Cardiac disease in pregnancy.

OBJECTIVES: To evaluate the maternal and fetal outcome of pregnancies complicated by cardiac disease in a developing country. METHODS: A retrospective analysis was carried out of 207 pregnancies in women with cardiac disease who delivered at >or=28 weeks of gestation from June 1994 through December 2000 at a tertiary care center. RESULTS: Rheumatic heart disease (n=183, 88%) with isolated mitral stenosis (n=71) was the predominant cardiac problem. Septal defects were the most common form of congenital heart disease (n=24). In 28 (13.52%) women, the diagnosis of cardiac disease was made during pregnancy. Cardiac complications were noted in 62 (29.95%) and fetal complications in 42 (20.28%) pregnancies. Patients in NYHA class I/II (n=175, 84.54%) had fewer maternal complications and their babies had a higher birth weight than those in NYHA class III/IV (n=32, 15.45%). Cardiac intervention was performed prior to pregnancy in 111 (60.65%) patients with rheumatic heart disease: PTMC/CMV in 73 and valve replacement (VR) in 38. Maternal and fetal outcome was better in patients with prosthetic valves (n=38) and the majority (97.4%) of them remained in NYHA class I/II. Cardiac intervention was safely carried out during pregnancy in 10 women (PTMC in 7, CMV in l, and VR in 2). One of them developed congestive cardiac failure during labor. None of the newborns of the 41 women who had received anticoagulants had any congenital malformation. CONCLUSIONS: Rheumatic heart disease was the predominant type. Patients in NYHA class I/II had a better maternal and fetal outcome than those in NYHA class III/IV. Surgical correction of the cardiac lesion prior to pregnancy was associated with better pregnancy outcome. Pregnant women with prosthetic valves tolerated pregnancy well.     

Pregnancy and the Rastelli operation

BACKGROUND: The aim of surgical correction of congenital heart disease is for the patient to live a relatively normal life, including potential pregnancy and childbirth. The Rastelli repair operation using a valved conduit for certain complex congenital heart lesions has resulted in survival into adult life. AIMS: We reviewed reproductive outcome of 22 women over 18 years of age who were survivors of the Rastelli operation performed between 1977 and 1999. RESULTS: Six women had a total of 12 pregnancies with six live births. Three women, with complex transposition of the great arteries, developed more severe subaortic obstruction during pregnancy. All required further heart surgery. Delivery was by Caesarean section in three patients and vaginally in the other three. All infants were healthy and free from defects. Two women had tubal ligations because of their cardiac problems. CONCLUSIONS: Women who have had Rastelli repair operation for complex congenital heart disease can have successful pregnancies. Subaortic stenosis can become a problem and should ideally be eliminated before pregnancy. Because of multiple operations, complications and genetic concerns, some women choose not to reproduce. Careful cardiac evaluation before, during and after pregnancy is essential.     

心脏矫正术对先天性心脏病妇女妊娠结局影响的Meta分析

目的：探讨孕前行心脏矫正术对先天性心脏病（先心病）孕产妇妊娠结局的影响。方法：检索2018年9月以前在中国知网（CNKI）、万方数据库（WangFang data）、维普数据库（VIP）、PubMed、Cochrane Library等数据库关于孕前心脏矫正术对先心病孕产妇妊娠结局影响的文献。对纳入文献进行质量评价及数据提取,使用RevMan 5.3软件对数据进行Meta分析。结果：共纳入17个队列研究共1 181例患者,其中手术组457例,未手术组724例。对于先心病妇女,孕前的心脏矫正术可以改善孕妇的心功能情况,心力衰竭发生率、剖宫产率、早产率、胎儿生长受限发生率、小于胎龄儿发生率、新生儿窒息发生率及围生儿死亡率与未手术组比较差异均有统计学意义（均P＜0.05）。然而,关于孕妇的死亡率及新生儿心脏病发生率,2组间比较差异无统计学意义（均P＞0.05）。结论：相比于孕前未行心脏矫正术的先心病患者,手术患者能取得较为理想的妊娠结局。     

