Master Class

Team Is Vital for Gravidas With Congenital Aortic Stenosis


 

BARCELONA — Complications occurred in nearly three-quarters of completed pregnancies in the largest-ever reported patient series involving women with congenital aortic stenosis, Dr. Sing-Chien Yap said at the joint congress of the European Society of Cardiology and the World Heart Federation.

Cardiac complications were common but for the most part nonsevere and readily manageable.

However, there were also high rates of general medical, obstetric, and neonatal complications. This underscores the merits of a team approach to management of pregnancy in adults with congenital aortic stenosis, with involvement of a cardiologist, neonatologist, and obstetrician, stressed Dr. Yap, a cardiologist at Erasmus University, Rotterdam, the Netherlands.

He reported on 48 women with congenital aortic stenosis who collectively had 70 completed pregnancies, defined as being of more than 20 weeks' duration. The women were part of the larger ZAHARA study, a Dutch nationwide retrospective study investigating pregnancy outcomes in women with all forms of congenital heart disease.

ZAHARA was undertaken with funding from the Netherlands Heart Foundation because treatment advances have resulted in far more women with congenital heart disease surviving into their childbearing years than was historically the case. Few data exist on the risk factors for and nature and frequency of pregnancy complications in these women, Dr. Yap explained.

Thirty-five of the women had valvular aortic stenosis, 11 had subvalvular disease, and the remainder had supravalvular aortic stenosis. Prepregnancy, 9 had severe aortic stenosis as defined by a valvular gradient in excess of 64 mm Hg, 17 had moderate aortic stenosis with a gradient of 36-44 mm Hg, and the rest had mild aortic stenosis. Mean gradients were unchanged after pregnancy.

The most common cardiac complication of pregnancy was deterioration in New York Heart Association functional class. It occurred during 19 of 70 pregnancies and persisted for longer than 1 year postpartum in 3. Heart failure occurred in two patients, both with severe aortic stenosis. Angina occurred in two patients. Four patients developed arrhythmias, mainly supraventricular arrhythmias treated with ?-blockers.

Seventeen women required hospitalization for general pregnancy disorders, most of which were hypertension related. There were six cases of isolated pregnancy-induced hypertension, three of preeclampsia, and one of eclampsia. Three women were hospitalized for dyspnea. One woman experienced a transient ischemic attack despite being on warfarin for atrial fibrillation.

Eight women had elective cesarean deliveries, and 11 had emergency cesarean sections. There were three cases of placental abruption and two of postpartum hemorrhage.

Mean pregnancy duration was 38.2 weeks. Eleven babies were born small for gestational age. There were 10 preterm deliveries. One neonate died as a consequence of prematurity. Two children were born with congenital heart disease.

Most of these complications occurred at significantly higher rates than in the general Dutch pregnant population. Complication rates were highest in women with severe aortic stenosis.

Because of the limitations inherent in a retrospective study, the investigators have launched a prospective nationwide study of pregnancy in congenital heart disease, according to Dr. Yap.

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