Pregnancy in congenital heart disease: risk prediction and counselling

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.

Unveiling women's lived experiences with care provided by a pregnancy heart team: A qualitative phenomenological study

OBJECTIVE

The purpose of this study was to gain an in-depth understanding of the lived experiences of women with CVD regarding their care by a pregnancy heart team (PHT) during pregnancy and the immediate postpartum period.

METHODS

Using a qualitative phenomenological study, data were collected through semi-structured interviews with 13 women receiving follow-up care from a PHT at a large tertiary center. Data were collected between December 2022 and September 2023, and thematic content analysis was conducted.

RESULTS

The lived experiences of women with CVD were reflected in the PHT by two main themes: "emotional distress" and "(dis-)organization of care." The "emotional distress" theme had sub-themes of "awareness and impact of CVD on pregnancy," "loneliness," and "need for psychological support." The theme of "(dis)organization of care" was expressed through the sub-themes of "(dis-)continuity of care" and "(expected) skills of healthcare providers."

CONCLUSION

The current study findings highlight the impact of CVD on pregnancy and the emotional challenges faced by women with CVD during the course of their pregnancy. Improvements in accessibility, timeliness, reciprocity and shared decision-making, and psychological support could contribute to more patient-centered care.

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.

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 care experiences for adults with congenital heart disease in the United States

BACKGROUND

Research to reduce maternal morbidity due to cardiovascular disease is vitally important in the United States, especially for the growing number of individuals with congenital heart disease (CHD) reaching childbearing age. Understanding patient experiences through patient engagement is critical to designing research that is aligned with the needs of adults with CHD undergoing pregnancy.

METHODS

This patient engagement project, grounded in human centered design, focuses on the discovering patient and healthcare provider priorities for reducing maternal morbidity in CHD through patient centered outcomes research (PCOR). In this first stage, a capacity building consortium of over 90 key partners, including patients, advocates, healthcare providers, and researchers, was assembled. Baseline education on patient engagement, PCOR, and survey instrument design was delivered virtually. Two questionnaires were designed to elicit tacit knowledge - 1 for patients and 1 for providers - regarding gaps and needs across 4 key pillars: access to clinical care, patient and provider education, mental health, and research opportunities. The pillars were determined through thematic summaries from consortium discussions.

RESULTS

The patient questionnaire received 828 responses (age range: 18-60 years) from 48 U.S. states. The provider questionnaire garnered 218 responses from professionals. Several common themes for areas of research were observed across all pillars including improved access to specialized cardio-obstetric care and improved education about the need for specialized care. Healthcare providers cited insufficient care coordination models and resources as a major barrier to providing effective clinical care. Both patients and providers expressed a need for improved access to mental health care. While only 28% of patient respondents who underwent a pregnancy reported a pre-existing mental health diagnosis, nearly 2/3 reported having significant anxiety symptoms related to their pregnancy. Of those with significant symptoms, 44% were unable to access mental health services. Additionally, only 55% of healthcare providers reported referral for assessment and treatment if mental health concerns arose during or after pregnancy.

CONCLUSION

The results provide valuable insights into the unique challenges faced by patients with CHD and their providers during pregnancy. By addressing the identified gaps through PCOR, we can work towards a goal to improve maternal care for women with CHD.

Contemporary Burden of Cardiovascular Disease in Pregnancy: Insights from a Real-World Pregnancy Electronic Health Record Cohort

Importance

Cardiovascular disease (CVD) is the leading cause of maternal morbidity and mortality, however the contemporary burden and secular trends in pregnancy-related CV complications are not well characterized.

Objective

We sought to examine contemporary trends in prevalence of maternal cardiometabolic comorbidities and established CVD, as well as future pregnancy-related CV complications across a large multi-institutional health system.

Design

Retrospective analysis of longitudinal electronic health record (EHR)-based cohort of pregnancies.

Setting

Multi-institutional healthcare network in New England.

Participants

Pregnancy encounters between 2001 to 2019 identified using diagnosis and procedure codes followed by manual adjudication within a previously validated primary care EHR cohort. Estimated gestational ages recovered from unstructured notes using regular expressions (RegEx) were used to define individual pregnancy episodes.

Main Outcomes and Measures

We quantified the prevalence of maternal cardiometabolic comorbidities and established CVD at time of pregnancy, as well as the incidence of pregnancy-related CV complications assessed within 1 year postpartum. We examined trends in cardiometabolic risk factors and CVD burden over nearly two decades.

Results

Our EHR pregnancy cohort comprised 57,683 pregnancies among 38,997 individuals (mean age range at start of pregnancy 27 to 37 years). RegEx recovered gestational age for 74% of pregnancies, with good correlation between gestational age ascertained via RegEx vs manual review (Pearson r 0.9). Overall prevalence of maternal CVD was 4% (age-adjusted 7%) and increased over 19 years of follow-up (age-adjusted prevalence of maternal CVD: 1% in 2001 to 7% in 2019, p <0.001). The incidence of pregnancy-related CV complications was 15% (age-adjusted 17%) and also increased over the follow-up period (age-adjusted incidence 11% in 2001 to 14% in 2019, p <0.001). Finally, CV complications were more likely to occur in individuals with greater burden of maternal CV comorbidities and CVD (diabetes: 6% vs 3%, hypertension: 23% vs 5%, pre-existing CVD: 10% vs 3%, P<0.001 for all).

Conclusions and Relevance

Analysis of a large-scale EHR-based pregnancy cohort spanning two decades demonstrates rising prevalence of both maternal cardiometabolic comorbidities and CVD at the time of pregnancy, as well as increasing incidence of subsequent pregnancy-related CV complications. Pregnancy represents a critical opportunity for cardiometabolic health optimization.

KEY POINTS

Question: What are the contemporary real-world trends in the prevalence of maternal cardiovascular comorbidities and cardiovascular disease and incidence of cardiovascular complications in pregnancy?Findings: In an analysis of 57,683 pregnancies among 38,997 individuals from a large scale EHR-based pregnancy cohort, prevalence of maternal cardiometabolic comorbidities and cardiovascular disease and incidence of pregnancy-related cardiovascular complications increased over the course of nearly two decades.Meaning: The contemporary burden of pregnancy-related cardiovascular complications is rising at an alarming rate and highlights pregnancy as a critical opportunity for cardiovascular health optimization.

