Matthew Cauldwell

A cohort study of women with a Fontan circulation undergoing preconception counselling

Objective To describe outcomes for women with a Fontan circulation attending preconception counselling (PCC). Exploring (1) impact of counselling on decision to become pregnant; (2) pregnancy rates in those opting for pregnancy and (3) short-term and long-term outcome of those who succeeded in becoming pregnant. Methods Retrospective review of women aged 16–45 years with a Fontan circulation from 1994 to 2014. Results 58 women were offered PCC, 3 declined and 55 received PCC. Following PCC, 15 opted against conception, 16 decided to delay pregnancy, 19 attempted pregnancy and 5 were lost to follow-up. Of the 19 women, 14 succeeded, becoming pregnant a total of 43 times (median 1, range 1–9). Of these, 6 miscarried all pregnancies. 8 carried 14 pregnancies to viability. Baseline hypoxaemia and cardiac disease in pregnancy (CARPREG) score was similar in those opting for and against pregnancy, but CARPREG score was better in those delaying conception. Women exclusively miscarrying or unable to conceive were more likely to have baseline hypoxaemia and greater CARPREG score. Cardiac complications included arrhythmia requiring treatment (n=4) and one thromboembolism. Obstetric complications were greater in women with a Fontan circulation, 10 preterm births (<37 weeks) and 8 small for gestational age babies (<10th centile). There was one neonatal death. At follow-up, there was no deterioration in clinical status as determined by echo. Conclusions Most women accept PCC and decided to pursue pregnancy; in some cases, this was despite being advised of a poor prognosis. Pregnancy outcome was related to baseline hypoxia and CARPREG scores.

Why is post-partum haemorrhage more common in women with congenital heart disease?

OBJECTIVE To identify the factors associated with an increased post-partum blood loss in women with congenital heart disease (CHD). METHODS The study was a retrospective cohort study, which included 366 nulliparous women with CHD and a singleton pregnancy cared for in a single tertiary centre (Chelsea and Westminster Hospital) between 1994 and 2014. The women were classified into one of 12 different functional groups and univariate and multivariate regression analysis were used to identify factors associated with increased blood loss at delivery. RESULTS The average volume of blood loss in women with CHD was twice that expected. Univariate analysis showed that White European women had the lowest blood loss. Women who had been on anticoagulants, had a forceps delivery, emergency Caesarean section or general anaesthesia lost more blood than those having a spontaneous vaginal birth under regional analgesia. Higher CARPREG scores were associated strongly with increased blood loss. Women with a Fontan circulation had the highest blood loss and the difference remained significant after correcting for other significant variables. CONCLUSIONS Women with CHD are at increased risk of PPH. We have identified several potentially modifiable risk factors that may be targeted to reduce this risk. In addition, women with a Fontan circulation were most prone to PPH, independent of other risk factors, suggesting the existence of lesion-specific abnormalities and the need for extra vigilance in this group of women at the time of birth.

The impact of electronic patient records on workflow in general practice.

The Patient Access to Electronic Healthcare Records System (PAERS) allows patients to register their arrival at a GPs surgery and to view their healthcare record electronically whilst in the waiting area. The research reported in this short article was carried out to identify potential changes in clinical and administrative workflow resulting from the introduction of the system. The study considers workflow pre and post the implementation of PAERS. It also makes comparisons between two UK London-based surgeries, one with PAERS (Wells Park Practice) and one without such a system (South Lewisham Group Practice). The impact of PAERS on workflow and the potential benefits for GPs, administrative staff and patients are highlighted.

Learning about maternal death and grief in the profession: a pilot qualitative study

The aim of this study was to explore the impact of maternal death on maternity professionals, and their related professional and personal needs.

Retrospective UK multicentre study of the pregnancy outcomes of women with a Fontan repair

Background The population of women of childbearing age palliated with a Fontan repair is increasing. The aim of this study was to describe the progress of pregnancy and its outcome in a cohort of patients with a Fontan circulation in the UK. Methods A retrospective study of women with a Fontan circulation delivering between January 2005 and November 2016 in 10 specialist adult congenital heart disease centres in the UK. Results 50 women had 124 pregnancies, resulting in 68 (54.8%) miscarriages, 2 terminations of pregnancy, 1 intrauterine death (at 30 weeks), 53 (42.7%) live births and 4 neonatal deaths. Cardiac complications in pregnancies with a live birth included heart failure (n=7, 13.5%), arrhythmia (n=6, 11.3%) and pulmonary embolism (n=1, 1.9%). Very low baseline maternal oxygen saturations at first obstetric review were associated with miscarriage. All eight women with saturations of less than 85% miscarried, compared with 60 of 116 (51.7%) who had baseline saturations of ≥85% (p=0.008). Obstetric and neonatal complications were common: preterm delivery (n=39, 72.2%), small for gestational age (<10th percentile, n=30, 55.6%; <5th centile, n=19, 35.2%) and postpartum haemorrhage (n=23, 42.6%). There were no maternal deaths in the study period. Conclusion Women with a Fontan circulation have a high rate of miscarriage and, even if pregnancy progresses to a viable gestational age, a high rate of obstetric and neonatal complications.

