A Growing Problem: Maternal Death and Peripartum Complications Are Higher in Women With Grown-Up Congenital Heart Disease

doi:10.1016/j.athoracsur.2011.05.088

The Annals of Thoracic Surgery

Volume 92, Issue 6, December 2011, Pages 2193-2199

Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.

https://doi.org/10.1016/j.athoracsur.2011.05.088 Get rights and content

Background

As patients with grown-up congenital heart disease (GUCH) increase, more women with GUCH will become pregnant. Heart surgeons may be involved in maternal GUCH care, yet the prevalence, characteristics, and outcomes for these women are unknown. We determined the national prevalence of GUCH parturients, their diagnostic makeup, and whether they have increased risk of peripartum complications, maternal or fetal death.

Methods

We searched the Nationwide Inpatient Sample for women undergoing delivery in the United States between 1998 and 2007, with GUCH patients indicated by a code for “congenital cardiac diagnosis complicating pregnancy,” Patient and hospital characteristics were compared between women with and without GUCH. National estimates for maternal and fetal mortality, cardiac complications, induction, caesarean or surgically assisted birth, and preterm delivery were derived. Outcomes were compared between women with and without GUCH, and also within diagnostic GUCH subgroups.

Results

A total of 39.9 million births occurred, 26,973 (0.07%) of which were GUCH. Mean age was 27 years for both groups. Most common congenital diagnoses included ventricular septal defect (VSD) in 15%, aortic stenosis or insufficiency in 13%, atrial septal defect in 13%, pulmonary stenosis in 4%, and tetralogy of Fallot in 2%. Stillborn delivery was equivalent among groups. Maternal mortality was 18-fold higher in GUCH parturients (0.09%) compared with women without GUCH (0.005%; p < 0.001). Complications were higher for GUCH parturients compared with age-matched women, including cardiac complications (2.3% vs 0.2%), induction (37% vs 33%), caesarean or surgically assisted birth (45% vs 35%), and preterm delivery (10% vs 7%), p < 0.001 for all. A diagnosis of VSD was associated with the highest risk of maternal death and complications (p < 0.05 for all). More GUCH women delivered at teaching hospitals (58%) compared with women without GUCH (45%; p < 0.001).

Conclusions

The GUCH parturients, especially those with VSD, have increased risk of mortality and peripartum complications compared with other age-matched women. Despite these risks, nearly 50% of GUCH patients deliver at nonteaching hospitals. Current national practice patterns for GUCH women are inadequate, and outcomes could be improved by education and proper triage of even relatively “simple” GUCH lesions such as atrial septal defect and VSD. Further studies that investigate risk-adjusted outcomes in a variety of care settings are necessary to resolve this complex issue.

Section snippets

Material and Methods

The Nationwide Inpatient Sample (NIS) is a stratified, cross-sectional database that includes approximately 20% of all non-Veterans Affairs hospital discharges in the United States. The NIS is managed under the Health Care Cost and Utilization Project of the Agency for Healthcare Research and Quality [10]. To ensure the representative nature of the database, the NIS is stratified by geographical region, hospital bed size, teaching status, urban versus rural location, and hospital ownership. The

Patients

We identified 39.9 million births. Of these, 26,973 (0.07%) were among GUCH parturients. Non-GUCH deliveries increased 26% over the study period, and, as expected, these numbers approximated the US national birth rate (Fig 1A). The GUCH deliveries, however, increased by 43% over the study period (Fig 1B). Regarding baseline demographics, mean age in both groups was similar at 27 years of age. The majority of GUCH parturients (57.2%) delivered at urban teaching hospitals, but nearly 10% of GUCH

Comment

We have shown that the number of GUCH parturients is increasing more rapidly than nonGUCH women during the last 10 years (43% vs 26%). The GUCH women continue to have higher mortality and a higher prevalence of obstetric and cardiac complications compared with non-GUCH parturients, and these risks are not mitigated by the current national practice patterns.

Although congenital heart surgeons may not be the primary caregivers for GUCH parturients, it is critical that surgeons (as part of a

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Cited by (39)

