional data covering 31% of births in Sweden. The source population consisted of women giving birth in the included areas March 1-December 31, 2020. Pregnant women with a positive SARS-CoV-2 PCR test ≤14 days before hospital admission were included, and admissions were stratified as either COVID-19-related or non-COVID (other obstetric healthcare). Information about public health policies was retrieved retrospectively.

RESULTS

In total, 392 382 maternities were considered. Of these, 600 women were diagnosed with SARS-CoV-2 infection and 137 (22.8%) were admitted for COVID-19 symptoms. The pooled incidence of COVID-19 admissions per 1000 maternities was 0.5 (95% confidence interval [CI] 0.2 to 1.2, I2 = 77.6, tau2 = 0.68, P = 0.0), ranging from no admissions in Iceland to 1.9 admissions in the Swedish regions. Interventions to restrict viral transmission were less stringent in Sweden than in the other Nordic countries.

CONCLUSIONS

There was a clear variation in pregnant women's risk of COVID-19 admission across countries with similar healthcare systems but different public health interventions to limit viral transmission. The meta-analysis indicates that early suppression policies protected pregnant women from severe COVID-19 disease prior to the availability of individual protection with vaccines.

Self-reported quality of life before, during, and after pregnancy in women with CHD

BACKGROUND

Adults with CHD are a growing patient group and childbirth is a relatively new phenomenon. EQ-5D is commonly used to measure health-related quality of life. We sought to investigate EQ-5D status before, during, and after pregnancy in women with CHD.

METHODS

We identified 128 pregnancies in 86 CHD women giving birth in Skåne County during 2009-2021. Repeated measures ANOVA was performed to test for differences between the five EQ-5D domains, EQ-VAS, and EQ-index over time points before, the second trimester, the third trimester, and after pregnancy.

RESULTS

Mean age at estimated childbirth was 30.3 (± 4.7) years; 56.25% of births were vaginal deliveries and 43.75% were Caesarean sections. The cohort consisted of patients with double outlet right ventricle (4.7%), transposition (Mustard/Senning 2.3%, arterial switch 4.7%), aortic anomalies (19.5%), Fallot's anomaly (16.4%), single ventricle (3.9%), shunt lesions (11.7%), cardiomyopathies (4.7%), coronary anomalies (1.6%), arrythmias (0.8%), and valve lesions: aortic (19.5%), mitral (5.5%), and pulmonary (4.7%). The women reported significantly worse mobility (p = 0.007) and higher pain/discomfort (p = 0.049) at trimester 3 compared to before pregnancy. The women had lower EQ-5D index during trimester 3 compared to after pregnancy (p = 0.004). We saw worse mobility during Tri 2 comparing multiparity with primiparity (p = 0.046). Looking at delivery mode, we noted significantly higher anxiety/depression before pregnancy (p =0.023) in women that had a Caesarean section.

CONCLUSIONS

In this study, women with CHD reported worse mobility and a higher pain level during Tri 3, although the overall health-related quality of life is acceptably high.

Pregnancy-related maternal deaths due to cardiovascular diseases in Japan from 2010 to 2019: an analysis of maternal death exploratory committee data

OBJECTIVE

Cardiovascular disease (CVD) is the leading cause of maternal deaths in high-income countries. This study aimed to assess the characteristics of maternal deaths due to CVDs and the quality of care provided to patients, and to identify elements to improve maternal care in Japan.

METHODS

This descriptive study used the maternal death registration data of the Maternal Deaths Exploratory Committee of Japan between 2010 and 2019.

RESULTS

Of 445 eligible pregnancy-related maternal deaths, 44 (9.9%) were attributed to CVD. The most frequent cause was aortic dissection (18 patients, 40.9%), followed by peripartum cardiomyopathy (8 patients, 18.2%), and pulmonary hypertension (5 patients, 11.4%). In 31.8% of cases, cardiopulmonary arrest occurred within 30 min after initial symptoms. Frequent symptoms included pain (27.3%) and respiratory symptoms (27.3%), with 61.4% having initial symptoms during the prenatal period. 63.6% of the patients had known risk factors, with age ≥35 years (38.6％), hypertensive disorder (15.9%), and obesity (15.9%) being the most common. Quality of care was assessed as suboptimal in 16 (36.4%) patients. Cardiac risk assessment was insufficient in three patients with preexisting cardiac disease, while 13 patients had symptoms and risk factors warranting intensive monitoring and evaluation.

CONCLUSION

Aortic dissection was the leading cause of maternal death due to CVDs. Obstetrics care providers need to be familiar with cardiac risk factors and clinical warning signs that may lead to impending fatal cardiac events. Timely risk assessment, patient awareness, and a multidisciplinary team approach are key to improving maternal care in Japan.

Timing and Preventability of Cardiovascular-Related Maternal Death

OBJECTIVE

To describe the clinical profile, management, and potential preventability of maternal cardiovascular deaths.

METHODS

We conducted a retrospective, descriptive study of all maternal deaths resulting from a cardiovascular disease during pregnancy or up to 1 year after the end of pregnancy in France from 2007 to 2015. Deaths were identified through the nationwide permanent enhanced maternal mortality surveillance system (ENCMM [Enquête Nationale Confidentielle sur les Morts Maternelles]). Women were classified into four groups based on the assessment of the national experts committee: those who died of a cardiac condition and those who died of a vascular condition and, within these two groups, whether the condition was known before the acute event. Maternal characteristics, clinical features and components of suboptimal care, and preventability factors, which were assessed with a standard evaluation form, were described among those four groups.

