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Poungsuntorn P, Suwanrath C, Chainarong N, Peeyananjarassri K, Cheewatanakornkul S, Duangpakdee P, Wongwaitaweewong K. Prediction of cardiac events in pregnant women with cardiac diseases using modified WHO, CARPREG II, and ZAHARA risk assessments in southern Thailand. Int J Gynaecol Obstet 2025. [PMID: 40318020 DOI: 10.1002/ijgo.70196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2025] [Revised: 04/14/2025] [Accepted: 04/22/2025] [Indexed: 05/07/2025]
Abstract
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.
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Affiliation(s)
- Panisa Poungsuntorn
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Chitkasaem Suwanrath
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Natthicha Chainarong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Krantarat Peeyananjarassri
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Sirichai Cheewatanakornkul
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Pongsanae Duangpakdee
- Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kanjarut Wongwaitaweewong
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Mir E, Khan SA, Fareed P, Ashraf H, Wani FJ. Maternal demography, clinical characteristics, & outcomes at an obstetric intensive care unit of a tertiary-care teaching maternity hospital in the Kashmir Valley. Indian J Med Res 2025; 161:278-286. [PMID: 40347505 PMCID: PMC12066136 DOI: 10.25259/ijmr_1081_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Accepted: 02/13/2025] [Indexed: 05/14/2025] Open
Abstract
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.
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Affiliation(s)
- Elias Mir
- Department of Chest Medicine, Sher-i-Kashmir Institute of Medical Sciences Medical College, Srinagar, India
| | - Shazia Ashraf Khan
- Department of Obstetrics and Gynaecology, Government Lalla Ded Hospital, Government Medical College, Srinagar, India
| | - Perveena Fareed
- Department of Obstetrics and Gynaecology, Government Lalla Ded Hospital, Government Medical College, Srinagar, India
| | - Huzaifa Ashraf
- Department of Obstetrics and Gynaecology, Government Lalla Ded Hospital, Government Medical College, Srinagar, India
| | - Fehim Jeelani Wani
- Faculty of Agriculture, Sher-e-Kashmir University of Agricultural Sciences and Technology - Kashmir, Srinagar, India
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Langen I, Langesæter E, Gunnes N, Almaas VM, Haugen G, Estensen M, Sørbye IK. Hypertensive disorders of pregnancy among women with cardiovascular disease in Norway: A historical cohort study. Acta Obstet Gynecol Scand 2024; 103:1457-1465. [PMID: 38597240 PMCID: PMC11168262 DOI: 10.1111/aogs.14841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/11/2024]
Abstract
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.
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Affiliation(s)
- Ingrid Langen
- Department of Obstetrics, Division of Obstetrics and GynecologyOslo University HospitalOsloNorway
- Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Eldrid Langesæter
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical CareOslo University HospitalOsloNorway
| | - Nina Gunnes
- Norwegian Research Center for Women's HealthOslo University HospitalOsloNorway
| | - Vibeke Marie Almaas
- Department of Cardiology, Division of Cardiovascular and Pulmonary DiseasesOslo University HospitalOsloNorway
| | - Guttorm Haugen
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Fetal Medicine, Division of Obstetrics and GynecologyOslo University HospitalOsloNorway
| | - Mette‐Elise Estensen
- Department of Cardiology, Division of Cardiovascular and Pulmonary DiseasesOslo University HospitalOsloNorway
| | - Ingvil Krarup Sørbye
- Department of Obstetrics, Division of Obstetrics and GynecologyOslo University HospitalOsloNorway
- Institute of Clinical MedicineUniversity of OsloOsloNorway
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Varpula R, Äyräs O, Aabakke AJM, Klungsøyr K, Svanvik T, Kanerva J, Jonasdottir E, Mentzoni CT, Thurn L, Jones E, Fredriksson L, Pettersson K, Nyfløt LT, Vangen S, Røe K, Júlíusson PB, Källén K, Gissler M, Pyykönen A, Jakobsson M, Krebs L, Engjom HM. Early suppression policies protected pregnant women from COVID-19 in 2020: A population-based surveillance from the Nordic countries. Acta Obstet Gynecol Scand 2024; 103:1063-1072. [PMID: 38382894 PMCID: PMC11103151 DOI: 10.1111/aogs.14808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/03/2024] [Accepted: 01/17/2024] [Indexed: 02/23/2024]
Abstract
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.
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Affiliation(s)
- Reetta Varpula
- Department of Obstetrics and Gynecology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Outi Äyräs
- Department of Obstetrics and Gynecology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Anna J M Aabakke
- Department of Obstetrics and Gynecology, Copenhagen University Hospital-Holbæk, Holbæk, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kari Klungsøyr
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department for Health Promotion, Norwegian Institute of Public Health, Bergen, Norway
| | - Teresia Svanvik
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Julia Kanerva
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Jonasdottir
- Department of Obstetrics and Gynecology, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Lars Thurn
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden
| | - Elin Jones
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Lisa Fredriksson
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Karin Pettersson
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Lill Trine Nyfløt
- Norwegian Research Center for Women's Health, Oslo University Hospital, Oslo, Norway
| | - Siri Vangen
- Norwegian Research Center for Women's Health, Oslo University Hospital, Oslo, Norway
| | - Kjerstine Røe
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
| | - Pétur B Júlíusson
- Department for Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway
| | - Karin Källén
- Department of Obstetrics and Gynecology, Institution of Clinical Sciences, Lund University, Lund, Sweden
| | - Mika Gissler
- Department of Knowledge Brokers, THL Finnish Institute of Health and Welfare, Helsinki, Finland
- Academic Primary Health Care Center, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | | | - Maija Jakobsson
- Department of Obstetrics and Gynecology, HUS Hyvinkää Hospital, Helsinki University, Helsinki, Finland
| | - Lone Krebs
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics and Gynecology, Copenhagen University Hospital-Amager and Hvidovre Hospital, Copenhagen, Denmark
| | - Hilde Marie Engjom
- Department for Health Promotion, Norwegian Institute of Public Health, Bergen, Norway
- Department for Health Registry Research and Development, Norwegian Institute of Public Health, Bergen, Norway
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Wedlund F, Hlebowicz J. Self-reported quality of life before, during, and after pregnancy in women with CHD. Cardiol Young 2024; 34:18-23. [PMID: 37132200 DOI: 10.1017/s104795112300080x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
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.