455例妊娠合并心脏病患者不同心功能状况对妊娠结局的影响

目的探讨妊娠合并心脏病不同心脏功能对妊娠结局的影响。方法对北京大学第三医院1994年1月至2008年12月间妊娠合并心脏病455例患者的临床资料进行回顾性分析。结果妊娠合并心脏病以心律失常（223例,49.01%）和先天性心脏病（140例,30.77%）最为常见,风湿性心脏病居第三位（33例,7.25%）。妊娠合并心律失常患者心功能均为Ⅰ～Ⅱ级,妊娠合并先天性心脏病患者心功能为Ⅰ～Ⅱ级者为135例,Ⅲ～Ⅳ级为5例,其中1例为为妊娠合并艾森曼格综合征,产后7 d猝死;妊娠期高血压性心脏病17例心功能Ⅲ～Ⅳ级,其中1例孕妇死亡;围生期心肌病5例,其心功能均为Ⅳ级。心脏功能Ⅲ～Ⅳ级患者的妊娠孕周明显小于心功能Ⅰ～Ⅱ级（P〈0.05）,医源性早产和围产儿死亡率显著增加（P〈0.01）。结论心脏功能Ⅲ～Ⅳ级患者以妊娠期高血压性心脏病、先天性心脏病和围生期心肌病多见,其医源性早产、孕产妇及围产儿死亡的发生增加。妊娠合并心脏病患者的心脏功能状态与其孕产妇及围产儿结局密切相关。     

Kardiologische Erkrankungen in der Schwangerschaft

Serious cardiac disease has a significant impact on maternal and fetal morbidity and mortality. The overall incidence is estimated at approximately 1%. In Germany, about 6000 pregnancies in women with congenital or acquired valvular lesions are expected per year. The etiology of the disease has changed during the past several years from predominantly rheumatic disease to an equal incidence of rheumatic and congenital heart disease. Normal physiologic changes during pregnancy and delivery can aggravate underlying cardiac disease and lead to the associated mortality and morbidity. Cardiovascular alterations during pregnancy are characterized by an increased vascular volume, cardiac output, and heart rate, with a fall in peripheral vascular resistance. The peripartal phase represents another critical period. Treatment and outcome will depend on the type of cardiac disease, on the functional impairment of the fetal heart and on the status of the fetus. Close interdisciplinary collaboration and tightly networked support are the prerequisite for successful management of high-risk pregnancies involving maternal heart disease.     

Pregnancy outcome in women with heart disease undergoing induction of labour

OBJECTIVE: To examine the safety and outcome of induction of labour in women with heart disease. DESIGN: Prospective single-centre comparative study. SETTING: Major university-based medical centre. POPULATION/SAMPLE: One hundred and twenty-one pregnant women with heart disease. METHODS: The sample included all women with acquired or congenital heart disease who attended our High-Risk Pregnancy Outpatient Clinic from 1995 to 2001. The files were reviewed for baseline data, cardiac and obstetric history, course of pregnancy and induction of labour and outcome of pregnancy. Findings were compared between women who underwent induction of labour and those who did not. Forty-seven healthy women in whom labour was induced for obstetric reasons served as controls. MAIN OUTCOME MEASURES: Pregnancy outcome. RESULTS: Of the 121 women with heart disease, 47 (39%) underwent induction of labour. There was no difference in the caesarean delivery rate after induction of labour between the women with heart disease (21%) and the healthy controls (19%). Although the women with heart disease had a higher rate of maternal and neonatal complications than controls (17%vs 2%, P= 0.015), within the study group, there was no difference in complication rate between the patients who did and did not undergo induction of labour. CONCLUSION: Induction of labour is a relatively safe procedure in women with cardiac disease. It is not associated with a higher rate of caesarean delivery than in healthy women undergoing induction of labour for obstetric indications, or with more maternal and neonatal complications than in women with a milder form of cardiac disease and spontaneous labour.     

