Planned vaginal delivery and cardiovascular morbidity in pregnant women with heart disease.

Abstract

BACKGROUND\nThough consensus guidelines on the management of cardiovascular disease (CVD) in pregnancy reserve cesarean delivery for obstetric indications, there is a paucity of data to support this approach.\n\n\nOBJECTIVES\nTo compare cardiovascular and obstetric morbidity in women with cardiovascular disease (CVD) according to plan for vaginal birth or cesarean delivery.\n\n\nSTUDY DESIGN\nWe assembled a prospective cohort of women delivering at an academic tertiary care center with a protocolized multidisciplinary approach to management of CVD between September 2011 and December 2016. Our practice is to encourage vaginal birth in women with CVD unless there is an obstetric indication for cesarean delivery. We allow women attempting vaginal birth a trial of Valsalva in the second stage with the ability to provide operative vaginal delivery if pushing leads to changes in hemodynamics or symptoms. Women were classified according to planned mode of delivery-either vaginal birth or cesarean delivery. We then used univariate analysis to compare adverse outcomes according to planned mode of delivery. The primary composite cardiac outcome of interest included sustained arrhythmia, heart failure, cardiac arrest, cerebral vascular accident, need for cardiac surgery or intervention, or death. Secondary obstetric and neonatal outcomes were also considered.\n\n\nRESULTS\nWe included 276 consenting women with congenital heart disease (68.5%), arrhythmias (11.2%), connective tissue disease (9.1%), cardiomyopathy (8.0%), valvular disease (1.4%) or vascular heart disease (1.8%) at or beyond 24 weeks gestation. Seventy-six percent (n=210) planned vaginal birth and 24% (n=66) planned cesarean delivery. Women planning vaginal birth had lower rates of left ventricular outflow tract obstruction, multiparity, and preterm delivery. All women attempting vaginal birth were allowed to Valsalva. Among planned vaginal deliveries 86.2% (n=181) were successful with a 9.5% operative vaginal delivery rate. Five women underwent operative vaginal delivery for the indication of cardiovascular disease without another obstetric indication at the discretion of the delivering provider. Four of these patients tolerated trials of Valsalva ranging from 15 to 75 minutes prior to delivery. Adverse cardiac outcomes were similar between planned vaginal birth and cesarean delivery groups (4.3% v. 3.0%, p=1). Rates of postpartum hemorrhage (1.9% v. 10.6%, p<0.01) and transfusion (1.9% v. 9.1%, p=0.01) were lower in the planned vaginal birth group. There were no differences in adverse cardiac, obstetric or neonatal outcomes in the cohort overall or the subset of women with high-risk CVD or a high burden of obstetric comorbidity.\n\n\nCONCLUSIONS\nThese findings suggest that cesarean delivery does not reduce adverse cardiovascular outcomes and lend support to a planned vaginal birth for the majority of women with CVD including those with high-risk disease.