The management of the third stage of labour in women with heart disease

Objective In women with heart disease (HD), the third stage of labour is managed with a reduced dose of oxytocin because it can have significant adverse cardiovascular effects. However, women with HD have high rates of postpartum haemorrhage (PPH); consequently, we designed a prospective study to investigate whether higher doses of oxytocin can be given safely and would reduce rates of PPH. Methods We performed a single centre, prospective, cohort study comparing the standard ‘low-dose’ oxytocin infusion (10 U of oxytocin in 500 mL of normal saline given intravenously at 36 mL/hour for 4 hours (12 mU/min), n=29) to the low-dose infusion and an additional 2 U of oxytocin given over 10 min immediately after birth (n=30). Maternal blood pressure was measured every minute for 10 min, continuous ECG (Holter) monitoring was performed and any symptoms (chest pain, dyspnoea) were recorded. Total blood loss and serum troponins were measured at 12 hours. Results There were no cardiac symptoms, arrhythmias, change in the ST segment or increase in serum troponins. The fall in blood pressure and increase in heart rate were greater with the additional oxytocin, but neither were statistically or clinically significant. The blood loss was significantly less in women receiving additional oxytocin (505 vs 849 mL) and the proportion of women having a PPH was lower. Conclusions The use of an additional 2 U of oxytocin for the management of third stage in women with HD had no cardiac consequences and was associated with a significantly lower blood loss. Further larger studies on a larger population of women with HD are needed.

Counselling women with congenital cardiac disease

They should be empowered to make informed choices

Preconception counseling, predicting risk and outcomes in women with mWHO 3 and 4 heart disease

OBJECTIVE All women with CHD, especially those with more severe disease, should be offered preconception counseling (PCC), to discuss the risk of complications and to plan a future pregnancy. Several scoring system have been devised to estimate the risk of adverse events in pregnancies complicated by maternal heart disease (HD) and while comparisons have been made across the whole population, none have focused on the high-risk population. METHODS Retrospective cohort study that included women classed as modified WHO (mWHO) 3 and 4 who had a pregnancy from at least 20weeks gestation between 1994 and 2015 managed within our institution. We assessed how well the quoted risk (at PCC) of an adverse event (maternal or fetal) related to the actual rate of occurrence. We calculated NYHA and CARPREG scores for all patients, and the clinician assessment of percentage risk, to predict the occurrence of an adverse outcome. RESULTS We identified 76 mWHO 3 and 4 women who had a total of 102 pregnancies. However, only in 63 pregnancies had the woman attended PCC. Both maternal and fetal adverse events were common. NYHA did not significantly predict any adverse events, whilst a CARPREG score of >3 score predicted heart failure and mWHO4 score predicted maternal death. However, the best prediction of adverse outcomes was a composite quoted risk (percent) given at PCC. CONCLUSIONS Women must have access to PCC as those with worse CARPREG and mWHO scores encounter greater adverse events.

Pre-pregnancy counseling for women with heart disease: A prospective study

BACKGROUND Women with cardiac disease and their infants are at a greater risk of mortality and morbidity during pregnancy. Expert groups recommend preconception counseling (PCC) for all women with cardiac disease so they are made aware of these risks. We have run a specialist maternal cardiac clinic since 1996. The aim of this study was to evaluate the experience of women who have received PCC within an established multidisciplinary tertiary clinic and to establish their views regarding the counseling they received. METHODS Single centre prospective study using a patient questionnaire was given to women attending a specialist cardiac preconception counseling clinic from November 2015 to August 2016, with analysis of descriptive data and free text comments from the questionnaire responders. RESULTS 40/65 returned patient questionnaires. Prior to the consultation fewer than half felt well informed regarding how their heart disease could impact upon pregnancy but a similar proportion felt nonetheless that they would be able to have a healthy pregnancy. Women reported two main areas of concerns, their own health (whether they would survive a pregnancy) and the health of their child. 15% of women reported that these concerns had prevented them from pursuing a pregnancy. Women reported high satisfaction rates with the clinic. CONCLUSIONS There is an increasing demand for PCC services for women with cardiac disease; our study is the first attempt to determine both the acceptability and the impact of PCC from the patient perspective. Patients reported a high level of satisfaction with the service provided.

Managing subfertility in patients with heart disease: What are the choices?

&NA; More women with heart disease are reaching reproductive age and will want to embark upon pregnancy. Furthermore, many of these women are delaying pregnancy until later in life when they may be exposed to a greater number of complications from their heart disease. A relatively high proportion of these women will pursue fertility treatment to achieve a pregnancy; consequently, the management of subfertile couples where the woman (or man) has heart disease is of growing importance. In this review, we discuss how fertility investigations and treatment can impact a women with heart disease and how some of the potential complications can be minimized or avoided. We also consider surrogacy, which is an important option when pregnancy is contraindicated.