Pregnancy with an artificial pacemaker

Complete heart block in pregnancy is not a common encounter. The first case was reported in 1914 by Nanta and today some 100 cases are documented. Heart block may be congenital or acquired secondary to cardiac surgery, rheumatic heart disease, or infective disorders. Heart block, whether congenital or acquired, rarely creates any special obstetric problems. Today there is an increasing use of cardiac pacemakers in younger people and the first reported obstetric experience with a cardiac pacemaker implanted before pregnancy was by Shouse and Acker. This review will document the course and outcome of all reported pregnancies in women conceiving with an artificial pacemaker, and discuss complications and principles of management. We will also report our experience with a woman suffering from a complete heart block in whom an internal cardiac pacemaker was inserted before pregnancy.     

妊娠合并先天性心脏病伴肺动脉高压79例妊娠结局分析

目的分析妊娠合并先天性心脏病伴肺动脉高乐患者的妊娠结局。方法回顾性分析2009年1月至2013年6月北京安贞医院妇产科收治的79例妊娠合并先天性心脏病伴肺动脉高压患者的临床资料,根据肺动脉压力将其分为轻度组、中度组、重度组。分析各组先天性心脏病种类、心功能级别、终止妊娠的方式以及母婴结局。结果先心病类型以房间隔缺损（房缺）和室间隔缺损（室缺）为主,肺动脉高压轻度组心功能以Ⅰ～Ⅱ级为主,重度组心功能以Ⅲ～Ⅳ级为主。79例患者中,行医源性流产者16例（20．8％）,经阴道分娩5例（6．5％）,剖宫产56例（72．7％）。重度组医源性流产率高于其他组,足月分娩率低于其他组,差异有统计学意义（P〈0．05）。新生儿早产20例（32．8％）,足月产41例（67．2％）,死产1例,随着肺动脉压力的增加,早产的发生率增加,三组之间相互比较差异有统计学意义（P〈0．05）。结论肺动脉高压患者应在妇产科及心脏科医师指导下妊娠,不宜妊娠者应及早终止妊娠。孕产妇终止妊娠方式以剖宫产为主,麻醉方式以硬膜外麻醉为宜。     

妊娠合并心脏病266例临床分析

探讨妊娠合燕心脏病患者不同心功能状态对母亲和围产儿的影响。方法对我国院１９９３年１月至１９９９年３月间、２６６例妊娠合并心脏病患者的临床资料进行回顾性分析。结果（１）妊娠合并心脏病患者以心肌炎、心肌炎后遗症及不明原因性心律失常的发生率最高（１７９例,６７．２９％）,其次为先天性心脏病（４１例,１５．４１％）,其发生率高于风湿性心脏病（２８例,１０．９１％）。（２）风湿性心脏病的先天性心脏病是导致心     

Cardiac disorders.

Most cardiovascular problems in pregnant women arise from the complications of preexisting chronic conditions (e.g., rheumatic and congenital heart disease) and hypertensive vascular disease. Regular supervision of these patients is essential to detect incipient pulmonary congestion or disturbances of cardiac rhythm. Even if the pregnancy has been uncomplicated, hospital admission 1-4 weeks before the due date is recommended to ensure optimal conditions for labor. Vaginal delivery at term with adequate sedation and use of forceps to shorten the 2nd stage of labor is the perferred mode. Induction of labor may be indicated in hypertensive vascular disease or in cases where adjusting or discontinuing drug therapy calls for precise timing of delivery. Eisenmenger's disease and primary hypertension are potential medical indications for pregnancy termination. The distribution pattern of organic heart disease encountered in pregnant women has changed in the past 20 years, with a decrease in rheumatic and an increase in congenital heart disease. The incidence of chronic rheumatic heart disease in pregnant women fell from 3.5% of all deliveries at Newcastle General Hospital in 1942-51 to 1.1% in 1962-71. Acute pulmonary edema in mitral stenosis is currently a major risk during pregnancy. There is no optimal stage of pregnancy for valvotomy, nor evidence that this procedure induces miscarriage in the early weeks. Pregnancy has become less hazardous in severe forms of congenital heart disease as more patients with these disorders have undergone cardiac surgery prior to pregnancy. Pregnancy is not believed to have any effect on the longterm course of rheumatic heart disease. Patients with aortic stenosis, coarctation of the aorta, primary pulmonary hypertension, Fallot's tetralogy, Eisenmenger's syndrome, and surgically untreated cyanotic lesions require special attention during pregnancy. The outlook for women who become pregnant after an acute cardiac infarction episode depends on the functional state of the heart at the time of pregnancy and the presence or absence of angina pain. There has been a gradual decline in perinatal mortality, especially in cases complicated by rheumatic heart disease.     