Pregnancy & cardiovascular disease: the PREG-CVD-HH registry

Background

Cardiovascular disease (CVD) remains the leading cause of death in pregnant and peripartal women in western countries. Physiological changes during pregnancy can lead to cardiovascular complications in the mother; women with pre-existing heart disease may not tolerate these changes well, increasing their susceptibility to adverse cardiovascular outcomes during pregnancy. The aim of this study is to characterize pregnancy-induced changes in cardiac function, biomarker concentrations and cardiovascular outcomes in women with CVD during pregnancy at a tertiary care hospital in Germany.

Methods

The PREG-CVD-HH study is a prospective single-center observational study of pregnant women with prevalent CVD treated at the University Medical Center Hamburg, Germany and currently includes 63 women with congenital or acquired heart disease and ten women from the general population included as controls. Participants underwent baseline assessment and dedicated comprehensive echocardiography. Biomarkers N-terminal pro B-type natriuretic peptide (NT-proBNP), MR-proadrenomedullin (MRproADM) and high-sensitivity cardiac troponin I (hs-cTnI) were measured serially throughout pregnancy and until 6 and 12 months postpartum. A maternal cardiac event was defined as death due to cardiovascular cause, arrhythmia, heart failure or hospitalization for other cardiac intervention.

Results

Mean maternal age was 34 years. A majority had a congenital heart disease (N=41), 10 patients developed pregnancy-associated CVD (e.g., preeclampsia, peripartum cardiomyopathy) and 12 women had known acquired heart disease (e.g., valvular disease, arrhythmia, cardiomyopathy). New-onset heart failure was observed in 14.1% of patients (N=9). Five patients developed arrhythmia and three patients developed preeclampsia. About 21.2% of patients were hospitalized due to cardiovascular events. Death from any or cardiovascular cause did not occur over the study period. Left and right ventricular global longitudinal strain (LV GLS, RV GLS) showed a transient worsening in the third trimester and peripartum period. NT-proBNP ranges broadened during the pregnancy and tended to progressively decrease postpartum in women with CVD. Hs-cTnI levels tended to trend upwards during pregnancy in patients with CVD, however, the hs-cTnI levels remained consistently low throughout pregnancy.

Conclusions

In our cohort, pregnancy was associated with a transient increase in cardiac biomarkers and worsening of cardiac function during the third trimester and peripartum. These temporal changes reversed at 6-12 months postpartum, potentially due to decreased cardiac load, fluid shifts and hormonal changes. Overall, data on reference ranges in echocardiographic and biomarker measurements in the pregnant cardiac population are limited and require further investigation. Albeit one third of our cohort was deemed at high and highest maternal risk during pregnancy, there was no maternal death. We recommend that women with CVD receive preconceptional counselling and ongoing management by a specialized "Pregnancy Heart Team" to optimize care and, potentially, maternal outcomes.

Exploring the Lived Experiences of Young Women With Congenital Heart Disease Through Adolescence: A Qualitative Feminist Study Using Focus Groups

OBJECTIVES

The overarching aim of this study is to explore, examine and identify the experience that young women with congenital heart disease face as they transition through adolescence into womanhood.

DESIGN

This is an empirical qualitative study conducted in the form of three focus groups. The study design and analysis adopted a feminist ontological positioning to elucidate the voice of women and offer an alternative perspective of cardiology health care. Data were analysed using the inductive thematic approach informed by the study aims.

PARTICIPANTS

A group of seven female participants (mean age 26) based in the United Kingdom, each with varying degrees of congenital heart defects that required open heart surgery growing up, was included in the study.

RESULTS

Three key themes with antecedent concepts emerged: (a) the impact of womanhood and the potential influence of motherhood on the young women themselves transitioning through adolescence with CHD within medical and sociocultural contexts, (b) the challenges of being a woman and undergoing heart surgery during adolescence on the young women's health before, during and after surgery and (c) the effect of existing online/offline healthcare and social structures on women's health during transitioning through adolescence These themes were encompassed under an overarching theme of psychological complexities developed throughout the cardiac journey from diagnosis through to post-surgery.

CONCLUSION

This study built on the limited exploration of being a young woman and having CHD and confirmed that there are vulnerabilities and challenges in having CHD as a young woman transitioning through adolescence. This was a result of sex (biological characteristics) and gender factors (socially constructed roles). This leads to short- and long-term implications on psychological well-being. This research indicates that enhancements are needed in the provision of care and psychological support for young women with CHD. This will help to enable women to achieve a good quality of life in addition to increased life expectancy offered by medical advancements.

PATIENT OR PUBLIC CONTRIBUTION

Active participant involvement was crucial to ensure the authentic female voice in the study. This study received support from young women with congenital heart disease. Young women contributed to the study design, recruitment of participants and analysis of results. Two of the women were also co-authors of this paper.

Maternal and Perinatal Outcomes in Pregnant Women with Heart Disease: A Case-Control Study

Objective: We analyzed the obstetric and cardiac characteristics and results of pregnant women with heart disease (HD) and compared their results with those of healthy controls. Methods: In this retrospective single-center case-control study, women with HD attended between 2010 and 2018 were matched at a 1:2 ratio (according to date of delivery, parity, and singleton or twin pregnancy) with controls without heart disease treated in the same referral center. Results: We identified 141 pregnant women with HD, of whom 132 reached 22 weeks of gestation and were paired with 264 healthy controls, for a total of 396 participants and 408 newborns. Most common HDs were congenital HD (53 women), arrhythmia (46), valvular HD (35), and cardiomyopathy (16), having women with more than one coexisting HD. During pregnancy or the puerperium, 19.9% of mothers experienced a major adverse cardiac event (MACE), with 5% requiring intensive care unit (ICU) admission. The rates of cesarean section were 37.1% in the case group and 18.2% in the control group, with an odds ratio (OR) of 2.66 (95% CI = 1.66-4.26, p < 0.001). We also found a higher use of general anesthesia, with an OR of 10.73 (95% CI = 2.32-49.75, p = 0.002); more prolonged hospitalizations, with an OR of 2.91 (95% CI 1.02-8.35, p = 0.023); and a higher incidence of low neonatal weight, with an OR of 1.96 (95% CI 1.09-3.52, p = 0.012). There were no differences between groups in terms of gestational age at delivery; however, we observed greater prematurity in women with HD, without reaching statistical significance. The rate of congenital heart disease among the newborns of mothers with HD was 13.2%. Conclusions: HD increases maternal morbidity during pregnancy and it is associated with higher rates of cesarean section and low birth weight.

