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Pre-pregnancy counseling ‘crucial’ for women with CVD
MUNICH — Fewer women with CVD die or develop HF during pregnancy compared with 10 years ago. However, maternal mortality in women with CVD is 100 times higher than expected, with the highest mortality in women with pulmonary arterial hypertension, according to new data from the ROPAC registry.
Jolien W. Roos-Hesselink, MD, PhD, from the department of cardiology at Erasmus University Rotterdam, the Netherlands, reported data from 5,739 pregnancies in 53 countries from 2007 to 2018 included in the ROPAC registry. More than half (57%) of the women had congenital heart disease and 29% had valvular heart disease. Other conditions in this registry included cardiomyopathy, ischemic heart disease, aortic pathology and PAH.
Mortality occurred in 0.6% of pregnancies overall in the ROPAC registry, compared with a mortality rate of 0.007% that is expected in pregnant women without CVD (P < .001 for comparison).
“That’s 100-times higher,” Roos-Hesselink said during a presentation at the European Society of Cardiology Congress. “However, many managed pregnancy without any complication.”
Women with PAH had the highest rate of mortality (9%), and also had greater risk for fetal and neonatal complications.
HF was the most common complication among pregnant women with CVD overall. HF occurred in 11% of pregnant women with CVD compared with less than 0.1% of pregnant women without CVD (P = .002), and was most prevalent in women with cardiomyopathy, valvular disease and PAH. Other complications that were more common in pregnant women with CVD included supraventricular tachycardia (2% vs. less than 0.5%; P < .05), ventricular tachycardia (2% vs. less than 0.5%; P < .05) and fetal mortality (1% vs. 0.35%; P < .001). Forty-four percent of women in the registry required cesarean section compared with 23% of women without CVD. Premature birth was more likely among women with CVD, at 16% vs. 8% (P = .06).
The researchers identified several pre-pregnancy predictors for maternal mortality and HF, including higher NYHA HF class, lower ejection fraction, higher WHO risk score, use of anticoagulation during pregnancy and symptoms or signs of HF before pregnancy.
When the researchers examined trends over time, after an initial increase in maternal mortality and HF diagnoses during pregnancy from 2007 to 2010, rates have declined in more recent years.
“The first guidelines ever on pregnancy and cardiovascular disease were published in 2011,” Roos-Hesselink said. “... I cannot make this a one-to-one explanation, but it might be that the introduction of the ESC guidelines had an impact on the improvement in the outcome of our patients.”
This declining trend over time occurred “despite the presence of more very high-risk women with heart disease being included in our registry as time went by,” Roos-Hesselink said. The WHO maintains a modified classification in pregnant women with congenital and acquired CVDs. In the ROPAC registry, the number of women identified as WHO class IV — which is a contraindication for pregnancy — increased from 2007 to 2018. Women with WHO class IV had an increased incidence of mortality, HF, cesarean section and premature birth.
“For all women who suffer from cardiac disease, pregnancy means a sort of exercise test for 9 months,” Roos-Hesselink said. “... The most important message of my talk is that all patients should be counseled not only that they are at high risk and that pregnancy is contraindicated, but also that they are at low risk. Indeed, patients [with CVD] can have a baby and can start a family, which is, of course, also crucial for our patients.”
The ESC issued new recommendations for the management of CVDs during pregnancy, in conjunction with the ESC Congress. The guidelines are published online in European Heart Journal. – by Darlene Dobkowski
References:
Roos-Hesselink JW, et al. Late-Breaking Science. Presented at: European Society of Cardiology Congress; Aug. 25-29, 2018; Munich.
Regitz-Zagrosek V, et al. Eur Heart J. 2018;doi:10.1093/Eurheartj/ehy340.
Disclosure: Roos-Hesselink reports no relevant financial disclosures.