心血管整体评分评估胎儿心功能不全的价值

目的：探讨心血管整体评分（CVPS）对胎儿心功能不全评估的价值。方法：对2013年1月—2016年1月来天津市中心妇产科医院超声中心就诊的孕妇行常规超声检查,检出其中有心功能异常表现（心脏增大、心肌收缩乏力）的胎儿,记录CVPS评分结果,同时行胎儿超声心动图检查,确定有无心内结构异常。依据追访结果,将病例分为2组：活产组和不良妊娠结局组。结果：共检出心功能不全胎儿38例,其中单胎35例,双胎3例。活产组12例,均为单胎,出生后体健10例,2例合并先心病：1例肺动脉瓣轻度狭窄,1例法乐四联症。不良妊娠结局组21例。单胎不良妊娠结局共18例,其中宫内死胎9例,死产2例,引产7例：CVPS持续降低心功能逐渐恶化直至心力衰竭5例,合并难治型先心病2例。双胎中2例为双胎输血综合征（TTTS）宫内死胎,1例为胎儿脑积水、颅内出血引产。失访5例。活产组胎儿CVPS的中位数（四分位数间距）[M（Q）]为7.62（7.00）,不良妊娠结局组胎儿CVPS的M（Q）为5.67（3.50）。受试者工作特征（ROC）曲线分析,曲线下面积（AUC）0.823,Cut-off值为6.5,P=0.002,有统计学意义。活产组胎儿脐动脉频谱评分、静脉频谱评分和心脏瓣膜功能评分均高于不良妊娠结局组,差异有统计学意义（均P＜0.05）。结论：随着胎儿心功能不全加重直至心力衰竭,CVPS逐渐降低,CVPS危险临界值为6.5,CVPS是连续动态评估胎儿心功能不全的有效指标。胎儿脐动脉频谱、静脉频谱及心脏瓣膜功能评分对预测不良妊娠结局具有一定价值。     

HLHS--congenital heart defect in High Risk Pregnancy Unit in 2001-2007

BACKGROUND: HLHS (hypoplastic left heart syndrome) is a serious congenital heart defect. In neonates with congenital heart disease HLHS accounts for nearly 25% of neonatal deaths. The etiology of HLHS is unknown. At present we expect to have those cases diagnosed in the second trimester of pregnancy. AIM: The main aim was to find the rate and outcome of the congenital heart defect--left heart hypoplasia (HLHS). MATERIAL AND METHODS: All cases of this heart defect found in the High Risk Pregnancy Clinic in 2001-2007 were presented. Twice the congenital malformation was diagnosed after delivery and once during pregnancy--in the second trimester. All babies were delivered between 38 and 39 weeks of pregnancy, one by the spontaneous normal delivery, one by elective caesarean section and one by emergency caesarean section because of fetal distress during the delivery. All of the newborns were transported to the Pediatric Cardio surgery Unit of M.U. and operated in first weeks after delivery. RESULTS: In two cases the operation was complicated and children died due to the cardiac arrest. One of the babies died before surgical correction. Two of the women, whose babies died after the operation gave birth to healthy newborns with no cardiac abnormalities. CONCLUSION: The HLHS is the most serious heart congenital malformation diagnosed often after the delivery because of lack of sufficient diagnostic system in healthy women. The prognosis for the children is bad, but the chance of giving birth to healthy children in the future is good.     