Pregnancy in patients with the Fontan operation

Improved survival rates for patients with a Fontan circulation has allowed more women with this complex cardiac physiology to contemplate pregnancy. However, pregnancy in women with a Fontan circulation is associated with a high risk of adverse maternal and foetal outcomes, high rates of miscarriage, and preterm delivery. Factors associated with a successful pregnancy outcome are younger age, normal body weight, absence of significant functional limitation, no Fontan-related complications, and well-functioning single ventricle physiology. Appropriate care with timely preconception counselling and regular, frequent clinical reviews by a multidisciplinary team based at a tertiary centre improves the chance of a successful pregnancy. Empowerment of patients with education on their specific congenital cardiac condition and its projected trajectory helps them make informed choices regarding their health, reproductive choices, and assists them to achieve their life goals.

Sex-Related Differences and Influence of Pregnancy in Transposition of Great Arteries With Systemic Right Ventricle

Background

There is a paucity of data regarding sex-related differences on cardiac outcomes in the context of transposition of the great arteries (TGA) with a systemic right ventricle and biventricular physiology (sRV-biV). Moreover, the long-term impact of pregnancy on cardiac outcomes remains unknown.

Objectives

The purpose of this study was to identify sex-related differences and the influence of pregnancy on cardiac outcomes in TGA sRV-biV population.

Methods

A retrospective cohort study was conducted on 213 adults with TGA sRV-biV, 82 (38.4%) women, age 42.6 ± 12.8 years, with a median follow-up of 16 years. Cardiac events, interventions, last follow-up sRV-biV dysfunction, and heart failure (HF) medications were compared between men vs women, and women with vs without pregnancies resulting in live births.

Results

Women had a lower incidence of nonsustained ventricular tachycardia (HR: 1.80; 95% CI: 1.04-3.09, P = 0.035) and nonsignificantly fewer HF-related hospitalizations than men (HR: 2.10; 95% CI: 0.95-4.67, P = 0.069) in univariable analysis. At the last follow-up, women had a lower prevalence of moderate to severe sRV-biV dysfunction than men (P < 0.001) and were less frequently prescribed HF therapy. Women had fewer implantable cardioverter-defibrillators for primary prevention than men (P = 0.016), with no difference for secondary prevention. Women who had pregnancies resulting in live births (N = 47), had a high prevalence of cardiac events in the 15 (IQR: 9-28) years following pregnancy with no significant differences with those without (N = 32) pregnancies.

Conclusions

Women with a sRV-biV have fewer adverse cardiovascular events than men. Due to sRV-biV, pregnancy remains with high maternal risk but is not associated with worse long-term cardiac outcomes under rigorous multidisciplinary cardio-obstetrical care.

The Impact of Social Determinants of Health on Transition From Pediatric to Adult Cardiology Care

Social determinants of health (SDoH) are the economic, social, environmental, and psychosocial factors that influence health. Adolescents and young adults with congenital heart disease (CHD) require lifelong cardiology follow-up and therefore coordinated transition from pediatric to adult healthcare systems. However, gaps in care are common during transition, and they are driven in part by pervasive disparities in SDoH, including race, ethnicity, socioeconomic status, access to insurance, and remote location of residence. These disparities often coexist and compound the challenges faced by patients and families. For example, Black and Indigenous individuals are more likely to be subject to systemic racism and implicit bias within healthcare and other settings, to be unemployed and poor, to have limited access to insurance, and to have a lower likelihood of transfer of care to adult CHD specialists. SDoH also are associated with acquired cardiovascular disease, a comorbidity that adults with CHD face. This review summarizes existing evidence regarding the impact of SDoH on the transition to adult care and proposes strategies at the individual, institutional, and population and/or system levels. to reduce inequities faced by transition-age youth. These strategies include routinely screening for SDoH in clinical settings with referral to appropriate services, providing formal transition education for all transition-age youth, including training on navigating complex medical systems, creating satellite cardiology clinics to facilitate access to care for those who live remote from tertiary centres, advocating for lifelong insurance coverage where applicable, mandating cultural-sensitivity training for providers, and increasing the diversity of healthcare providers in pediatric and adult CHD care.

Time to childbirth and assisted reproductive treatment in women with congenital heart disease

OBJECTIVE

To investigate the time to first childbirth and to compare the prevalence of assisted reproductive treatment (ART) in women with congenital heart disease (CHD) compared with women without CHD.

METHODS

All women in the national register for CHD who had a registered first childbirth in the Swedish Pregnancy Register between 2014 and 2019 were identified. These individuals (cases) were matched by birth year and municipality to women without CHD (controls) in a 1:5 ratio. The time from the 18th birthday to the first childbirth and the prevalence of ART was compared between cases and controls.

RESULTS

830 first childbirths in cases were identified and compared with 4137 controls. Cases were slightly older at the time for first childbirth (28.9 vs 28.5 years, p=0.04) and ART was more common (6.1% vs 4.0%, p<0.01) compared with controls. There were no differences in ART when stratifying for the complexity of CHD. For all women, higher age was associated with ART treatment (OR 1.24, 95% CI 1.20 to 1.28).

CONCLUSIONS

Women with and without CHD who gave birth to a first child did so at similar ages. ART was more common in women with CHD, but disease severity did not influence the need for ART. Age was an important risk factor for ART also in women with CHD and should be considered in consultations with these patients.

Navigating the path of TOF- A Literature review unveiling maternal-fetal dynamics, treatment strategies and psychological dimensions

Tetralogy of Fallot (TOF) is a complex congenital heart defect that poses unique challenges for both mothers and their unborn children. This comprehensive review, aims to provide a holistic exploration of the maternal-fetal dynamics, treatment strategies, and psychological dimensions involved in navigating the path of TOF during pregnancy. It delves into the physiological changes that occur during pregnancy in TOF patients, including pulmonary regurgitation, right ventricular hypertrophy, and the overriding aorta. By understanding these dynamics, healthcare professionals can tailor treatment strategies to optimize maternal and fetal outcomes. The review further investigates the treatment strategies employed in managing TOF during pregnancy, encompassing medical interventions, cardiac monitoring, and multidisciplinary care. It explores the role of advanced imaging techniques, such as echocardiography and cardiac magnetic resonance imaging, in assessing TOF severity and guiding treatment decisions. The psychological factors influencing maternal adaptation, coping strategies, and the long-term implications on the child's psychological development are also examined. The integration of multidisciplinary approaches, including cardiac care, psychosocial support, and mental health interventions, can orchestrate a harmonious symphony of maternal-fetal well-being in the challenging journey of TOF pregnancies. Future research endeavours should continue to explore these dimensions, further refining treatment strategies and enhancing the understanding of TOF pregnancies for improved outcomes.

