Pregnancy and delivery following cardiac operations

For young female patients with cardiac diseases, to be married, pregnancy and delivery are serious problems. Ninety-two post-operative patients (138 deliveries) and 57 non-surgical patients (86 deliveries) were subjected to analysis of their cardiac and obstetric conditions. A stable course and successful delivery were observed in the patients treated whose cardiac diseases were treated with surgical therapy. Among the non-surgical patients, however, impairment of their clinical condition was experienced including 3 maternal deaths. Incidence of various complications occurring during the course of pregnancy and delivery was 12.3% in the surgical and 18.6% in the non-surgical groups. It was clinically demonstrated that women suffering from cardiac diseases might well tolerate their pregnancy and delivery if accorded proper surgical treatment.     

Pregnancy and delivery in women with von Willebrand disease

Given the wide heterogeneity of phenotypes and of the underlying pathophysiological mechanisms associated with the disorder, pregnancy and delivery in von Willebrand disease (VWD) represent a significant clinical challenge. The variable pattern of changes observed during pregnancy of von Willebrand factor (VWF) and factor VIII (FVIII), the protein carried by VWF, prompts a careful evaluation of pregnant women with VWD to plan the most appropriate treatment at the time of parturition. However, there are also instances during pregnancy (amniocentesis, vaginal bleeding associated with placental detachment, sudden abortion) that may require urgent hemostatic treatment to prevent bleeding. Thus, women with VWD should start pregnancy after being well characterised as to their type, subtype and treatments. Women with VWD who have VWF and FVIII basal levels >30 U/dL typically normalise these levels at the end of pregnancy and specific anti‐haemorrhagic prophylaxis is seldom required. On the contrary, those with basal levels <20 U/dL usually show a lesser increase and specific treatment is required. Some women with DNA variants associated with increased clearance can be treated with desmopressin, while those unresponsive or with contra‐indications to this agent need replacement therapy. For these latter women, the risk of vaginal bleeding during pregnancy may be increased and prophylaxis with VWF concentrates required. Similarly, women with type 2 VWD who maintain reduced VWF activity throughout pregnancy require replacement therapy with FVIII/VWF concentrates. Delayed postpartum bleeding may occur when replacement therapy is not continued for some days. Tranexamic acid is useful at discharge to avoid excessive lochia.     

Pregnancy interruption in cardiac patients

Aspects of pregnancy interruption in cardiac patients are discussed on the basis of 18 such operations performed during the past 12 years. The most frequent indication was rheumatic heart valve disease, but cases of congenital heart defects and primary myocardial disease were also seen. Abortion was usually decided upon when clear clinical or radiological signs of cardiac disturbance were observed. (The electrocardiogram was usually unchanged.) Resistance of the condition to medical and/or surgical treatment constitutes a valid indication. Abortion is accomplished by abdominal hysterotomy (70%) or vaginal curettage (30%), usually accompanied by tubal ligation, during the first trimester of pregnancy. Infectious, occlusive, or hemorrhagic complications were observed in 37.5% of cases. Pregnancy should therefore not be terminated except to save the life of the mother, an increasingly rare medical eventuality.     

Pregnancy after cardiac transplantation

More women are reporting pregnancy following heart transplantation. Although successful outcomes have been reported for the mother, transplanted heart, and newborn, such pregnancies should be considered high risk. Hypertension, preeclampsia, and infection should be treated. Vaginal delivery is recommended unless cesarean section is obstetrically necessary. Most outcomes are live births, and long-term follow-up of children show most are healthy and developing well. Maternal survival, independent of pregnancy-related events, should be part of prepregnancy counseling.     

Pregnancy in Crohn's disease

Over a 13-year period, the course of 109 pregnancies in 68 women with Crohn's disease was studied. A total of 76 children were delivered. There were no gemellary deliveries, and none of the children had congenital malformations. Pregnancy entailed no increased risk of an exacerbation of the bowel disease. As compared with the reference population and with women with ulcerative colitis, the total material showed an increased risk of premature delivery and spontaneous abortion, but a further analysis showed that this was due only to an increased risk in women with active disease at the time of conception and in women who had undergone bowel resection during pregnancy. Birth weight and birth length corresponded to those in the reference population. The frequency of neonatal hyperbilirubinaemia was not higher in children of mothers with Crohn's disease than in children of healthy mothers. Treatment with sulphasalazine, salazosulphadimidine, and corticosteroids did not influence the course of pregnancy or the frequency of neonatal jaundice or malformations. Consequently, in Crohn's disease a pregnant woman should be given the same medical treatment as when not pregnant. Generally, the women should be advised preferably to conceive at a time when their bowel disease is inactive. The risk groups should be followed up with frequent obstetrical examinations throughout pregnancy.     