Pregnancy After Cardiac Transplantation: Principles of Nursing Care

The number of cardiac transplants for chronic end-stage disease, congenital heart disease, and primary pulmonary hypertension has increased during the past 20 years. Decreased symptoms, decreased incidence of rejection, and greater tolerance of medical regimens have improved the quality of life for heart transplant recipients. Women of childbearing age who have undergone cardiac transplantation may now consider pregnancy. The principles of nursing care for pregnant women who have undergone heart transplantation are presented in this article. A case report of pregnancy after cardiac transplantation is included.     

Maternal cardiac arrhythmias in pregnancy

OBJECTIVES: Perinatal care of women with cardiac arrhythmias is very important for every obstetrician. Maternal heart disease complicates 0.2 to 4% of pregnancies. DESIGN: The purpose of this study was to analyze the course of pregnancy, delivery and postpartum period pregnant women with cardiac arrhythmias MATERIALS AND METHODS: We analyzed 14 pregnant women with cardiac arrhythmias. hospitalized in the Department of Obstetrics of Medical University of Gdańsk, 1998-2003. Time of delivery, weight and length of neonates in patients with cardiac arrhythmias was presented. RESULTS: Delivery and postpartum period were uncomplicated in all the patients and no stimulation was used. In two women with congenital complete atrio-ventricular block dicavital heart stimulator was applied. All patients and infants were discharged from hospital in good condition. CONCLUSION: We found no cardiological complications during pregnancy in patients with cardiac arrhythmias.     

Maternal cardiac disease in pregnancy

The 2019 MBRRACE-UK report highlighted the prevalence of cardiac disease amongst pregnant women, and its role as a driver in maternal mortality. Advancing maternal age, a rise in cardiovascular co-morbidities, and the improvements in congenital heart disease care have all contributed to this static prevalence, despite improvements in obstetric and cardiac care. In this review we consider the importance of pre-conception counselling for women with known heart disease, review the physiological changes of pregnancy which place increased demand on the cardiovascular system, and explore maternal risk, from a cardiovascular perspective. Contemporary management of women with moderate to severe heart disease during pregnancy should be delivered by the pregnancy heart team, a term coined by the European Society of Cardiology in its 2018 guidelines. Individualized care empowers trust and shared decision making and early access to multidisciplinary care is vital in optimizing maternal and fetal outcomes.     

Costs of NHS maternity care for women with multiple pregnancy compared with high-risk and low-risk singleton pregnancy

Objective  To compare antenatal and obstetric costs for multiple pregnancy versus singleton pregnancy risk groups and to identify factors driving cost differentials.
Design  Observational study over 15 months (2001–02).
Setting  Four district hospitals in southeast England.
Population  Consecutive women with multiple pregnancy and singleton women with risk factors for fetal congenital heart disease (CHD) (pregestational diabetes, epilepsy, or family history of CHD) or Down syndrome, and a sample of low-risk singleton women.
Methods  Clinical care was audited from the second trimester anomaly scan until postnatal discharge, and the resource items were costed. Multiple regression analysis determined predictors of costs.
Main outcome measures  NHS mean costs of antenatal and obstetric care for different types of pregnancy.
Results  A total of 959 pregnancies were studied. Three percent of 243 women with multiple pregnancy reached 40 weeks of gestation compared with 54–55% of 163 low-risk and 322 Down syndrome risk women and 36% of 231 cardiac risk women. Antenatal costs for cardiac risk (£1,153) and multiple pregnancy (£1,048) were nearly double the costs for other two groups ( P < 0.001). As 63% of multiple births were delivered by caesarean section, the obstetric cost for multiple pregnancy (£3,393) was £1,000 greater overall. Pregestational diabetes was the most influential factor driving singleton costs, resulting in similar total costs for multiple pregnancy women (£4,442) and for women with diabetes (£4,877).
Conclusions  Our analyses confirm that multiple pregnancies are substantially more costly than most singleton pregnancies. Identifying women with diabetes as equally costly is pertinent because of the findings of the Confidential Enquiry into Maternal and Child Health that standards of maternal care for diabetics often are inadequate.     

