Jack M. Colman

Pregnancy complicated by heart disease: a review of Canadian experience

The physiological adaptations to pregnancy can potentially worsen the prognosis in women whose pregnancy is complicated by heart disease. A comprehensive systematic approach to risk identification is desirable. The ability to predict a subgroup of women that are at a particularly increased risk of pregnancy-related complications can enhance the obstetric care we provide to this population. A retrospective review of 276 pregnancies associated with pre-existing heart disease was undertaken in three Toronto teaching institutions. During the course of the pregnancy, 45 (18%) of 252 completed gestations were complicated by adverse cardiovascular events (congestive heart failure, arrhythmia and stroke). 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 converted into a point score. If a point score was 0, 1 or more than 1, the risk of a given patient running into cardiovascular complication was 3%, 30% and 66%, respectively. The Canadian Prospective Multicenter Study offered the validation of this prediction rule. In this study, 13 centres recruited prospectively 599 patients with completed gestations. Similar factors were identified in their ability to predict adverse cardiac events. In addition, neonatal complications (20% of pregnancies) were associated with poor functional class or cyanosis, left heart obstruction, anticoagulation, smoking and multiple gestation. A sample of this prospective cohort (302 pregnancies) was compared to 572 matched pregnancies with no underlying heart disease. The neonatal complication rate was higher in the study group when compared to controls, 18% versus 7%, respectively. The highest neonatal complication rate (33%) was seen in gravidas with underlying heart disease who had previously identified cardiac risk factors, were at both extremes of reproductive age, had obstetrical risk factors, smoked or received anticoagulants. Both maternal and neonatal morbidity are increased significantly in gravidas with pre-existing heart disease, although mortality is low. Factors that place the mother and the neonate at risk can be identified before pregnancy. This allows informed counselling and development of a patient-specific management plan.

A Contemporary Approach to the Obstetric Management of Women with Heart Disease

OBJECTIVES Recommendations for the peripartum obstetric management of women with heart disease have included early induction of labour, shortening the second stage of labour during vaginal delivery, and low threshold for elective Caesarean section, although such techniques may result in complications. The objective of this study was to determine whether a less aggressive approach without routine preterm induction, shortening of the second stage, or Caesarean section adversely affects the mother or neonate. METHODS We examined peripartum obstetric management and its relationship with adverse maternal and neonatal outcomes in 1677 pregnancies: 559 in women with heart disease and 1118 in women without heart disease (control subjects). Logistic regression with propensity matching was used to compare outcomes in women with and without heart disease. RESULTS Women with heart disease were more likely than control subjects to undergo induction of labour (P < 0.001). Induction of labour tended to be at term and for logistical reasons, not for the indication of maternal heart disease. Assisted vaginal deliveries were more common in women with heart disease (29% vs. 11%, P < 0.001) than in those without, and the second stage of labour was also more prolonged in women with heart disease. Rates of Caesarean section were similar in both groups (P = 0.66). A significant proportion of women with heart disease had unassisted vaginal deliveries. Invasive cardiac monitoring was rarely used. Adverse maternal cardiac events at delivery were rare (2% of pregnancies) and were not associated with mode of delivery. In multivariate analysis, maternal heart disease was not predictive of adverse neonatal events or third- or fourth- degree lacerations. Maternal heart disease was associated with postpartum hemorrhage, but this was not related to assisted delivery or prolonged second stage of labour. CONCLUSION This large study has shown that in women with heart disease, avoidance of early induction of labour, rare use of Caesarean section for cardiac indications, and selective use of invasive monitoring produces safe obstetric outcomes.

Aortic dimensions on cardiovascular magnetic resonance imaging relate to pregnancy outcomes in women with coarctation of the aorta: a multicenter study

To examine the association between aortic dimensions on cardiovascular magnetic resonance imaging (CMR) and risk of adverse events related to pregnancy in women with coarctation of the aorta (CoA).

Relationship between cardiac magnetic resonance imaging parameters and pregnancy outcomes in women post mustard repair: a multi-center study

Background Summary: To examine the relationship between cardiovascular magnetic resonance imaging (CMR) parameters and pregnancy outcomes post Mustard palliation. Background: Impaired systemic ventricular function and presence of a systemic right ventricle (RV) are associated with adverse events in pregnancy. Women with transposition of the great arteries post atrial switch (Mustard procedure) are at risk of worsening arrhythmia and heart failure antenatally. Contemporary guidelines suggest that women with “more moderate systemic RV dysfunction” should be advised against pregnancy; however a threshold RV ejection fraction (EF) has not been defined as all studies to date have examined RV function using echocardiography alone. The CMR characteristics of women post Mustard palliation undergoing pregnancy and the relationship between CMR parameters and pregnancy outcomes have not yet been described. Methods A total of 17 consecutive women post Mustard procedure seen at 2 tertiary care centers who had undergone CMR within 2 years of pregnancy were included. Parameters of ventricular function were assessed by a single experienced reader using steady-state free-precession cine CMR acquired in the short-axis orientation. Adverse cardiovascular events (sustained arrhythmia, heart failure, stroke, cardiac arrest and/or urgent cardiac intervention), obstetric complications (eclampsia, pre-term labour, hemorrhage) and fetal/neonatal events (stillbirth/death, prematurity, low birthweight, intensive care unit admission) were recorded. Results

The impact of asymmetry on aortic root measurements in patients with bicuspid aortic valves

Methods Steady-state free precession cine acquisitions across the aortic root in short axis in patients with a diagnosis of BAV from January 2006 to December 2008 were evaluated at our institution using a 1.5 T magnet. For each aortic root, end-systolic measurements were obtained in duplicate by a single observer from cusp-to-commissure (3 measurements: right, left and non-coronary cusps to opposite commissure respectively) and cusp-to-cusp (3 measurements: right-left, right-non and left-non coronary cusps) using CMR. Using TTE, measures of the aortic root were recorded from the parasternal long axis view. Aortic root asymmetry was defined by comparing the standard deviation (SD) of the average of the 3 measurements of an individual (SDi) to the SD of the entire population (SDp). Two groups were generated: symmetric (SDi SDp) aortic roots.