Pregnancy-related obstetric and cardiologic problems in women after atrial switch operation for transposition of the great arteries.

BACKGROUND: The number of women with congenital heart disease reaching reproductive age has increased due to therapeutic advances. The aim of this study was to examine obstetric and cardiac problems during pregnancy after Mustard/Senning repair for transposition of the great arteries. METHODS AND RESULTS: Sixty pregnancies in 34 women from 3 centers were studied. The women were interviewed, and their records reviewed for clinical status and diagnostic evaluation. Age range was 16-34 years during first pregnancy, and all were in a low functional class. There were 11 miscarriages and 5 abortions. Of 44 successful pregnancies, 20 were vaginal deliveries and 24, cesarean sections. A total of 25% were delivered prematurely. Thirteen babies had birth weight <2,500g. Deterioration in functional class occurred in 7 pregnancies, without recovery in 5. Deterioration in systolic function occurred in 4 of 44 echocardiographically documented pregnancies, without recovery in 75%. In 2 women resuscitation was necessary during delivery, in 1, supraventricular tachycardia occurred during labor. CONCLUSIONS: Pregnancy is usually well-tolerated, but outcome is unforeseeable and life-threatening problems can occur. These women belong in cardiac care conducted by experienced congenital cardiologists, who systematically check for typical residua. The pregnancy should be planned and gynecologists/obstetricians with special expertise integrated into the consultations. During delivery a congenital cardiologist, and an anesthetist experienced in congenital cardiology, should be present for possible severe cardiac events.

What is the "normal" fetal heart rate?

Aim. There is no consensus about the normal fetal heart rate. Current international guidelines recommend for the normal fetal heart rate (FHR) baseline different ranges of 110 to 150 beats per minute (bpm) or 110 to 160 bpm. We started with a precise definition of "normality" and performed a retrospective computerized analysis of electronically recorded FHR tracings. Methods. We analyzed all recorded cardiotocography tracings of singleton pregnancies in three German medical centers from 2000 to 2007 and identified 78,852 tracings of sufficient quality. For each tracing, the baseline FHR was extracted by eliminating accelerations/decelerations and averaging based on the "delayed moving windows" algorithm. After analyzing 40% of the dataset as "training set" from one hospital generating a hypothetical normal baseline range, evaluation of external validity on the other 60% of the data was performed using data from later years in the same hospital and externally using data from the two other hospitals. Results. Based on the training data set, the "best" FHR range was 115 or 120 to 160 bpm. Validation in all three data sets identified 120 to 160 bpm as the correct symmetric "normal range". FHR decreases slightly during gestation. Conclusions. Normal ranges for FHR are 120 to 160 bpm. Many international guidelines define ranges of 110 to 160 bpm which seem to be safe in daily practice. However, further studies should confirm that such asymmetric alarm limits are safe, with a particular focus on the lower bound, and should give insights about how to show and further improve the usefulness of the widely used practice of CTG monitoring.

Advanced metastatic melanoma during pregnancy: a multidisciplinary challenge.

BACKGROUND: Metastatic melanoma during pregnancy represents a life-threatening situation not only for the mother but also for the fetus due to aggressive therapy and potential maternal-fetal metastasis. CASE REPORT: We report the case of a 37-year-old woman with advanced metastatic malignant melanoma during her first pregnancy, with a review of the literature. In this case, a tight and primarily interdisciplinary obstetrical and dermatological case management enabled the delivery of a small but healthy premature infant in the 29th week of gestation by planned Cesarean section. However, due to progressive disease, the mother died only 10 weeks after the delivery of the baby. CONCLUSION: Sufficient perinatal and oncologic experience provided, diagnostic and surgical interventions as well as radiotherapy and chemotherapy in metastatic melanoma disease are feasible and relatively safe even during pregnancy.