Complex pregnancies after heart transplant underscore need for patient counseling
Key takeaways:
- Women who become pregnant after a heart transplant have significantly higher risk for maternal morbidity.
- Multidisciplinary care and counseling are key for women who desire pregnancy after heart transplant.
Data show pregnancy after heart transplant brings significant risks for all-cause and CV maternal morbidity as well as higher risks for cesarean delivery and hospital readmission within 1 year, highlighting the need for patient counseling.
Female patients aged 18 to 49 comprised approximately 8% of heart transplant recipients in 2021, Amanda Craig, MD, assistant professor in the division of maternal-fetal medicine at Duke University Hospital, and colleagues wrote in JACC: Heart Failure. Heart transplant recipients are increasingly living longer, healthier lives, with more patients contemplating pregnancy and its implications.
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“Pregnant individuals with history of heart transplant are at significantly increased risks with pregnancy, labor and delivery, including increased risk for severe maternal morbidity and hospital readmission within the first year following delivery,” Craig told Healio. “These findings can help providers when counseling this high-risk patient population both pre- or post-transplant, or during the preconception period. These data may also be useful in guiding multidisciplinary care teams taking care of pregnant patients with history of heart transplant.”
In a retrospective study, Craig and colleagues analyzed diagnosis and procedure codes from the 2010-2020 Nationwide Readmissions Database to identify delivery hospitalizations, history of heart transplant, comorbid conditions and outcomes. Researchers compared rates of severe maternal morbidity, nontransfusion severe maternal morbidity, CV severe maternal morbidity and preterm birth rates between heart transplant recipients and nonrecipients. Researchers also assessed readmission to 330 days postpartum.
Among 19,399,521 deliveries, 105 were in heart transplant recipients.
In unadjusted comparisons between heart transplant and nontransplant delivery hospitalizations, rates of all outcomes were higher among heart transplant recipients. Heart transplant recipients were at higher risk for all severe maternal morbidity (24.8% vs. 1.7%), nontransfusion severe maternal morbidity (20.8% vs. 0.7%), CV severe maternal morbidity (8.5% vs. 0.12%), and preterm birth (44.3% vs. 8%; P < .001 for all comparisons).
In analyses adjusted for age, demographic and facility characteristics, comorbidities, calendar year and quarter, heart transplant recipients had 15-fold greater odds for severe maternal morbidity (adjusted OR = 15.73; 95% CI, 9.17-27), 28-fold greater odds for nontransfusion severe maternal morbidity (aOR = 28.12; 95% CI, 15.65-50.53), 38-fold greater odds for CV severe maternal morbidity (aOR = 37.7; 95% CI, 17.39-82.01) and sevenfold greater odds for preterm birth (aOR = 7.15; 95% CI, 4.75-10.77). Heart transplant recipients also had higher readmission rates within 1 year after delivery compared with patients with no heart transplant (HR = 6.02; 95% CI, 3.73-9.75).
Rates for cesarean delivery among women with heart transplant were also significantly higher, according to the researchers.
“Data were not available regarding indication for cesarean, so it is unclear if this increase was strictly caused by history of heart transplant vs. complications of pregnancy, but is a notable point to acknowledge with these patients,” the researchers wrote.
The researchers wrote that the findings demonstrate the importance of counseling heart transplant patients at early gestational ages to provide information about anticipated risks during pregnancy and the postpartum period to allow patients the opportunity to make informed choices.
“These are high-risk pregnancies and when they are continued are best cared for by multidisciplinary pregnancy heart teams in centers with expertise in high-risk obstetrics and heart failure cardiology,” the researchers wrote.
As Healio previously reported, a recent state-of-the-art review published in JACC: Heart Failure stated that comprehensive care for women with HF or other serious CVDs must begin with thorough preconception counseling that highlights the potential risks that come with pregnancy, adding that obstetricians and cardiologists should work together to ensure those risks are minimized.
“Additional research is needed to stratify these risks in the context of time from a patient's heart transplant, as the risk of allograft rejection is highest and immunosuppression regimen the most aggressive during the first 12 months after transplant,” Craig told Healio. “Additionally, future studies need to evaluate how the risks identified in this study vary with race, ethnicity and other patient clinical or social factors, as these data elements are not available in the NRD dataset.”
For more information:
Amanda Craig, MD, can be reached at amanda.craig@duke.edu; X (Twitter): @amc8806.
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