Pregnancy outcomes in women with heart disease: Experience of a tertiary center in the Netherlands.

OBJECTIVES: Clinical data of pregnant women with heart disease were obtained with the intention to provide input for local counseling and management guidelines. STUDY DESIGN: Retrospective data from all pregnant women with congenital or acquired heart disease between 2000 and 2011 in the VU University Medical Centre Amsterdam. MAIN OUTCOME MEASURES: Maternal and neonatal outcomes were evaluated. RESULTS: Data of 122 women with 160 pregnancies were obtained. The most common heart diseases were congenital heart disease (n=65, 53.3%) and arrhythmia (n = 20, 16.4%). Based on the functional criteria of the New York Heart Association (NYHA), 114/122 patients (93.4%) were classified NYHA class I-II. Patients in NYHA class III-IV (n = 8/122, 6.6%), mainly had a history of myocardial infarction or pulmonary hypertension. There were 156 singleton and 4 twin pregnancies. 22 (13.5%) pregnancies were complicated by hypertensive disorders. Heart failure developed in 11 women (9.0%), 37.5% in NYHA class III-IV and 6.5% in NYHA class I-II. Mean gestational age and birth weight were 270 days and 3196 g in NYHA class I-II compared to 237 days and 1972 g for NHYA class III-IV. There were two maternal deaths (1.6%) and 5 fetal deaths (3.1%). There were 29 (12.8%) preterm births, 20 (12.8%) neonates small for gestational age and 34 (21.8%) admittances on the Neonatal Intensive Care Unit (NICU). CONCLUSIONS: Pregnancy in women with pre-existing heart disease in all NYHA classes is associated with increased maternal morbidity and perinatal morbidity. Risk of structural fetal anomalies is especially high in women with congenital heart disease.

Cervical tourniquet in case of uncontrollable haemorrhage during caesarean section owing to a placenta accreta.

This case report describes a 38-year-old woman in whom a primary caesarean section for placenta previa was complicated by postpartum haemorrhage due to a placenta accreta. Despite tamponade with a Bakri balloon and placement of a B-Lynch suture, the amount of blood loss could not be effectively reduced. The blood loss was eventually minimised by the placement of a Penrose drain around the cervix as a cervical tourniquet. We think that a cervical tourniquet is an effective method of stopping haemorrhage during caesarean section, as shown in this case report, and we consider this technique to be a valuable addition to several existing methods through which fertility is preserved by preventing emergency hysterectomy.

PP150. Pregnancy outcome in women with heart disease in a single tertiary care center.

INTRODUCTION: The number of women presenting with cardiac disease during pregnancy is increasing because more women with repaired congenital heart disease are reaching childbearing age and because of more pregnancies occurring in women with ischemic heart disease. Cardiac disease is the leading cause of indirect maternal mortality in the Netherlands. OBJECTIVES: Clinical data of pregnant women with heart disease that received obstetric care and delivered in our center have been obtained with the intention to evaluate the cardiac and obstetric pregnancy outcomes and to provide data for local counseling and management guidelines. METHODS: Data were collected from all pregnant women with congenital or acquired heart disease who delivered between 2000 and 2010 in the VU University Medical Center Amsterdam. At least one consultation of a cardiologist during pregnancy was advised. The maternal outcomes of these pregnancies were evaluated. RESULTS: Data of 122 women with 160 pregnancies were obtained. In this study the main heart diseases in pregnancy were congenital heart disease (n=75.61%) and arrhythmia (n=22.18%). Rheumatic heart disease was accountable for 6% (n=7) and ischemic heart disease for 4% (n=5) of inclusions. Based on the functional criteria of the New York Heart Association (NYHA), 114/122 patients (93.4%) were classified NYHA Class I-II. Patients in NYHA Class III-IV (n=8/122, 6.6%), mainly had a history of myocardial infarction or pulmonary hypertension. Of all the women, 35 had cardiac surgery before pregnancy, mainly repair of congenital heart disease. In women with acquired heart disease the interventions before pregnancy included permanent cardiac pace-maker implantation (n=2), radiofrequency catheter ablation (RFCA) (n=4) and percutaneous transluminal coronary angioplasty or coronary artery bypass graft (n=4). There were 156 singleton and 4 twin pregnancies. Termination of pregnancy was performed in 3 cases; 1 for maternal cardiac and 2 for obstetric indications. There were 156 life-births of which 100 (64.1%) were spontaneous vaginal deliveries, 17 (10.9%) operative vaginal deliveries and 39 (25%) cesarean sections: 9 for maternal cardiac indication and 30 for obstetric reasons. 36 (36%) women received epidural analgesia during labor and delivery. Cesarean section under general anesthesia was performed in 14 cases (7 for maternal cardiac indication); 25 were performed under spinal/epidural anesthesia. Induction of labour occurred in 48 pregnancies: 10 for maternal cardiac indications and 38 for other maternal and fetal indications. 28 (17.5%) pregnancies were complicated by hypertensive disorders. Cardiac complications such as heart failure developed in 15 (9.4%) pregnancies. There were two maternal deaths (1.6%). CONCLUSION: Congenital heart disease is the type of heart disease that has the highest incidence in pregnancy, while main types of heart disease that lead to impaired cardiac function during pregnancy are ischemic disease and pulmonary hypertension. Incidence of pregnancy induced hypertensive disorders is increased in women with preexistent cardiac disorders. Maternal outcome is generally favourable for women with cardiac heart in NYHA class I/II.

[Mortality in pregnant and newly delivered women due to psychiatric disorders]. / Sterfte bij zwangeren en kraamvrouwen door psychiatrische stoornissen.

Two women, aged 28 and 37 years, both suffering from a psychiatric disorder i.e. puerperal psychosis and mood-disorder respectively, violently ended their lives at 12 days and 5 months after delivery. Early identification of risk factors in a multidisciplinary setting can lead to effective early management of psychiatric disorders during pregnancy and the puerperium. Negative outcomes such as suicide and even infanticide may consequently be prevented. The most common risk factors for suicide during pregnancy and the puerperium are: a history of psychiatric disorders, a family history of psychiatric disorders and current psychiatric symptomatology. Important recommendations to reduce maternal mortality due to psychiatric disorders include improvement of communication between health professionals and systematic registration of maternal mortality.