David Ouyang

Pregnancy Outcomes in Women With Congenital Heart Disease

Background— Pregnant women with congenital heart disease are at increased risk for cardiac and neonatal complications, yet risk factors for adverse outcomes are not fully defined. Methods and Results— Between January 1998 and September 2004, 90 pregnancies at age 27.7±6.1 years were followed in 53 women with congenital heart disease. Spontaneous abortions occurred in 11 pregnancies at 10.8±3.7 weeks, and 7 underwent elective pregnancy termination. There were no maternal deaths. Primary maternal cardiac events complicated 19.4% of ongoing pregnancies, with pulmonary edema in 16.7% and sustained arrhythmias in 2.8%. Univariate risk factors included prior history of heart failure (odds ratio [OR], 15.5), NYHA functional class ≥2 (OR, 5.4), and decreased subpulmonary ventricular ejection fraction (OR, 7.7). Independent predictors were decreased subpulmonary ventricular ejection fraction and/or severe pulmonary regurgitation (OR, 9.0) and smoking history (OR, 27.2). Adverse neonatal outcomes occurred in 27.8% of ongoing pregnancies and included preterm delivery (20.8%), small for gestational age (8.3%), respiratory distress syndrome (8.3%), intraventricular hemorrhage (1.4%), intrauterine fetal demise (2.8%), and neonatal death (1.4%). A subaortic ventricular outflow tract gradient >30 mm Hg independently predicted an adverse neonatal outcome (OR, 7.5). Cardiac risk assessment was improved by including decreased subpulmonary ventricular systolic function and/or severe pulmonary regurgitation (OR, 10.3) in a previously proposed risk index developed in pregnant women with acquired and congenital heart disease. Conclusions— Maternal cardiac and neonatal complication rates are considerable in pregnant women with congenital heart disease. Patients with impaired subpulmonary ventricular systolic function and/or severe pulmonary regurgitation are at increased risk for adverse cardiac outcomes.

Obstetric outcomes in pregnant women with congenital heart disease

BACKGROUND Predictors of adverse maternal and neonatal outcomes in pregnant women with congenital heart disease (CHD) have been described, but not for obstetrical outcomes. The primary aim of this study was to determine what risk factors predict sustaining adverse obstetric events in pregnant women with CHD. In addition, a secondary aim was to assess the impact of avoiding Valsalva on obstetrical outcomes, an intervention commonly recommended, but never studied. METHODS A retrospective cohort study examined outcomes in women with CHD who delivered between 1998 and 2005. We examined baseline cardiac characteristics in a multivariate logistic regression model to assess which were associated with adverse obstetric events. We also compared outcomes of women who avoided Valsalva versus those who were allowed to Valsalva. RESULTS The study included 65 women with 112 pregnancies. An adverse obstetric event occurred in 32.6% (n=32) of ongoing pregnancies, the most common being preterm delivery (n=19), post-partum hemorrhage (n=13), and preterm premature rupture of membranes (n=9). There were no independent predictors for sustaining an adverse obstetric event. Women who avoided Valsalva had increased rates of post-partum hemorrhage and 3rd/4th degree lacerations. CONCLUSIONS Although one-third of pregnancies were associated with an adverse obstetric outcome, these events could not be predicted by baseline hemodynamic characteristics. The routine practice of avoiding Valsalva may be associated with high rates of post-partum hemorrhage and 3rd/4th degree lacerations.

Development of a pregnancy-specific screening tool for sleep apnea.

STUDY OBJECTIVE The Berlin Questionnaire and Epworth Sleepiness Scale (ESS) are commonly used to screen for sleep apnea in non-pregnant populations. We sought to evaluate the Berlin and ESS in pregnancy and to determine whether an alternative screening approach could better detect sleep apnea in pregnant women. METHODS Pregnant women at high risk for sleep apnea (women with chronic hypertension, pre-gestational diabetes, obesity, and/or a prior history of preeclampsia) completed a sleep survey composed of the Berlin and ESS, and participated in an overnight sleep evaluation with the Watch-PAT100 (WP100), a wrist-mounted device designed to diagnose sleep apnea, defined as an apnea hypopnea index ≥ 5. Using multivariable statistics, demographic, clinical, and subjective symptoms that were independently associated with sleep apnea were determined and a prediction rule for the presence of sleep apnea was developed. The predictive capacity of this newly developed system was compared to that of the Berlin and ESS using receiver-operating curve (ROC) statistics. RESULTS Of the 114 women who participated and had a valid WP100 study, 100 completed the Berlin and 96 the ESS. The Berlin and ESS did not accurately predict sleep apnea in this high-risk pregnancy cohort, with ROC area under the curves (AUC) of 0.54 (p = 0.6) and 0.57 (p = 0.3), respectively. Conversely, a model incorporating frequent snoring, chronic hypertension, age, and body mass index performed significantly better (AUC 0.86, p > 0.001). CONCLUSION The Berlin and ESS are not appropriate tools to screen for sleep apnea in high-risk pregnant women. Conversely, our four-variable model more accurately predicts sleep apnea in pregnancy.

Clinical implementation of noninvasive prenatal testing among maternal fetal medicine specialists.

To assess the clinical implementation of non‐invasive prenatal testing (NIPT) among maternal‐fetal medicine (MFM) specialists.