Pregnancy and heart disease

Pregnancy and delivery are associated with substantial physiological changes that require adaptations in the cardiovascular system. These changes, well-tolerated in pregnant women without heart disease, expose woman with cardiovascular disease to serious risk. In fact, heart disease is the most frequent cause of maternal death, after psychiatric disorders, and the number of pregnant women with heart disease is expected to grow in the coming years. Preventing cardiovascular complications should be the main aim of every cardiologist involved in managing pregnant woman with congenital or acquired heart disease. Unfortunately, there is a lack of data which would help in the management of these patients during pregnancy and the clinical practice guidelines are often based on assumptions regarding how a specific substrate is going to respond to the physiological changes occurring due to pregnancy.     

Pregnancy and Crohn's disease

Crohn's disease commonly affects women of childbearing age. Available data on Crohn's disease and pregnancy show that women with Crohn's disease can expect to conceive successfully, carry to term and deliver a healthy baby. Control of disease activity before conception and during pregnancy is critical, to optimize both maternal and fetal health. Generally speaking, pharmacological therapy for Crohn's disease during pregnancy is similar to pharmacological therapy for non-pregnant patients. Patients maintained in remission by way of pharmacological therapy should continue it throughout their pregnancy. Most drugs, including sulfasalazine, mesalazine, corticosteroids, and immunosuppressors such as azathioprine and 6-mercaptopurine, are safe, whereas methotrexate is contraindicated.     

Pregnancy and liver disease

Although liver disease does not occur frequently during pregnancy, when it does, it can cause significant morbidity and mortality for both fetus and mother. Recent advances in molecular genetics have provided some insight into the pathogenesis of diseases such as intrahepatic cholestasis of pregnancy (IHCP) and acute fatty liver of pregnancy. Newer studies linking serum bile acid levels with fetal outcome support the importance of this marker in IHCP. Randomized trials with ursodeoxycholic acid have shown promising results in reducing maternal symptoms and serum bile acid levels in IHCP. Although further studies must be performed, early strategies aimed at reducing viral loads in mothers may reduce perinatal transmission of hepatitis B.     

Pregnancy and gallbladder disease

Gallbladder disease is a highly prevalent disease in western countries as a consequence of several genetic, biochemical, and environmental factors. Females are a high risk group, and pregnancy increases this risk considerably. In fact, gallbladder diseases are the second most common indication for nonobstetric surgical intervention in pregnancy. In this review, we discuss the most important aspects of gallbladder disease and pregnancy as part of the Symposium on Liver and Pregnancy, co-sponsored by the Mexican Association of Hepatology and the Mexican Association of Gynecologists and Obstetrics.     

Pregnancy and liver disease

Liver disease has an impact on women's health during pregnancy because of the complex interactions between the physiologic changes induced by pregnancy and the pathophysiologic changes of liver disease. In particular, liver diseases that predominantly afflict females, such as primary biliary cirrhosis and autoimmune hepatitis, pose a special problem for conception and management of pregnancy. Pregnancy, moreover, specifically is associated with several potentially life-threatening liver diseases. This article reviews comprehensively the impact of liver diseases on pregnancy and of pregnancy on liver function and liver disease.     

妊娠与心脏瓣膜病

<正>妊娠合并心脏病属高危妊娠,是孕产妇死亡的重要原因之一,病死率达0.1%～1%。因此,关于计划怀孕的患有心脏瓣膜病的育龄妇女、在产前检查时发现患有心脏瓣膜病的患者及已知有心脏     

Pregnancy in diabetes and kidney disease

With appropriate multi-disciplinary team care, most women with diabetic nephropathy will have successful pregnancy outcomes; however, pregnancy complications are increased compared to non-diabetic individuals, particularly in those with poor glycaemic control. Women with more severe renal impairment, especially those with hypertension and proteinuria at are highest risk of worse pregnancy outcomes and deterioration in pre-existing renal function. Pre-pregnancy counselling should be offered to all women with diabetes in order to optimise diabetic care, and inform women of potential complications. Pregnancy is an indicator of long-term health, and may indicate important issues for the future management of women with diabetic nephropathy.