Twin pregnancy with sudden heart failure and pulmonary hypertension after atrial septal defect repair: A case report

BACKGROUND

Pulmonary arterial hypertension (PAH) in pregnancy is one of the major obstetric complications and is considered a contraindication to pregnancy as it is classified as a class IV risk in the revised risk classification of pregnancy by the World Health Organisation. Pregnancy, with its adaptive and expectant mechanical and hormonal changes, negatively affects the cardiopulmonary circulation in pregnant women. Do patients with repaired simple congenital heart disease (CHD) develop other pulmonary and cardiac complications during pregnancy? Can pregnant women with sudden pulmonary hypertension be treated and managed in time? In this paper, we present a case of a 39-year-old woman who underwent cesarean section at 33 wk' gestation and developed PAH secondary to repaired simple CHD. Our research began by a PubMed search for "pulmonary hypertension" and "pregnancy" and "CHD" case reports. Three cases were selected to review PAH in pregnancy after correction of CHD defects. These studies were reviewed, coupled with our own clinical experience.

CASE SUMMARY

Herein, a case involving a woman who underwent atrial septal defect repair at the age of 34, became pregnant five years later, and had a sudden onset of PAH and right heart failure secondary to symptoms of acute peripheral edema in the third trimester of her pregnancy. As a result, the patient underwent a cesarean section and gave birth to healthy twins. Within three days after cesarean delivery, her cardiac function deteriorated as the pulmonary artery pressure increased. Effective postpartum management, including diuresis, significant oxygen uptake, vasodilators, capacity and anticoagulants management, led to improvements in cardiac function and oxygenation. The patient was discharged from hospital with a stable recovery and transferred to local hospitals for further PAH treatment.

CONCLUSION

This case served as a reminder to obstetricians of the importance of pregnancy after repair of CHD. It is crucial for patients with CHD to receive early correction. It suggests doctors should not ignore edema of twin pregnancy. Also, it provides a reference for the further standardization of antenatal, intrapartum and postpartum management for patients with CHD worldwide.

Care for the Obstetric Patient with Complex Cardiac Disease

The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.

Clinical outcomes of pulmonary hypertension in pregnancy among women with congenital heart disease in China

OBJECTIVE

Pulmonary arterial hypertension (PAH) increases the risk for perinatal women and newborns, especially in women with congenital heart disease (CHD). We explored the maternal, perinatal, and postneonatal outcomes of PAH in pregnant women with CHD in China.

METHODS

A total of 95 pregnant women with CHD-PAH in Beijing Anzhen Hospital from 2009 to 2013 were included retrospectively. We described their characteristics and examined the associations between the grade of PAH and maternal, perinatal, and postneonatal outcomes.

RESULTS

The New York Heart Association (NYHA) classification grade, delivery mode, and infant outcomes in CHD-PAH patients were analyzed. Overall 95 patients with CHD-PAH, there were 17 patients in mild group(17.7%), 27 patients in moderate group (28.1%), and 51 patients in severe group (53.1%)。The CHD patients with mild PAH, were mostly NYHA class I-II and CHD patients with severe PAH were NYHA class II-IVs. Cesarean section (67.7%) was the most common method of delivery. The rate of therapeutic abortion in the severe group (76.9%) was obviously higher than that in other groups (11.5% in mild group and moderate group respectively), whereas there was no term delivery in severe group, with 2 cases in mild group and moderated group respectively . The rates of heart failure and therapeutic abortion in pregnant women were positively associated with the severity of PAH. The rate of term delivery was higher in patients whose CHD had been corrected by cardiac surgery (83.3%) before pregnancy.

CONCLUSION

Patients with severe PAH have poor cardiac adaptability, poor maternal and fetal outcomes, and are contraindicated during pregnancy. Patients with mild PAH are not absolutely contraindicated during pregnancy, but their heart burden increases significantly in the third trimester. Patients in mid-gestation should preferentially be delivered by cesarean section. When pregnant patients prefer to continue pregnancy, their close monitoring is essential. We provide useful data for guiding management of pregnancy and delivery in patients with CHD in China.

Pregnancy following personalised aortic root support in Marfan syndrome

Marfan syndrome (MFS) is linked with adverse pregnancy events, one of the most significant being aortic dissection. We present a case of a woman with MFS with prior aortic root dilatation who opted for a Personalised External Aortic Root Support (PEARS). To date, she is only the fifth woman to have had this valve-sparing procedure prior to pregnancy. We outline her care in a tertiary centre with multidisciplinary expertise, from preconception through to the postpartum period.

Outcomes of pregnancy in women with different types of pulmonary hypertension

BACKGROUND

Pulmonary hypertension (PH) is considered to increase maternal and fetal risk, and we attempt to explore pregnancy outcomes in women with different types of PH.

METHODS

We retrospectively analyzed the clinical data of pregnant women with PH who were admitted to Anzhen Hospital from January 2010 to December 2019, and followed up on these parturients and their offspring.

RESULTS

Three hundred and sixty-six pregnant women with PH were collected, including 265 pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD), 65 PH caused by left heart disease, 12 idiopathic PH, and 24 PH associated with other diseases. Maternal mean age was 28.4 ± 4.4 years and 72.1% were nulliparous. The estimated systolic pulmonary artery pressure was < 50 mmHg in 40.2% of patients, 50-70 mmHg in 23.2%, and > 70 mmHg in 36.6%. In more than 94% of women, a diagnosis of PH was made before pregnancy. During pregnancy, heart failure occurred in 15% of patients. Cesarean section was performed in 90.5% (20.4% emergency). Complications included fetal mortality (0.5%), preterm delivery (40.4%), and low birth weight (37.7%). A total of 20 mothers died (5.5%). The highest mortality rate was found in patients with idiopathic PH (4/12, 33.3%). A total of 12 children died (3.3%), 5 (1.4%) of them after discharge from the hospital, and 7 (1.9%) were in hospital.

CONCLUSIONS

Although most of these women are fertile, PH does increase maternal and fetal risk. Women with idiopathic PH and Eisenmenger syndrome are not recommended to have children.

Pregnancy in women with congenital heart disease: a focus on management and preventing the risk of complications

INTRODUCTION

Congenital heart disease (CHD) is the most common cardiac disorder in pregnancy in the western world (around 80%). Due to improvements in surgical interventions more women with CHD are surviving to adulthood and choosing to become pregnant.

