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AHA: With proper management, successful pregnancy feasible for women with complex congenital heart disease
Women with high-risk congenital heart disease have traditionally been advised to avoid pregnancy, but that is no longer the case if the pregnancy is managed properly, according to a new American Heart Association scientific statement.
“Women with complex congenital heart disease were previously advised not to get pregnant because of the risk to their life,” Mary M. Canobbio, RN, MN, FAHA, lecturer at the UCLA School of Nursing and chair of the writing committee for the scientific statement, said in a press release. “Now scientific research demonstrates that with proper management in the hands of experienced cardiologists and obstetricians, these women can have successful pregnancies.”
Canobbio and colleagues recommended that women with complex congenital heart disease — including single ventricle, transposition of the great arteries, pulmonary hypertension, Eisenmenger’s syndrome and severe aortic stenosis — undergo prepregnancy counseling to better understand how pregnancy can affect their health and that of their child.
Once pregnancy occurs, a delivery plan should be devised to anticipate any problems that could happen during and after delivery, according to the authors.
Delivery should occur at a traditional medical center with a cardiologist trained in managing complex congenital heart disease, obstetricians trained in high-risk maternal–fetal medicine, cardiac anesthesia and a cardiac surgical team, Canobbio and colleagues wrote.
Monitoring should continue for 6 weeks to 6 months after delivery, they wrote.
Canobbio said in the release that the statement covers “what we know about the risks for these patients, what the potential complications are, what cardiologists, advanced practice nurses and other cardiac health providers should discuss in counseling these women, and once pregnant, recommendations in terms of things we should be looking out for when caring for these women.” – by Erik Swain
Disclosure: The authors report no relevant financial disclosures. One reviewer reports serving as an expert witness in two maternal mortality cases.
Perspective
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This is a comprehensive document that provides a summary of the extensive research on pregnancy in congenital heart disease that has surged over the past decade. An important theme throughout the statement is the emphasis on the heterogeneous nature of congenital heart disease and that care should be individualized with attention to the clinical profile specific to each woman. Though the statement focuses on complex disease, the authors point out that the designation of "complex" goes beyond lesion severity, and that even those with simple congenital heart disease may be at elevated risk if accompanied by serious comorbidities, further underscoring the concept of care tailored to each woman.
The statement gives recommendations on who should be cared for in a center with experience in the care of parturients with congenital heart disease and those who are considering pregnancy. The authors underscore the importance of preconception counseling and risk assessment for each woman as the best way to ensure a healthy pregnancy.
Last, the authors summarize challenges and caveats unique to specific forms of congenital heart disease with current data supporting these recommendations.
The recommendations are consistent with how I counsel and care for these women. The authors review basic principles of care for these women which are critical for a healthy pregnancy:
- planning the pregnancy with preconception counseling and consultation with subspecialists across the spectrum
- multidisciplinary care involving a team of clinicians for these women with benefits of regular conferences and/or joint visits which enhance communication amongst team members
- patient and family involvement in joint decision-making and honest discussion of risk including that to mother as well as fetus
- understanding the limits of applying risk scores such as CARPREG and ZAHARA to an individual and instead focusing on the clinical status of the woman and her comorbidities in the setting of her particular congenital heart disease
- setting the tone for as "normal" a pregnancy as possible with cesarean section reserved for exceptions and/or obstetric indications and no need for early induction before 39 weeks if otherwise clinically stable; and
- evolution of care throughout the pregnancy from preconception counseling and testing or even intervention, throughout pregnancy, labor and delivery and postpartum.
The authors addressed the knowledge gaps out there in a succinct way. They touch on uncertainties in certain clinical scenarios such as anticoagulation, potential long-term impact of pregnancy/pregnancies on cardiac health, if and when to recommend interventions/surgeries to address sequelae of congenital heart disease as a means to reduce pregnancy risk. Fertility is discussed but impact of assisted reproductive techniques is an area we know little about in this population.
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