Abstract

Background The mechanistic basis of the proposed relationship between maternal cardiac output and neonatal complications in pregnant women with heart disease has not been well elucidated. Methods and Results Pregnant women with cardiac disease and healthy pregnant women (controls) were prospectively followed with maternal echocardiography and obstetrical ultrasound scans at baseline, third trimester, and postpartum. Fetal/neonatal complications (death, small‐for‐gestational‐age or low birthweight, prematurity, respiratory distress syndrome, or intraventricular hemorrhage) comprised the primary study outcome. One hundred and twenty‐seven women with cardiac disease and 45 healthy controls were enrolled. Neonatal events occurred in 28 pregnancies and were more frequent in the heart disease group as compared with controls (n=26/127 or 21% versus n=2/45 or 4%; P=0.01). Multiple complications in an infant were counted as a single outcome event. Neonatal complications in the heart disease group were small‐for‐gestational‐age/low birthweight (n=18), prematurity (n=14), and intraventricular hemorrhage/respiratory distress syndrome (n=5). Preexisting obstetric risk factors (P=0.003), maternal cardiac output decline from baseline to third trimester (P=0.017), and third trimester umbilical artery Doppler abnormalities (P<0.001) independently predicted neonatal complications and were incorporated into a novel risk index in which 0, 1, and >1 predictor corresponded to expected complication rates of 5%, 30%, and 76%, respectively. Conclusions Decline in maternal cardiac output during pregnancy and abnormal umbilical artery Doppler flows independently predict neonatal complications. These findings will enhance the identification of higher risk pregnancies that would benefit from close antenatal surveillance.

Abstract

Abstract Objective: To validate and compare the performance of four risk stratification tools—the DEVI (Adverse Cardiac Events in Valvular Rheumatic Heart Disease in Pregnancy) score, Zwangerschap bij Aangeboren Hartafwijking (ZAHARA) score, Cardiac Disease in Pregnancy II (CARPREG II), and modified WHO (mWHO) classification—in predicting adverse cardiac events during pregnancy in women with valvular heart disease (VHD). Methods: This retrospective cohort study was conducted at Fernandez Hospital, a tertiary care referral center in Hyderabad, India, utilizing clinical data from pregnancies managed between January 2011 and December 2023. The primary outcome was the development of composite adverse cardiac events. Discriminative ability was assessed using the area under the receiver operating characteristic curve (AUC), calibration was evaluated via calibration plots, and clinical utility was determined by decision curve analysis (DCA). Categorical variables were reported as frequencies and percentages and continuous variables were presented as means with standard deviations or medians with interquartile ranges. Individual risk assessment was conducted using both the CARPREG II and DEVI risk stratification models, while the ZAHARA score was calculated by aggregating weighted parameters according to established scoring criteria. Results: The study enrolled 176 women and analyzed 205 pregnancies with adverse cardiac events in 19 pregnancies (9.3%). The DEVI score demonstrated superior discrimination (AUC = 0.846, 95% CI: 0.765-0.927, P < 0.001), followed by mWHO (AUC = 0.826, 95% CI: 0.736–0.917, P < 0.001), CARPREG II (AUC = 0.762, 95% CI: 0.652–0.872, P < 0.001), and ZAHARA (AUC = 0.716, 95% CI: 0.628–0.803, P < 0.001). Calibration plots revealed an overestimation of risk at higher probabilities for DEVI and CARPREG II. DCA indicated net clinical benefit for both tools at 10–30% threshold probabilities. Conclusion: The DEVI score showed the highest discriminative performance, though its calibration and clinical utility were comparable to CARPREG II. These findings support its use for risk stratification in pregnant women with VHD, particularly in resource-limited settings where rheumatic VHD predominates.