AREAS COVERED

Preconception counseling, antenatal management of CHDs and strategies to prevent maternal and fetal complications.Preconception counseling should start early, before the transition to adult care and be offered to both men and women. It should include the choice of contraception, lifestyle modifications, pre-pregnancy optimization of cardiac state, the chance of the child inheriting a similar cardiac lesion, the risks to the mother, and long-term prognosis. Pregnancy induces marked physiological changes in the cardiovascular system that may precipitate cardiac complications. Risk stratification is based on the underlying cardiac disease and data from studies including CARPREG, ZAHARA, and ROPAC.

EXPERT OPINION

Women with left to right shunts, regurgitant lesions, and most corrected CHDs are at lower risk and can be managed in secondary care. Complex CHD, including systemic right ventricle need expert counseling in a tertiary center. Those with severe stenotic lesions, pulmonary artery hypertension, and Eisenmenger's syndrome should avoid pregnancy, be given effective contraception and managed in a tertiary center if pregnancy does happen.

Coarctation of the Aorta: Diagnosis and Management

Coarctation of the aorta (CoA) accounts for approximately 5-8% of all congenital heart defects. Depending on the severity of the CoA and the presence of associated cardiac lesions, the clinical presentation and age vary. Developments in diagnosis and management have improved outcomes in this patient population. Even after timely repair, it is important to regularly screen for hypertension. Patients with CoA require lifelong follow-up with a congenital heart disease specialist as these patients may develop recoarctation and complications at the repair site and remain at enhanced cardiovascular risk throughout their lifetime.

Pregnancy in Patients with Moderate and Highly Complex Congenital Heart Disease

Although not completely devoid of risk, pregnancy can be managed in virtually all patients affected by even the most complex forms of congenital heart disease. It is not however advisable in patients with any form of pulmonary arterial hypertension. Pregnancy is even manageable in patients with univentricular heart converted to Fontan circulation. A personalised risk stratification should be performed, and patients affected by advanced NYHA functional class appropriately warned of the potential risks. In this setting, metabolomics might represent a novel tool for use in conducting personalised risk stratification. All pregnancies, particularly those at higher risk, should be managed in a tertiary care centre capable of providing the necessary assistance to both the mother and infant. With a few rare exceptions, vaginal delivery is to be preferred over caesarean section due to the lower degree of maternal and foetal complications. The desire for motherhood, at times extreme in women with congenital heart disease, may often be accomplished, thus providing a ray of hope in the lives of these patients.

Introducing and Implementing Genetic Assessment in Cardio-Obstetrics Clinical Practice: Clinical and Genetic Workup of Patients with Cardiomyopathy

Cardiovascular disease (CVD) during pregnancy varies significantly worldwide, influenced by factors such as access to healthcare, delayed diagnosis, causes, and risk factors. Our study sought to explore the spectrum of CVD present in pregnant women in the United Arab Emirates to better understand this population's unique needs and challenges. Central to our study is an emphasis on the importance of implementing a multidisciplinary approach that involves the collaboration of obstetricians, cardiologists, geneticists, and other healthcare professionals to ensure that patients receive comprehensive and coordinated care. This approach can also help identify high-risk patients and implement preventive measures to reduce the occurrence of adverse maternal outcomes. Furthermore, increasing awareness among women about the risk of CVD during pregnancy and obtaining detailed family histories can help in the early identification and management of these conditions. Genetic testing and family screening can also aid in identifying inherited CVD that can be passed down through families. To illustrate the significance of such an approach, we provide a comprehensive analysis of five women's cases from our retrospective study of 800 women. The findings from our study emphasize the importance of addressing maternal cardiac health in pregnancy and the need for targeted interventions and improvements in the existing healthcare system to reduce adverse maternal outcomes.

New Hypertension After Pregnancy in Patients With Heart Disease

Background After pregnancy, patients with preexisting heart disease are at high risk for cardiovascular complications. The primary objective was to compare the incidence of new hypertension after pregnancy in patients with and without heart disease. Methods and Results This was a retrospective matched-cohort study comparing the incidence of new hypertension after pregnancy in 832 patients who are pregnant with congenital or acquired heart disease to a comparison group of 1664 patients who are pregnant without heart disease; matching was by demographics and baseline risk for hypertension at the time of the index pregnancy. We also examined whether new hypertension was associated with subsequent death or cardiovascular events. The 20-year cumulative incidence of hypertension was 24% in patients with heart disease, compared with 14% in patients without heart disease (hazard ratio [HR], 1.81 [95% CI, 1.44-2.27]). The median follow-up time at hypertension diagnosis in the heart disease group was 8.1 years (interquartile range, 4.2-11.9 years). The elevated rate of new hypertension was observed not only in patients with ischemic heart disease, but also in those with left-sided valve disease, cardiomyopathy, and congenital heart disease. Pregnancy risk prediction methods can further stratify risk of new hypertension. New hypertension was associated with an increased rate of subsequent death or cardiovascular events (HR, 1.54 [95% CI, 1.05-2.25]). Conclusions Patients with heart disease are at higher risk for developing hypertension in the decades after pregnancy when compared with those without heart disease. New hypertension in this young cohort is associated with adverse cardiovascular events highlighting the importance of systematic and lifelong surveillance.

Transthoracic Echocardiographic Assessment of the Heart in Pregnancy-a position statement on behalf of the British Society of Echocardiography and the United Kingdom Maternal Cardiology Society

Pregnancy is a dynamic process associated with profound hormonally mediated haemodynamic changes which result in structural and functional adaptations in the cardiovascular system. An understanding of the myocardial adaptations is important for echocardiographers and clinicians undertaking or interpreting echocardiograms on pregnant and post-partum women. This guideline, on behalf of the British Society of Echocardiography and United Kingdom Maternal Cardiology Society, reviews the expected echocardiographic findings in normal pregnancy and in different cardiac disease states, as well as echocardiographic signs of decompensation. It aims to lay out a structure for echocardiographic scanning and surveillance during and after pregnancy as well as suggesting practical advice on scanning pregnant women.