Maternal and neonatal outcomes in women with congenital heart disease: A nationwide population-based study
2024, Journal of the Formosan Medical Association
We evaluated the outcomes of pregnancy in women with congenital heart disease (CHD) and their offspring in Taiwan. We also investigated how different severity levels may influence the outcomes.
We used data (2009–2017) from the Birth Certificate Application database in Taiwan, which is linked to the National Health Insurance Research Database and Taiwan Maternal and Child Health Database. We identified 2990 women with CHD who had 4227 births. Based on the CHD subtypes, patients were further divided into “severe CHD” and “simple CHD” groups.
Women with CHD have a significant risk of stillbirth. In maternal cardiac events, they had the highest risk of heart failure, followed by arrhythmia. The severity of CHD had a significant effect on the outcomes as well. The neonatal birth event that mothers with CHD have the highest risk of is preterm birth at < 32 weeks of gestation. The prominent difference in neonatal morbidities between mothers with severe and simple CHD is recurrent CHD in the offspring. The offspring of the severe CHD group had a higher risk of severe CHD, whereas those of the simple CHD group had a higher risk of simple CHD.
During pregnancy, the monitoring of heart function and cardiac rhythm could be more intensive in mothers with CHD. In addition to accurately assessing fetal growth and development during antenatal care, mothers with severe CHD should be provided with careful fetal heart structure assessment and genetic testing along with counseling.
Delivering Coordinated Cardio-Obstetric Care from Preconception through Postpartum
2021, Cardiology Clinics
Citation Excerpt :
Although the event rate of CV complications is fairly low (6%–12%),86,87 their potential repercussions are devastating.18,27,60,75–77 This is also a high-risk period for women to fall through the cracks of a fragmented health care system.76 During the postpartum period, women are often transitioning from inpatient to outpatient care and out of the obstetrics space and into the primary care setting.35,88
Contraceptive methods of privately insured US women with congenital heart defects
2020, American Heart Journal
Citation Excerpt :
Our findings suggest, even among women with cardiology and/or OB-GYN provider visits, there may be missed opportunities to increase safe, effective contraceptive use among women with CHD who wish to avoid pregnancy. Recent AHA1 recommendations advise that women with CHD be counseled about risks associated with pregnancy and safe, effective contraceptive options as soon as possible post-menarche, as women with CHD are at higher risk of adverse pregnancy outcomes and pregnancy may exacerbate pre-existing heart conditions.1,16,18,19 In addition, among a similar population of privately insured women with CHD, recent research indicates that, in the year before pregnancy, less than 1% of women with CHD received all AHA-recommended preconception care and nearly one in 10 of these women filled a prescription for a FDA category D or X cardiac-related medication.2
The American Heart Association recommends women with congenital heart defects (CHD) receive contraceptive counseling early in their reproductive years, but little is known about contraceptive method use among women with CHD. We describe recent female sterilization and reversible prescription contraceptive method use by presence of CHD and CHD severity in 2014.
Using IBM MarketScan Commercial Databases, we included women aged 15 to 44 years with prescription drug coverage in 2014 who were enrolled ≥11 months annually in employer-sponsored health plans between 2011 and 2014. CHD, CHD severity, contraceptive methods, and obstetrics-gynecology and cardiology provider encounters were identified using billing codes. We used log-binomial regression to calculate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to compare contraceptive method use overall and by effectiveness tier by CHD presence and, for women with CHD, severity.
Recent sterilization or current reversible prescription contraceptive method use varied slightly among women with (39.2%) and without (37.3%) CHD, aPR = 1.04, 95% CI [1.01-1.07]. Women with CHD were more likely to use any Tier I method (12.9%) than women without CHD (9.3%), aPR = 1.41, 95% CI [1.33-1.50]. Women with severe, compared to non-severe, CHD were less likely to use any method, aPR = 0.85, 95% CI [0.78-0.92], or Tier I method, aPR = 0.84, 95% CI [0.70-0.99]. Approximately 60% of women with obstetrics-gynecology and <40% with cardiology encounters used any included method.
There may be missed opportunities for providers to improve uptake of safe, effective contraceptive methods for women with CHD who wish to avoid pregnancy.
Perinatal outcomes and long-term offspring cardiovascular morbidity of women with congenital heart disease
2020, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Nevertheless, the risk for pediatric long-term cardiovascular morbidity was not greater among offspring of women with congenital heart disease. The association between maternal congenital heart disease and cesarean delivery rates has been previously investigated. [8,16,17] Roos-Hesselink et al. [16] reported a significantly higher cesarean delivery rate among mothers with congenital heart disease compared to the general population.
Due to advances in medical care available for patients with congenital heart disease, these patients now have a longer life span. As a result, the number of pregnancies of mothers with congenital heart disease has increased. The purpose of the current study was to evaluate perinatal outcomes of women with congenital heart disease and to examine long-term cardiovascular morbidity of offspring to mothers with congenital heart disease.
