Katherine E. Economy

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.

Post-term induction of labor revisited.

Post-term pregnancy (longer than 42 weeks or 294 days) occurs in approximately 10% of all singleton gestations. The adverse outcomes of post-term pregnancy include a substantial increase in perinatal mortality and morbidity. ACOG currently recommends induction of labor for low-risk pregnancy during the 43rd week of gestation. However, that recommendation dates from 1989. Recent reports mandate reconsideration of the management of post-term pregnancy, including reinterpretation of the statistical risk of stillbirth in post-term pregnancies using ongoing (undelivered) rather than delivered pregnancies as the denominator, which shows a far higher risk to post-term fetuses than believed. Recent data also suggest that the risk of cesarean delivery after induction of labor at term is lower than reported, possibly because of improvements in methods for cervical ripening. Those findings provide rationale for earlier labor induction in low-risk pregnancies.

Primary prevention of gynecologic cancers

A shift from treatment to prevention of the three major gynecologic cancers is overdue. The traditional approach to cervical, endometrial, and ovarian cancers has been secondary or tertiary prevention--early detection and treatment or mitigation of damage, respectively. We reviewed the literature on these cancers to identify strategies for primary prevention. Cervical cancer behaves as a sexually transmitted disease. As with other such diseases, barrier and spermicidal contraceptives lower the risk of cervical cancer; the risk reduction approximates 50%. Combination oral contraceptives help prevent both endometrial and epithelial ovarian cancers. The risk of endometrial cancer among former oral contraceptive users is reduced by about 50% and that of ovarian cancer by about 30% to 60%. Weight control confers strong protection against endometrial cancer. Breast-feeding and tubal sterilization also appear to protect against ovarian cancer. Although women have a range of practical, effective measures available to reduce their risk of these cancers, few are aware of them. Without this information, women cannot make fully informed decisions about their health.

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.

Pregnant women with congenital heart disease: cardiac, anesthetic and obstetrical implications

Remarkable advances in surgical and clinical management have resulted in survival to adulthood in the large majority of patients with congenital heart malformations, even with the most complex disease. Over 1 million adults with congenital heart disease currently live in the USA, approximately half of whom are women of childbearing age. Collectively, congenital malformations are the most common form of heart disease in pregnant women. Indeed, in North America, congenital defects are now the leading cause of maternal morbidity and mortality from heart disease. This article begins with a summary of cardiovascular changes during pregnancy and highlights key features in pre-pregnancy counseling, maternal cardiac and obstetric risk, and neonatal complications. Management issues regarding pregnancy and delivery are elaborated, including anesthesia considerations. While it is beyond the scope of this article to discuss particulars related to all forms of congenital heart disease, selected subtypes are detailed at greater length. In the absence of clinical trial evidence to inform the care of pregnant women with congenital heart disease, this article is inspired by the premise that knowledgeable multidisciplinary assessment and management provides the best opportunity to substantially improve outcomes for mother and baby.

The effects of pregnancy on right ventricular remodeling in women with repaired tetralogy of Fallot

OBJECTIVES The aim of this study was to better understand the quantitative volumetric changes associated with pregnancy in women with repaired tetralogy of Fallot (TOF), utilizing sequential cardiovascular magnetic resonance (CMR) imaging. BACKGROUND An increasing number of women with repaired TOF are reaching childbearing age. Limited echocardiographic studies suggest accelerated remodeling of the right ventricle (RV) in women with repaired TOF after pregnancy. METHODS Sequential CMRs from a group of women with repaired TOF who completed pregnancy and from a matched comparison group of nulliparous women with repaired TOF were evaluated. The two groups were matched according to baseline QRS duration, RV end-diastolic volume (EDV), age at CMR and time between CMRs. Longitudinal change of CMR parameters was compared between the groups. RESULTS Thirteen women (mean age 26.6 ± 7.4 years) with repaired TOF who completed pregnancy and 26 nulliparous women with repaired TOF (mean age 22.6 ± 8.0 years) were included in this analysis. The rate of increase of RV EDV in the pregnancy group was higher than the comparison group (4.1 ± 1.1 ml/m(2)/year vs. 1.6 ± 0.6 ml/m(2)/year, p=0.07). RV EF did not change significantly in either group. No definitive interaction between degree of pulmonary regurgitation and increase of RV EDV was identified. CONCLUSIONS Women with repaired TOF who have completed pregnancy appear to experience an accelerated rate of right ventricular remodeling, defined as an increase in end-diastolic volume; however RV systolic function does not deteriorate. Further investigations with a prospective study design, larger cohorts, and longer follow-up are needed to confirm these initial observations.