The role of the pregnancy heart team in clinical practice

Significant maternal and fetal morbidity and mortality risk has been shown to be associated with cardiovascular disease in pregnancy. Several determinants, such as the increasing number of females with corrected congenital heart disease in reproductive age, a more advanced maternal age associated with cardiovascular risk factors, and a greater prevalence of preexisting comorbidities related to cardiac disorders such as cancer and COVID-19), lead to a higher incidence of cardiac complications in pregnancy in the last few decades. However, adopting a multidisciplinary strategy may influence maternal and neonatal outcomes. This review aims at assessing the role of the Pregnancy Heart Team, which should ensure careful pre-pregnancy counseling, pregnancy monitoring, and delivery planning for both congenital and other cardiac or metabolic disorders, addressing several emerging aspects in the multidisciplinary team-based approach.

Which risk score best predicts cardiovascular outcome in pregnant women with congenital heart disease?

BACKGROUND

Management of pregnancy and risk stratification in women with congenital heart diseases (CHD) are challenging, especially due to physiological haemodynamic modifications that inevitably occur during pregnancy.

AIMS

To compare the accuracy of the existing pregnancy cardiovascular risk scores in prediction of maternal complications during pregnancy in CHD patients.

METHOD AND RESULTS

From 2007 to 2018, all pregnant women with a CHD who delivered birth after 20 weeks of gestation were identified. The discriminating power and the accuracy of the five existing pregnancy cardiovascular risk scores [CARPREG, CARPREG II, HARRIS, ZAHARA risk scores, and modified WHO (mWHO)] were evaluated.Out of 104 pregnancies in 65 CHD patients, 29% experienced cardiovascular complications during pregnancy or post-partum. For the five scores, the observed rate of cardiovascular events was higher than the expected risk. The values of area under the ROC curve were 0.75 (0.62-0.88) for mWHO, 0.65 (0.53-0.77) for CARPREG II, 0.60 (0.40-0.80) for HARRIS, 0.59 (0.47-0.72) for ZAHARA, and 0.58 (0.43-0.73) for CARPREG.

CONCLUSION

The modified WHO classification appeared to better predict cardiovascular outcome in pregnant women with CHD than the four other existing risk scores.Clinical Trial Registration: Clinicaltrials.gov: NCT04221048.

Trends in outcomes of pregnancy in patients with congenital heart disease

PURPOSE OF REVIEW

This review aims to analyze the trends in the management of pregnant patients with congenital heart disease (CHD).

RECENT FINDINGS

The literature that this article reviews specifically highlights the importance of multidisciplinary and specialized care, the unique and variable physiologic differences within the umbrella of CHD in pregnancy, and recommendations for obstetric and anesthetic care in the prenatal and peripartum period.

SUMMARY

The findings that this article summarizes have profound implications for clinical practice and management of the patient with CHD, including the optimization of preoperative screening, facilitation of ideal prenatal care to include qualified specialists and resources, and recommendations for optimal anesthetic management during labor and delivery.

Pregnancy Outcomes in Women with Arrhythmias following Surgical Repair of Cardiac Defects

OBJECTIVE

 The goal of this study was to investigate whether preexisting cardiac arrhythmias are associated with adverse obstetrical outcomes in women with a history of open cardiac surgery.

STUDY DESIGN

 This was a retrospective cohort study of women with a history of open cardiac surgery who delivered at MedStar Washington Hospital Center (Washington, DC) from January 2007 through December 2018. Women with the isolated percutaneous cardiac surgical repair were excluded. Maternal and neonatal outcomes were compared between patients with preexisting cardiac arrhythmias and patients without preexisting cardiac arrhythmias. Maternal outcomes studied were intensive care unit admission, postpartum blood loss greater than 1,000 mL, congestive heart failure development, preeclampsia with severe features, postpartum readmission, postpartum cardiac events, and postpartum length of stay >5 days. Neonatal outcomes investigated were low birth weight <2,500 g, Apgar's scores <7 at 5 minutes, and neonatal intensive care unit admission. Multivariate logistic regression model was used to calculate the adjusted odds ratio (aOR) and 95% confidence intervals.

RESULTS

 The outcomes for 69 deliveries from 56 women with a history of open cardiac surgery were examined. Thirty-three women (48%) had arrhythmias after cardiac surgery with fourteen (20%) requiring implantable cardioverted defibrillators. Two women (6%) with preexisting arrhythmias after cardiac surgery developed postpartum volume overload requiring readmission (p = 0.06). After controlling for age, gestational age at delivery, and BMI, preeclampsia with severe features (p = 0.02) and low birth weight neonates (p = 0.02, aOR = 2.26 [0.56-9.03]) remained statistically more like to occur in patients with preexisting cardiac arrhythmias than in patients without preexisting arrhythmias.

CONCLUSION

 Women with a history of open cardiac surgery and preexisting cardiac arrhythmias prior to pregnancy are more likely to develop preeclampsia with severe features and have low birth weight neonates compared with women with a history of open cardiac surgery without preexisting cardiac arrhythmias.

KEY POINTS

· Preexisting arrhythmias after cardiac surgery was associated with a risk of preeclampsia.. · Neonates of women with preexisting cardiac arrhythmias are more likely to be low birth weight.. · Forty-seven percent of women with open cardiac surgery developed subsequent arrhythmias..

Temporal trends of arrhythmias at delivery hospitalizations in the United States: Analysis from the National Inpatient Sample, 2009-2019

BACKGROUND

Cardiac arrhythmias are associated with increased maternal morbidity. There are limited data on trends of arrhythmias among women hospitalized for delivery.

MATERIALS AND METHODS

We used the National Inpatient Sample (NIS) database to identify delivery hospitalizations for individuals aged 18-49 years between 2009 to 2019 and utilized coding data from the 9th and 10th editions of the International Classification of Diseases to identify supraventricular tachycardias (SVT), atrial fibrillation (AF), atrial flutter, ventricular tachycardia (VT), and ventricular fibrillation (VF). Arrhythmia trends were analyzed by age, race-ethnicity, hospital setting, and hospital geographic regions. Multivariable logistic regression was used to evaluate the association of demographic, clinical, and socioeconomic characteristics with arrhythmias.

RESULTS

Among 41,576,442 delivery hospitalizations, the most common arrhythmia was SVT (53%), followed by AF (31%) and VT (13%). The prevalence of arrhythmia among delivery hospitalizations increased between 2009 and 2019. Age > 35 years and Black race were associated with a higher arrhythmia burden. Factors associated with an increased risk of arrhythmias included valvular disease (OR: 12.77; 95% C1:1.98-13.61), heart failure (OR:7.13; 95% CI: 6.49-7.83), prior myocardial infarction (OR: 5.41, 95% CI: 4.01-7.30), peripheral vascular disease (OR: 3.19, 95% CI: 2.51-4.06), hypertension (OR: 2.18; 95% CI: 2.07-2.28), and obesity (OR 1.69; 95% CI: 1.63-1.76). Delivery hospitalizations complicated by arrhythmias compared with those with no arrhythmias had a higher proportion of all-cause in-hospital mortality (0.95% vs. 0.01%), cardiogenic shock (0.48% vs. 0.00%), preeclampsia (6.96% vs. 3.58%), and preterm labor (2.95% vs. 2.41%) (all p < 0.0001).