A population-based cohort analysis was performed including all singleton deliveries occurring between years 1991–2014 at Soroka University Medical Center. The primary exposure was defined as maternal congenital heart disease. Short-term perinatal outcomes as well as long-term cardiovascular related hospitalizations of the offspring up to the age of 18 years were compared between women with and without congenital heart disease. To compare perinatal outcomes between the two study groups, we conducted a Generalized Estimation Equation (GEE) model accounting for maternal age and multiple occurrence in the cohort, parity, fertility treatment, smoking and induction of labor. To compare cumulative long-term cardiovascular morbidity, we compared cardiovascular hospitalization incidence of offspring of mothers with and without congenital heart disease using Kaplan-Meier survival curve and Weibull regression analysis to control for maternal age, diabetes, smoking, hypertension, birth weight, and cesarean delivery.
During the study period 243,313 deliveries met the inclusion criteria, of which 369 were of mothers with congenital heart disease. Maternal congenital heart disease was found to be an independent risk factor for low birth weight (adjusted OR = 1.5 CI 95 % 1.06–2.32, p=0.022) and cesarean delivery (adjusted OR = 1.4 CI 95 % 1.09–1.86, p = 0.008). Mothers with congenital heart disease also had higher risk for placental abruption, but it was not statistically significant (adjusted OR = 2.3 CI 95 % 0.87–6.16, p = 0.09). Long-term cardiovascular morbidity was comparable between the groups (Log rank p = 0.251; adjusted HR = 1.6 CI 95 % 0.62–4.42, p = 0.313).
In conclusion, pregnancies of women with congenital heart disease are at an increased risk for adverse short-term perinatal outcomes, such as low birth weight and cesarean delivery. However, we did not find an increase in long-term cardiovascular morbidity among offspring of these women; still this association cannot be ruled out.
Maternal Comorbidities and Complications of Delivery in Pregnant Women With Congenital Heart Disease
2019, Journal of the American College of Cardiology
Pregnant women with congenital heart defects (CHDs) may be at increased risk for adverse events during delivery.
This study sought to compare comorbidities and adverse cardiovascular, obstetric, and fetal events during delivery between pregnant women with and without CHDs in the United States.
Comorbidities and adverse delivery events in women with and without CHDs were compared in 22,881,691 deliveries identified in the 2008 to 2013 National Inpatient Sample using multivariable logistic regression. Among those with CHDs, associations by CHD severity and presence of pulmonary hypertension (PH) were examined.
There were 17,729 deliveries to women with CHDs (77.5 of 100,000 deliveries). These women had longer lengths of stay and higher total charges than women without CHDs. They had greater odds of comorbidities, including PH (adjusted odds ratio [aOR]: 193.8; 95% confidence interval [CI]: 157.7 to 238.0), congestive heart failure (aOR: 49.1; 95% CI: 37.4 to 64.3), and coronary artery disease (aOR: 31.7; 95% CI: 21.4 to 47.0). Greater odds of adverse events were observed, including heart failure (aOR: 22.6; 95% CI: 20.5 to 37.3), arrhythmias (aOR: 12.4; 95% CI: 11.0 to 14.0), thromboembolic events (aOR: 2.4; 95% CI: 2.0 to 2.9), pre-eclampsia (aOR: 1.5; 95% CI: 1.3 to 1.7), and placenta previa (aOR: 1.5; 95% CI: 1.2 to 1.8). Cesarean section, induction, and operative vaginal delivery were more common, whereas fetal distress was less common. Among adverse events in women with CHDs, PH was associated with heart failure, hypertension in pregnancy, pre-eclampsia, and pre-term delivery; there were no differences in most adverse events by CHD severity.
Pregnant women with CHDs were more likely to have comorbidities and experience adverse events during delivery. These women require additional monitoring and care.
Management of Pregnancy With Underlying Congenital and Acquired Cardiac Disease
2017, Encyclopedia of Cardiovascular Research and Medicine
Heart disease complicates 1% of all pregnancies with a quarter of all pregnancy-related maternal deaths related to cardiovascular causes. A half of those deaths are felt to be due to substandard care highlighting the need for a better understanding of the hemodynamics of pregnancy in such women. Risk stratification for the woman and fetus during pregnancy has led to three approaches with the modified WHO classification outperforming the ZAHARA and CARPREG scores. Prudent preconception counseling is paramount, and a thoughtful approach to labor and delivery is required. A detailed discussion of the approaches to anticoagulation is also provided.

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Original articlePediatric cardiacA Growing Problem: Maternal Death and Peripartum Complications Are Higher in Women With Grown-Up Congenital Heart Disease

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Patients

Comment

J Am Coll Cardiol

Prog Paediatr Cardiol

Ann Thorac Surg

J Am Coll Cardiol

Ann Thorac Surg

National practice patterns for management of adult congenital heart disease: operation by pediatric heart surgeons decreases in-hospital death

Circulation

Retrospective analysis of outcome of pregnancy in women with congenital heart disease: single-centre experience from North India

Aus N Z J Obstet Gynaecol

Near misses and disasters in the treatment of grown-up congenital heart patients

J R Soc Med

Pregnancy-related health behavior of women with congenital heart disease: room for behavioral change interventions

Congenit Heart Dis

What do adult patients with congenital heart disease know about their disease, treatment, and prevention of complications?A call for structured patient education

Heart

Original article
Pediatric cardiac
A Growing Problem: Maternal Death and Peripartum Complications Are Higher in Women With Grown-Up Congenital Heart Disease