Abstract

Abstract Aims With a growing population of women with congenital heart disease (CHD), pregnancies in this group are expected to increase. However, pregnancy in women with CHD is associated with increased adverse outcomes for both mother and child. The aim of this study was to evaluate pregnancy and foetal complications in women with CHD and to test their association with the modified WHO (mWHO) classification. Methods and results Using two national registers, the national register for CHD and the Pregnancy Register, primiparous women giving birth between 2014 and 2019 were identified. Women with CHD, n = 829, and women without CHD, n = 4137, were matched by birth year and municipality in a ∼1:5 ratio. The women with CHD were classified according to the mWHO criteria. Caesarean deliveries (25.7 vs. 17.2%, P < 0.001), preterm delivery (10.3 vs. 6.4%, P < 0.001), and preeclampsia (6.2 vs. 4.1%, P = 0.007) were more common in women with CHD compared with controls. Using logistic regression, there was an association between high mWHO class (mWHO III, IV) and caesarean section [odds ratio (OR) 3.4, 95% confidence interval (CI) 1.8–6.7], preterm birth (<37 weeks) (OR 8.3, 95% CI 4.1–17.1), and preeclampsia (OR 3.8, 95% CI 1.5–9.9). Conclusion Pregnancy complications are more common in women with CHD. In women with CHD, the mWHO classification is associated with maternal complications and preterm birth. Thus, large national register data corroborate the advice provided in current guidelines, and the mWHO class is deemed a valuable risk stratification tool in women with CHD.

Abstract

<jats:sec sec-type="background" xml:lang="en"> <jats:title>Background</jats:title> <jats:p xml:lang="en">Current recommendations for delivery timing of pregnant persons with congenital heart disease (CHD) are based on expert opinion. Justification for early‐term birth is based on the theoretical concern of increased cardiovascular stress. The objective was to evaluate whether early‐term birth with maternal CHD is associated with lower adverse maternal or neonatal outcomes.</jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Methods and Results</jats:title> <jats:p xml:lang="en"> This is a retrospective cohort study of pregnant persons with CHD who delivered a singleton after 37 0/7 weeks gestation at a quaternary care center with a multidisciplinary cardio‐obstetrics care team between 2013 and 2021. Patients were categorized as early‐term (37 0/7 to 38 6/7 weeks) or full‐term (≥39 0/7) births and compared. Multivariable logistic regression was conducted to calculate the adjusted odds ratio for the primary outcomes. The primary outcomes were composite adverse cardiovascular, maternal obstetric, and adverse neonatal outcome. Of 110 pregnancies delivering at term, 55 delivered early‐term and 55 delivered full‐term. Development of adverse cardiovascular and maternal obstetric outcome was not significantly different by delivery timing. The rate of composite adverse neonatal outcomes was significantly higher in early‐term births (36% versus 5%, <jats:italic>P</jats:italic> &lt;0.01). After adjusting for confounding variables, early‐term birth remained associated with a significantly increased risk of adverse neonatal outcomes (adjusted odds ratio 11.55 [95% CI, 2.59–51.58]). </jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Conclusions</jats:title> <jats:p xml:lang="en">Early‐term birth for pregnancies with maternal CHD was associated with an increased risk of adverse neonatal outcomes, without an accompanying decreased rate in adverse cardiovascular or obstetric outcomes. In the absence of maternal or fetal indications for early birth, induction of labor before 39 weeks for pregnancies with maternal CHD should be reserved for routine obstetrical indications.</jats:p> </jats:sec>

Abstract

<jats:p>Cardio-obstetrics has emerged as an important multidisciplinary field that requires a team approach to the management of cardiovascular disease during pregnancy. Cardiac conditions during pregnancy include hypertensive disorders, hypercholesterolemia, myocardial infarction, cardiomyopathies, arrhythmias, valvular disease, thromboembolic disease, aortic disease, and cerebrovascular diseases. Cardiovascular disease is the primary cause of pregnancy-related mortality in the United States. Advancing maternal age and preexisting comorbid conditions have contributed to the increased rates of maternal mortality. Preconception counseling by the multidisciplinary cardio-obstetrics team is essential for women with preexistent cardiac conditions or history of preeclampsia. Early involvement of the cardio-obstetrics team is critical to prevent maternal morbidity and mortality during the length of the pregnancy and 1 year postpartum. A general understanding of cardiovascular disease during pregnancy should be a core knowledge area for all cardiovascular and primary care clinicians. This scientific statement provides an overview of the diagnosis and management of cardiovascular disease during pregnancy.</jats:p>