CONCLUSION

Pregnant individuals with age > 35 years, obesity, hypertension, valvular heart disease, or severe pulmonary disease are more likely to have an arrhythmia history or an arrhythmia during a delivery hospitalization. Delivery hospitalizations with a history of arrhythmia are more likely to be complicated by all-cause in-hospital mortality, cardiovascular, and adverse pregnancy outcomes (APOs). These data highlight the increased risk associated with pregnancies among individuals with arrhythmias.

An Exploratory Analysis of Maternal Health Variables Increasing the Severity of Congenital Heart Disease in Infants

BACKGROUND

Congenital heart defects (CHD) are the most prevalent birth anomaly and leading cause of infant morbidity and mortality worldwide. Heart defects are often attributed to chromosomal abnormality or environmental factors, but most causes remain unknown. The purpose of this analysis was to explore maternal health variables and the relationships to birth outcomes in infants with CHD.

METHODS

Secondary analysis of data from the Wisconsin Pediatric Cardiac Registry.

RESULTS

Maternal history of CHDs (odds ratio [OR] = 2.38; 95% confidence interval [CI], 1.42-3.98) and serious health conditions (OR = 1.537; 95%: CI, 1.08-2.17) increase infant risk and CHD severity. Maternal history of hypertension, serious health conditions, CHD, obesity, and income were predictors of birth weight (R² = 0.049, P < .05). Maternal history of hypertension, influenza, serious health conditions, and housing were predictors of gestational age (R2 = 0.045, P < .05). Birth weight (BW) and gestational age (GA) did not correlate to the severity of CHD in this study (simple vs complex, BW = -0.014, GA = 0.011, r).

DISCUSSION

Maternal well-being influences the health of infants born with CHD. Positive maternal health contributes to near-normal birth weight and gestational age.

CONCLUSION

Nurses must discuss optimal reproductive life planning strategies for decreasing risk of CHD and other infant disorders.

How Parental Predictors Jointly Affect the Risk of Offspring Congenital Heart Disease: A Nationwide Multicenter Study Based on the China Birth Cohort

Objective

Congenital heart disease (CHD) is complex in its etiology. Its genetic causes have been investigated, whereas the non-genetic factor related studies are still limited. We aimed to identify dominant parental predictors and develop a predictive model and nomogram for the risk of offspring CHD.

Methods

This was a retrospective study from November 2017 to December 2021 covering 44,578 participants, of which those from 4 hospitals in eastern China were assigned to the development cohort and those from 5 hospitals in central and western China were used as the external validation cohort. Univariable and multivariable analyses were used to select the dominant predictors of CHD among demographic characteristics, lifestyle behaviors, environmental pollution, maternal disease history, and the current pregnancy information. Multivariable logistic regression analysis was used to construct the model and nomogram using the selected predictors. The predictive model and the nomogram were both validated internally and externally. A web-based nomogram was developed to predict patient-specific probability for CHD.

Results

Dominant risk factors for offspring CHD included increased maternal age [odds ratio (OR): 1.14, 95% CI: 1.10–1.19], increased paternal age (1.05, 95% CI: 1.02–1.09), maternal secondhand smoke exposure (2.89, 95% CI: 2.22–3.76), paternal drinking (1.41, 95% CI: 1.08–1.84), maternal pre-pregnancy diabetes (3.39, 95% CI: 1.95–5.87), maternal fever (3.35, 95% CI: 2.49–4.50), assisted reproductive technology (2.89, 95% CI: 2.13–3.94), and environmental pollution (1.61, 95% CI: 1.18–2.20). A higher household annual income (100,000–400,000 CNY: 0.47, 95% CI: 0.34–0.63; &gt; 400,000 CNY: 0.23, 95% CI: 0.15–0.36), higher maternal education level (13–16 years: 0.68, 95% CI: 0.50–0.93; ≥ 17 years: 0.87, 95% CI: 0.55–1.37), maternal folic acid (0.21, 95% CI: 0.16–0.27), and multivitamin supplementation (0.33, 95% CI: 0.26–0.42) were protective factors. The nomogram showed good discrimination in both internal [area under the receiver-operating-characteristic curve (AUC): 0.843] and external validations (development cohort AUC: 0.849, external validation cohort AUC: 0.837). The calibration curves showed good agreement between the nomogram-predicted probability and actual presence of CHD.

Conclusion

We revealed dominant parental predictors and presented a web-based nomogram for the risk of offspring CHD, which could be utilized as an effective tool for quantifying the individual risk of CHD and promptly identifying high-risk population.

Cardiac disease in pregnancy

In the developed world, cardiovascular disease has become the most frequent cause of death during pregnancy and postpartum, outnumbering by far obstetric causes of death such as bleeding or thromboembolism. Many factors contribute to this phenomenon, including an increasing age of pregnant women, co-morbidities, and an unhealthy lifestyle. The cardiovascular system is not only significantly challenged by physiological alterations in pregnancy but also by obstetric medication. Depending upon the severity of the underlying condition, pregnant women with cardiovascular disease should be managed by a multidisciplinary heart team in which anaesthesiologists play an important role. Profound knowledge of the cardiac pathophysiology is a prerequisite for the successful anaesthesiologic management of pregnant patients with cardiovascular disease. As there is no difference in general and regional anaesthesia regarding maternal outcomes, neuraxial anaesthesia using incremental techniques should be preferred for labour and (caesarean) delivery if not contraindicated by non-cardiac issues.