RESULTS

During the 9-year period, 103 women died of cardiac or vascular disease, which corresponds to a maternal mortality ratio from these conditions of 1.4 per 100,000 live births (95% CI 1.1-1.7). Analyses were conducted on 93 maternal deaths resulting from cardiac (n=70) and vascular (n=23) disease with available data from confidential inquiry. More than two thirds of these deaths occurred in women with no known pre-existing cardiac or vascular condition. Among the 70 deaths resulting from a cardiac condition, 60.7% were preventable, and the main preventability factor was a lack of multidisciplinary prepregnancy and prenatal care for women with a known cardiac disease. For those with no known pre-existing cardiac condition, preventability factors were related mostly to inadequate prehospital care of the acute event, in particular an underestimation of the severity and inadequate investigation of the dyspnea. Among the 23 women who died of a vascular disease, three had previously known conditions. For women with no previously known vascular condition, 47.4% of deaths were preventable, and preventability factors were related mostly to wrong or delayed diagnosis and management of acute intense chest or abdominal pain in a pregnant woman.

CONCLUSION

Most maternal deaths attributable to cardiac or vascular diseases were potentially preventable. The preventability factors varied according to the cardiac or vascular site and whether the condition was known before pregnancy. A more granular understanding of the cause and related risk factors for maternal mortality is crucial to identify relevant opportunities for improving care and training health care professionals.

Maternal beta-blocker dose and risk of small-for gestational-age in women with heart disease

INTRODUCTION

Beta-blockers are prescribed for many pregnant women with heart disease, but whether there is a dose-dependent effect on fetal growth remains to be examined. We aimed to investigate if antenatal beta-blocker use and dose were associated with delivering a small-for-gestational-age infant among women with heart disease.

MATERIAL AND METHODS

Our cohort included women with heart disease who delivered at Oslo University Hospital between 2006 and 2015. Maternal heart disease was classified into modified WHO risk scores. Women with beta-blocker treatment were dichotomized into whether they had been treated with a low or high dose based on clinical factors. We compared the risk of delivering a small-for-gestational-age infant in women exposed to high doses, low doses, or with no exposure to antenatal beta-blockers while adjusting for severity of maternal heart disease in logistic regression models.

RESULTS

Of a total of 540 pregnancies among women with heart disease, 163 (30.2%) were exposed to beta-blocker treatment. The majority were treated with metoprolol (86.5%). Almost twice as many babies in the beta-blocker group were small-for-gestational-age, compared with the non-exposed group (19.8 vs 9.5%, P < 0.001). Women using a high-dose beta-blocker had a five-fold increased risk of delivering a small-for-gestational-age infant compared with non-exposure (adjusted odds ratio [aOR] 4.89, 95% confidence interval [CI] 2.22-10.78, P < 0.001). Women using a low dose of beta-blocker had a two-fold increased risk of delivering a small-for-gestational-age infant; however, the confidence interval included the null (aOR 1.75, 95% CI 0.83-3.72, P = 0.143). Results when restricting the analyses to metoprolol showed the same pattern, but with attenuation of risks.

CONCLUSIONS

We found a five-fold increased risk of delivering a small-for-gestational-age infant in women with heart disease treated with a high dose of beta-blocker, and a two-fold increased risk among those treated with a low dose, showing an apparent dose-response relation. Close monitoring of fetal growth is warranted among women with heart disease treated with beta-blockers. As drug therapy in pregnancy concerns both mother and fetus, an optimum balance for both should be the goal.

Cardiac and obstetric outcomes in pregnant women with heart disease: appraisal of the 2018 mWHO classification

OBJECTIVE

To appraise the application of the 2018 European Society of Cardiology-adapted modified WHO (mWHO) classification to pregnant women with heart disease managed at our maternal-fetal medicine referral centre and to assess whether the lack of a multidisciplinary Pregnancy Heart team has influenced their outcomes.

METHODS

A retrospective cohort study including all pregnancies with heart disease managed at our centre between June 2011 and December 2020. Cardiac conditions were categorised in five classes according to the mWHO classification. An additional class, named X, was created for conditions not included in this classification. Outcomes were compared among all classes and factors potentially associated to cardiac complications were assessed.

RESULTS

We identified 162 women with 197 pregnancies, for a prevalence of 0.7%. Thirty-eight (19.3%) gestations were included in class X. Caesarean section was performed in 64.9% pregnancies in class X, a rate similar to that of class II, II-III, and III/IV, and mostly for obstetric indications; in turn, it was more commonly performed for cardiology reasons in class II-III and III/IV. Cardiac complications occurred in 10.7%, with class X and II pregnancies showing the highest number of events (n=30.8% and 34.6%, respectively). Multiple gestation and urgent caesarean section associated with a 5-fold and 6.5-fold increase in complication rates.

CONCLUSIONS

Even in a maternal-fetal medicine referral centre, the lack of a multidisciplinary team approach to women with heart disease may negatively impact their outcomes.

Reassuringly expensive - A commentary on obstetric emergency training in high-resource settings

The pathophysiologic origins of obstetrical emergencies are complicated and may well be influenced by events prior to conception. Such problems are not likely to be resolved soon, and in the meantime, high-resource countries simply cannot afford to divert more and more money to litigation and the costs of preventable morbidities for either mother or child. It is long past time we tackled these acute care problems where most first occur-the Maternity unit. It is reasonable to ask whether hospitals (and society at large) are getting what they believe they are buying. Training to satisfy a regulation without improving patient outcomes functionally erects one more barrier to the pursuit of optimal patient outcomes. Why then continue squandering limited resources and precious lives if current hospital training is not improving outcomes? In this monograph, I focus on training programs for the management of obstetrical emergencies.