Prospective multicenter study of pregnancy outcomes in women with heart disease.

BACKGROUND: The maternal and neonatal risks associated with pregnancy in women with heart disease receiving comprehensive prenatal care have not been well defined. METHODS AND RESULTS: We prospectively enrolled 562 consecutive pregnant women with heart disease and determined the outcomes of 599 pregnancies not ending in miscarriage. Pulmonary edema, arrhythmia, stroke, or cardiac death complicated 13% of pregnancies. Prior cardiac events or arrhythmia, poor functional class or cyanosis, left heart obstruction, and left ventricular systolic dysfunction independently predicted maternal cardiac complications; the cardiac event rate can be predicted using a risk index incorporating these predictors. Neonatal complications (20% of pregnancies) were associated with poor functional class or cyanosis, left heart obstruction, anticoagulation, smoking, and multiple gestations. CONCLUSIONS: Pregnancy in women with heart disease is associated with significant cardiac and neonatal complications, despite state-of-the-art obstetric and cardiac care. Maternal cardiac risk can be predicted with the use of a risk index.

Congenital heart disease in pregnancy.

Care of pregnant patients with congenital heart disease requires understanding of the specific congenital defect, the nature of previous surgical correction, and the residua and sequelae. General risks and principles can be adduced in management decisions. In addition, lesion- and patient-specific details are important. There are only a few conditions that place patients at a high enough risk to advise that pregnancy be avoided under all circumstances (pulmonary vascular obstructive disease, Marfan syndrome with dilated aortic root, severe aortic stenosis, and severe systemic ventricular dysfunction). Preconception counseling, optimization of status, and meticulous multidisciplinary management during pregnancy and the postpartum period will improve outcomes.

Risk and predictors for pregnancy-related complications in women with heart disease.

BACKGROUND: The physiological changes of pregnancy can result in cardiovascular complications in the mother, which in turn may have fetal implications. Prior studies have focused on specific cardiac lesions or identified univariate predictors. There is a need to refine the risk stratification of women with heart disease so they can receive appropriate obstetrical counseling and care. METHODS AND RESULTS: We examined the outcomes of 221 women with heart disease who underwent 276 pregnancies and received their obstetrical care at three Toronto hospitals from 1986 through 1994. Those who underwent therapeutic abortions were excluded. Among the study participants, there were 24 miscarriages and 252 completed pregnancies (pregnancies not ending in miscarriage). Maternal heart failure, arrhythmia, or stroke occurred in 45 completed pregnancies (18%). There were no maternal deaths. Poor maternal functional class or cyanosis, myocardial dysfunction, left heart obstruction, prior arrhythmia, and prior cardiac events were predictive of maternal cardiac complications. These predictors were incorporated into a point score that can be used to estimate the probability of a cardiac complication in the mother. The rate of cardiac complications for a patient with 0, 1, and >1 of the above factors was 3%, 30%, and 66%, respectively. Neonatal complications occurred in 42 completed pregnancies (17%). Neonatal events included death (2), respiratory distress syndrome (16), intraventricular hemorrhage (2), premature birth (35), and small-for-gestational-age birth weight (14). Poor maternal functional class or cyanosis was predictive of neonatal events. CONCLUSIONS: Despite low maternal and neonatal mortality, pregnancy in women with heart disease is associated with significant cardiac and neonatal morbidity. The probability of maternal cardiac or neonatal events can be predicted from baseline characteristics of the mother.

Pregnancy after the fontan procedure for tricuspid atresia. A case report.

BACKGROUND: Pregnancy is contraindicated in uncorrected tricuspid atresia. Even following palliative surgery with the Fontan procedure, only four pregnancies have been reported. CASE: A 32-year-old female presented at 8 weeks' gestation in her first pregnancy with a history of the Fontan procedure performed seven years earlier for cardiac decompensation despite two previous palliative procedures for tricuspid atresia. She remained class I with no deterioration and required no medication throughout the pregnancy. Amniocentesis for positive maternal alpha-fetoprotein screening was normal. The pregnancy was complicated by antepartum hemorrhage at 29 weeks and premature rupture of membranes at 33 weeks, resulting in preterm labor and delivery of a 2.5-kg infant five days later. Apart from postpartum hemorrhage, the puerperium was uneventful, and the patient was well 20 weeks after delivery. CONCLUSION: Five similar pregnancies, including this one, have been reported. Although all were successful, three infants were preterm and two growth retarded. This observation suggests that for these patients, pregnancy must be monitored closely even though the mothers may be hemodynamically stable.

Pregnancy and functional deterioration in a woman with a univentricular heart. A case report.

A patient who had undergone Pott's procedure and a right Blalock-Taussig shunt in childhood for complex cyanotic congenital heart disease with a single ventricle presented with a planned pregnancy at age 22. Although asymptomatic prior to pregnancy, she experienced functional deterioration from the first trimester and had preterm labor with a footling breech presentation at 29 weeks following prelabor rupture of the membranes. A normal, 900-g female infant was delivered by cesarean section. Despite delivery the patient continued to experience progressive functional deterioration and returned to her prepregnancy cardiac status only after a Fontan operation, performed 14 months postpartum.

Pregnancy following surgical correction for transposition of the great arteries.

OBJECTIVE: To determine the maternal and fetal outcomes in pregnant patients with prior surgical correction of dextro-transposition of the great arteries. METHODS: A retrospective review was conducted of seven pregnancies managed from 1986-1992 in four women who had surgical correction for dextro-transposition of the great arteries. RESULTS: Three of the four patients had had the Mustard operation and the other had had the Rastelli operation. There were no maternal deaths. One patient who received the Mustard operation experienced functional deterioration in the last of three pregnancies, so it was terminated. Three of the remaining six pregnancies resulted in preterm deliveries, but there was no perinatal mortality and no infants had congenital heart disease. CONCLUSION: Maternal outcome can be satisfactory and the perinatal outcome good in patients with surgically corrected dextro-transposition of the great arteries.

Congenital aortic stenosis and pregnancy--a reappraisal.

OBJECTIVE: This study was performed to determine the maternal and fetal outcome in pregnant patients with congenital aortic stenosis without previous valvular replacement. STUDY DESIGN: A retrospective review of 25 pregnancies in 13 patients delivered at our centers from September 1976 to September 1992 was undertaken. RESULTS: Five (38%) patients had associated congenital heart lesions, three (23%) had severe stenosis (echocardiographically estimated valve area < or = 0.7 cm2), two had prior open aortic valve commissurotomy, and one had balloon valvuloplasty during pregnancy. There were no maternal deaths. Of the 25 pregnancies, five (20%) resulted in therapeutic abortions. There was no perinatal mortality, preterm labor, or increased incidence of pregnancy complications or fetal growth retardation in the remaining 20 pregnancies. One infant (5%) had congenital heart disease. CONCLUSION: Pregnancy outcome is generally satisfactory in patients with congenital aortic stenosis.

Torsade de pointes ventricular tachycardia. A complication of disopyramide shared with quinidine.

Two cases of documented torsade de pointes ventricular tachycardia in association with the use of disopyramide are described. One patient had previously experienced an episode suggestive of quinidine induced ventricular tachycardia while the other developed ventricular tachycardia during quinidine treatment which was later exacerbated and sustained by the administration of disopyramide. Both patients exhibited a prolonged QTc or QUc interval at the time of the arrhythmia. These cases suggest that a propensity of ventricular arrhythmias induced by quinidine may identify individuals who are likely to develop similar arrhythmias disopyramide treatment as well.