Maternal and fetal outcomes of pregnant women with pulmonary arterial hypertension associated with congenital heart disease in Beijing, China: a retrospective study

As pulmonary arterial hypertension associated with congenital heart disease (PAH‐CHD) may increase maternal and fetal risk, this study explored the pregnancy outcomes of Chinese women with PAH‐CHD. The clinical data of pregnant women with PAH‐CHD admitted to the Beijing Anzhen Hospital from 2010 to 2019 were retrospectively analyzed; these patients and their offspring were followed up, with a mean period of 5.9 ± 2.7 years. Overall, 260 patients with PAH‐CHD were included. The mean maternal age was 27.7 ± 4.1 years, and 205 (78.8%) patients were nulliparous. The estimated systolic pulmonary artery pressure was 40–50 mmHg in 34.6% of the patients, 50–70 mmHg in 23.1%, and >70 mmHg in 42.3%. More than 96% of patients were diagnosed with PAH‐CHD before pregnancy. During pregnancy, heart failure occurred in 19.2% of the patients. Cesarean delivery was performed in 88.1% (15.0% emergency) of the patients. Complications included fetal distress (5.8%), preterm delivery (34.2%), and low birth weight (33.8%). A total of 15 mothers (5.8%) died, with the highest mortality rate in those with Eisenmenger syndrome (10/43, 23.3%), and 10 offspring died (3.8%), two (0.8%) following hospital discharge and eight (3.1%) while in hospital. Although most pregnant women with PAH‐CHD were able to have children, PAH increased the maternal and fetal risk. Thus, an individualized risk‐based approach with shared decision‐making may be more appropriate in pregnant women with PAH‐CHD.

Total atrioventricular block in pregnancy -Case report

Introduction and importance

Bradycardia in pregnancy due to total atrioventricular block (TAVB) is a rare occurrence, often asymptomatic and may arise from a congenital disorder. Pacemaker is often required. Cases are few and management is not yet standardised.

Case presentation

A 24-year-old G2P0A1 of 9 months gestation presented with labor pains. She had had history of bradycardia diagnosed since a year prior but had not undergone tests nor received treatments. Her heart rate was 55-60 x/minute, her cardiotocography was reassuring and electrocardiogram revealed a TAVB with ventricular escape rhythm. As she had not had a pacemaker, an urgent cardiologist consultation was arranged during which a temporary pacemaker was installed. She underwent a caesarean section with general anaesthesia after which she had an uneventful recovery.A 38-year-old G2P1A0 of 2 months of gestation presented with slow heart rhythm and a history of asthma to the outpatient clinic. She also had not undergone tests nor received medication. At presentation, her heart rate was 48 x/minute and her ECG revealed a TAVB with junctional escape rhythm. She had a pacemaker installed at 8 months of gestation and subsequently underwent an elective caesarean section at 37 weeks under regional anaesthesia. She had an uneventful recovery afterwards.

Clinical discussion

TAVB in pregnancy requires a concerted effort involving obstetricians, cardiologists, and intensivists. Pacemaker implantation is recommended. Whilst vaginal delivery remains first-choice, caesarean section is indicated under obstetric indications.

Conclusion

Screening, early recognition, risk stratification and thorough planning are required to successfully manage TAVB in pregnancy.

Selección de lo mejor del año 2021 en cardiopatías congénitas

En este artículo se muestran las publicaciones que consideramos más relevantes sobre cardiopatías congénitas (CC) en el último año. La pandemia de COVID-19 ha seguido marcando la actividad científica en este periodo, y ya desde el inicio se ha especulado sobre el riesgo de complicaciones por la COVID-19 entre los adultos con CC. Asimismo, se ha estudiado la afectación de los niños con CC. En este año destaca la publicación de la guía europea para el tratamiento de las CC, segunda edición tras 10 años, que será de gran utilidad en la estandarización del tratamiento de estos pacientes complejos. Entre las publicaciones originales destacan las relacionadas con los temas que más preocupan a los cardiólogos de CC: el avance en la prevención primaria de las arritmias ventriculares, la hepatopatía del Fontan, el avance en las técnicas percutáneas de valvulación pulmonar, la aplicación de nuevos fármacos para la insuficiencia cardiaca avanzada en las CC complejas y en ventrículo derecho sistémico y las complicaciones a largo plazo de los adultos jóvenes con transposición de grandes arterias sometidos a cirugía de switch arterial.

Management of acute cardiovascular complications in pregnancy

The growing population of women with heart disease of reproductive age has been associated with an increasing number of high-risk pregnancies. Pregnant women with heart disease are a very heterogeneous population, with different risks for maternal cardiovascular, obstetric, and foetal complications. Adverse cardiovascular events during pregnancy pose significant clinical challenges, with uncertainties regarding diagnostic and therapeutic approaches potentially compromising maternal and foetal health. This review summarizes best practice for the treatment of common cardiovascular complications during pregnancy, based on expert opinion, current guidelines, and available evidence. Topics covered include heart failure (HF), arrhythmias, coronary artery disease, aortic and thromboembolic events, and the management of mechanical heart valves during pregnancy. Cardiovascular pathology is the leading cause of non-obstetric morbidity and mortality during pregnancy in developed countries. For women with pre-existing cardiac conditions, preconception counselling and structured follow-up during pregnancy are important measures for reducing the risk of acute cardiovascular complications during gestation and at the time of delivery. However, many women do not receive pre-pregnancy counselling often due to gaps in what should be lifelong care, and physicians are increasingly encountering pregnant women who present acutely with cardiac complications, including HF, arrhythmias, aortic events, coronary syndromes, and bleeding or thrombotic events. This review provides a summary of recommendations on the management of acute cardiovascular complication during pregnancy, based on available literature and expert opinion. This article covers the diagnosis, risk stratification, and therapy and is organized according to the clinical presentation and the type of complication, providing a reference for the practicing cardiologist, obstetrician, and acute medicine specialist, while highlighting areas of need and potential future research.

Cardiovascular adverse events in pregnancy: A global perspective

Pregnant women with heart disease are vulnerable to many adverse cardiovascular events (AE). AEs during and after pregnancy continue to be important causes of maternal mortality and morbidity worldwide, with huge variations in burden in different countries and regions. These AEs are classified as having direct or indirect causes, depending on whether they are directly caused by pregnancy or due to some pre-existing disease and/or non-obstetric cause, respectively. The risks continue throughout pregnancy and even after childbirth. Apart from immediate complications during pregnancy, there is increasing evidence of a significant link between several events and the risk of cardiovascular disease (CVD) later in life. A significant number of pregnancy-related deaths caused by cardiovascular disease are preventable. This prevention can be realized through increasing awareness of cardiovascular AE in pregnancy, coupled with the application of strategies for prevention and treatment. Knowledge of the risks associated with CVD and pregnancy is of extreme importance in that regard. We discuss the global distribution of cardiovascular maternal mortality, adverse events during and after pregnancy, their predictors and risk stratification. In addition, we enumerate possible solutions, particularly the role of cardio-obstetric clinics.