Neonatal Outcome and Its Relationship with Maternal Age

The relationship between maternal age and neonatal outcome was examined in 22,689 pregnancies using various determinants of neonatal well-being which included evidence of fetal distress, birth-weight, Apgar scores, the necessity for admission to the neonatal unit and other indicators of neonatal morbidity. Differences in the incidence of congenital malformations and perinatal mortality were also studied. There was a trend towards more frequent fetal heart monitoring, lower birth-weight and a higher rate of neonatal unit admission for infants delivered by younger women. There was also a significant increase in the Caesarean section rate with advancing maternal age. Maternal age had no effect, however, on the incidence of fetal distress, Apgar score, the development of respiratory disease, the need for intubation and ventilation nor on subsequent neonatal central nervous system complications. There was also no association between maternal age and either perinatal mortality or the incidence of congenital malformations. The favourable outcome in teenagers in this study may have been influenced by the extremely low pregnancy rate amongst young adolescents in Hong Kong, but a similar outcome in the mature age women was likely to have reflected the recognition of risk and its appropriate management.     

Pregnancy in cases of congenital heart disease

Objective

To evaluate the maternal and fetal risks in women with various types of congenital heart disease. Methods: 348 women with various types of heart disease delivered during a period of 4 years 8 months from January 2003–August 2007. This is a prospective study of pregnancy outcome in 112 women with congenital heart disease. The ratio of CRHD:CHD was 1.91:1.

Results

The various common cardiac lesions were ASD-33, VSD-28, PS-9, co-arctation of aorta-8, PDA-7, TR-6, myxomatous mitral valve-6, bicuspid aortic valve-4, TGA-3 and TOF-3. We had more Muslim women with CHD in our study. 96.43% were in NYHAclass-I, 53.13% were diagnosed in the index pregnancy, 20.54% had prior surgical correction, 62.39% delivered vaginally and 37.62% had Cesarean section. Live births were 98.18%.

Conclusions

PNM was 1.81%. MMR was 1.78%. A high rate of PIH-23.63%, LBW-44.54% and IUGR-38.18% were noted. We have routinely advocated IE prophylaxis in CHD. PPH which causes hypotension should be avoided at all costs.     

The recurrence risk of adverse outcome in the second pregnancy in women with rheumatic disease1

OBJECTIVE: To study recurrence risks of adverse pregnancy outcome in the second pregnancy in women with rheumatic disease. METHODS: In a national population-based cohort study, women with rheumatic disease recorded from 1967 to 1995 in the Medical Birth Registry of Norway were compared with mothers without such diagnoses with regard to recurrence risks of adverse pregnancy outcomes in the second pregnancy. The odds ratios (ORs) of all outcomes were adjusted for maternal age, those of cesarean delivery for time period, and those of preeclampsia for interpregnancy interval. RESULTS: Women with rheumatic disease an dadverse pregnancy outcome in the first pregnancy had a statistically significant higher recurrence risk of the same event in the second pregnancy than women without rheumatic disease (preeclampsia: OR 2.22; 95% confidence interval [CI] 1.18, 4.19) (cesarean delivery: OR 1.52; 95% CI 1.05, 2.21) (preterm birth: OR 1.86; 95% CI 1.12, 3.11). In women with rheumatic disease diagnosed between the first and second births, a significantly increased recurrence risk of low birth weight occurred. Women with rheumatic disease also had a higher occurrence of markers for placental dysfunction (preeclampsia, preterm birth, or small for gestational age) in the second birth after any of these outcomes in the first birth (OR 1.35; 95% CI 1.02, 1.78) (35.1% versus 29.2%). CONCLUSION: The recurrence risk of an adverse outcome in the second pregnancy is increased in any woman, but was even higher in women with a rheumatic disease. These patients should be counseled accordingly, be closely monitored during pregnancy, and have access to appropriate subspecialists.