Comparison of Risk of Hypertensive Complications of Pregnancy Among Women With Versus Without Coarctation of the Aorta

Hypertension is a common consequence of coarctation of the aorta. The frequency of hypertensive complications of pregnancy in women with coarctation in the general population is undefined. In this study, we used the 1998 to 2007 Nationwide Inpatient Sample, a nationally representative data set, to identify patients admitted to an acute care hospital for delivery. The frequency of hypertensive complications of pregnancy was compared between women with and without coarctation. Secondary outcomes, including length of stay, hospital charges, Caesarean delivery, and adverse maternal outcomes, were also assessed. There were an estimated 697 deliveries among women with coarctation, compared to 42,601,409 deliveries by women without coarctation. The frequency of hypertensive complications of pregnancy was 24.1 ± 3.3% for women with coarctation compared to 8.0 ± 0.1% for women without coarctation (multivariate odds ratio [OR] 3.6, 95% confidence interval [CI] 2.5 to 5.2). Preexisting hypertension complicating pregnancy (10.2 ± 2.5% vs 1.0% ± 0.02%, multivariate OR 10.8, 95% CI 5.9 to 19.8) and pregnancy-induced hypertension (13.9 ± 3.0% vs 7.0% ± 0.1%, multivariate OR 2.1, 95% CI 1.3 to 3.3) were more common in women with coarctation. Women with coarctation were more likely to deliver by Caesarean section (41.6 ± 3.3% vs 26.4% ± 0.2%, multivariate OR 2.0, 95% CI 1.4 to 2.8), have adverse cardiovascular outcomes (4.8 ± 2.2% vs 0.3 ± 0.01%, multivariate OR 16.7, 95% CI 6.7 to 41.5), have longer hospital stays, and incur higher hospital charges (both p values <0.0001) than women without coarctation. In conclusion, women with coarctation are more likely to have hypertensive complications of pregnancy, deliver by Caesarean section, have adverse cardiovascular outcomes, have longer hospitalizations, and incur higher hospital charges than women without coarctation.

A Crisis in Late Pregnancy

A 31-year-old woman in the 37th week of an uncomplicated pregnancy presented to the emergency department with severe bitemporal headache and shortness of breath of gradual onset.

Contemporary Management of Arrhythmias During Pregnancy

Cardiac arrhythmias are among the most common cardiac complications encountered during pregnancy.1 In some, pregnancy may trigger exacerbations of pre-existing arrhythmias, whereas in others arrhythmias may manifest for the first time.2 Fortunately, severe arrhythmias requiring aggressive or invasive therapies are rare. There are unfortunately few randomized studies, little data on the efficacy or safety of antiarrhythmic drugs (AADs), or even explicit guidelines to support decision making on pregnant women with arrhythmias. Thus, much of the clinical care is guided by knowledge of the physiology of pregnancy and educated risk/benefit decisions made in collaboration with high-risk obstetric colleagues in Maternal-Fetal Medicine, as well as with the patient. The precise mechanism of increased arrhythmia burden during pregnancy is unclear, but it is likely because of a combination of hemodynamic, hormonal, and autonomic changes. Increases in effective circulating blood volume of 30% to 50% are seen beginning at 8 weeks of gestation and peaking at ≈34 weeks. Cardiac output is increased as well, with an average of 6.7 L/min in the first trimester and ≤8.7 L/min in the third trimester. This is the result of a 35% increase in stroke volume and a 15% increase in heart rate. The increase in plasma volume causes stretching of atrial and ventricular myocytes, and this may result in early after depolarizations, shortened refractoriness, slowed conduction, and spatial dispersion through activation of stretch-activated ion channels.3,4 A larger heart can also potentially sustain re-entry more easily because of an increase in path length of potential reentrant circuits. The increase in heart rate during pregnancy, seen predominantly in the third trimester, may also predispose to arrhythmia, as a high resting heart rate has been associated with markers of arrhythmogenesis.5 Hormonal and autonomic changes may also contribute to arrhythmogenesis. Estradiol and progesterone have been …

A comparison of MRI and laparoscopy in detecting pelvic structures in cases of vaginal agenesis.

OBJECTIVE To determine whether laparoscopy improves detection of uterine structures over MRI in cases of vaginal agenesis. DESIGN Prospective case series. SETTING Ambulatory pediatric gynecology clinic in a tertiary care childrens hospital. PARTICIPANTS Subjects with vaginal agenesis who had an MRI to detect uterine structures. MAIN OUTCOME MEASURES A chart review identified subjects with vaginal agenesis who had an MRI to assess müllerian structures. The MRI findings were correlated with physical exam, presenting symptoms, and operative findings. We assessed degree of agreement between laparoscopy and MRI in patients both with and without pelvic pain to determine sensitivity and specificity of MRI in predicting uterine structures confirmed on laparoscopy. RESULTS Twenty-two subjects with vaginal agenesis were identified and 14 had both an MRI and laparoscopic evaluation. MRI successfully predicted uterine anomalies in six cases (43%) and lack of uterine structures in one case (8%). MRI diagnosis did not correlate with laparoscopic findings in the remaining seven cases (50%). Among subjects presenting with no complaints of pelvic pain (n = 6), three had negative MR imaging but positive laparoscopy. Using laparoscopy as a gold standard, MRI had a sensitivity of 53% for accurately detecting uterine anomalies confirmed on laparoscopy. CONCLUSION Laparoscopy improves detection of uterine structures over MRI alone in women with vaginal agenesis.