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Affiliation(s)
- Frida Wedlund
- Department of Cardiology, Skåne University Hospital, Lund University, Malmö, Sweden
- Clinical sciences, Lund University, Lund, Sweden
| | - Joanna Hlebowicz
- Clinical sciences, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
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Matsushita T, Arakaki T, Sekizawa A, Hasegawa J, Tanaka H, Katsuragi S, Nakata M, Murakoshi T, Ikeda T, Ishiwata I. Pregnancy-related maternal deaths due to cardiovascular diseases in Japan from 2010 to 2019: an analysis of maternal death exploratory committee data. J Matern Fetal Neonatal Med 2023; 36:2175207. [PMID: 36750232 DOI: 10.1080/14767058.2023.2175207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
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.
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Affiliation(s)
- Tomomi Matsushita
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Tatsuya Arakaki
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Junichi Hasegawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Shinji Katsuragi
- Department of Obstetrics and Gynecology, University of Miyazaki, Miyazaki, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University, Tokyo, Japan
| | - Takeshi Murakoshi
- Obstetrics and Gynecology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Isamu Ishiwata
- Ishiwata Obstetrics and Gynecology Hospital, Ibaraki, Japan
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Diguisto C, Choinier PM, Saucedo M, Bruyere M, Verspyck E, Morau E, Bonnet MP, Deneux-Tharaux C. Timing and Preventability of Cardiovascular-Related Maternal Death. Obstet Gynecol 2023:00006250-990000000-00754. [PMID: 37141627 DOI: 10.1097/aog.0000000000005176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 03/02/2023] [Indexed: 05/06/2023]
Abstract
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.
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Affiliation(s)
- Caroline Diguisto
- Université Paris Cité, Centre for Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Paediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, Pôle de Gynécologie Obstétrique, Médecine Fœtale, Médecine et Biologie de la Reproduction, Centre Olympe de Gouges, CHRU de Tours, and Université de Tours, Tours, Department of Anesthesiology and Critical Care Medicine, Beaujon Hospital, AP-HP, Paris University, Paris, Service d'Anesthésie Réanimation Médecine Périopératoire, Hôpital Bicêtre, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, Departments of Obstetrics and Gynecology, University Hospital of Rouen, Rouen, Département d'Anesthésie Réanimation, Hôpital Universitaire Carémeau, Nîmes, and Sorbonne University, Department of Anaesthesiology and Critical Care Medicine, Armand Trousseau Hospital, DMU DREAM, GRC 29, AP-HP, Paris, France
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Sørbye IK, Haualand R, Wiull H, Letting AS, Langesaeter E, Estensen ME. Maternal beta-blocker dose and risk of small-for gestational-age in women with heart disease. Acta Obstet Gynecol Scand 2022; 101:794-802. [PMID: 35467752 DOI: 10.1111/aogs.14363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Anne-Sofie Letting
- Department of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
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Affiliation(s)
- Janet I Ma
- Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Doreen DeFaria Yeh
- Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ada C Stefanescu Schmidt
- Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ornaghi S, Bellante N, Abbamondi A, Maini M, Cesana F, Trabucchi M, Corsi D, Arosio V, Mariani S, Scian A, Colciago E, Lettino M, Vergani P. Cardiac and obstetric outcomes in pregnant women with heart disease: appraisal of the 2018 mWHO classification. Open Heart 2022; 9:openhrt-2021-001947. [PMID: 35332050 PMCID: PMC8948382 DOI: 10.1136/openhrt-2021-001947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/07/2022] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Sara Ornaghi
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy .,Department of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy
| | - Nicolo' Bellante
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy
| | - Alessandra Abbamondi
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy
| | - Marzia Maini
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy
| | | | | | - Davide Corsi
- Department of Cardiology, San Gerardo Hospital, Monza, Italy
| | - Viola Arosio
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy
| | - Silvana Mariani
- Department of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy
| | - Antonietta Scian
- Department of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy
| | | | | | - Patrizia Vergani
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Obstetrics, MBBM Foundation Onlus at San Gerardo Hospital, Monza, Italy
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Reassuringly expensive - A commentary on obstetric emergency training in high-resource settings. Best Pract Res Clin Obstet Gynaecol 2021; 80:14-24. [PMID: 34893439 DOI: 10.1016/j.bpobgyn.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 11/05/2021] [Accepted: 11/15/2021] [Indexed: 11/22/2022]
Abstract
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.
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