Abstract
Abstract Background Maternal congenital heart disease (CHD) is the most common cardiac condition to complicate pregnancy and women now become pregnant even with complex CHD. The Registry Of Pregnancy And Cardiac disease (ROPAC) examines the relationship between maternal heart disease and pregnancy outcome. Methods The ESC EORP ROPAC is a worldwide prospective registry of pregnancies in women with structural heart disease (n=5739, recruiting between 2007-2018), including CHD. Maternal and fetal outcomes were examined in all women with CHD. Multivariable regression was used to identify associations with a composite endpoint of maternal mortality and/or heart failure. Results In CHD pregnancies (n=3295, mean age 29 years), maternal mortality was 0.3% and heart failure occurred in 6.6%. Preterm births (16%) and Caesarean section (46.3%) were higher than global averages, but otherwise cardiac, obstetric and fetal outcomes were good. The composite endpoint was highest in complex CHD: Eisenmenger syndrome (58.1%), congenitally corrected transposition of the great arteries (12.8%), Fontan circulation (11.2%), double outlet right ventricle (11.1%). Pre-pregnancy signs of heart failure (OR 10.6, 95% CI 7.1-16), multiple gestation (4.6, 2-10.8), pulmonary hypertension (2.5, 1.5-4), estimated LVEF Conclusion Overall pregnancy outcomes for women with CHD are good but women with complex CHD are at increased risk of complications. Pre-pregnancy assessment can identify women at increased risk of an adverse outcome and should be used to counsel women appropriately.
Highlights
Pregnancy is a major burden on the maternal cardiovascular system
We found increased risks for women living in a low- or middle income country, independent of pre-pregnancy cardiac morbidity or the presence of uncorrected congenital heart disease (CHD), which are both probably higher in low or middle-income (LMIC) [8]
We identified multiple gestation as a risk factor for mortality and heart failure, which was not found in the Zwangerschap bij Aangeboren HARtAfwijking (ZAHARA) study and not assessed in the CARdiac disease in PREGnancy (CARPREG) II study [23,24]
Summary
Hormonal changes cause a drop in systemic vascular resistance and a compensatory volume expansion, leading to a 30–50% increase in cardiac output [1]. Pain, stress and the uterine contractions increase cardiac output by another 25%. These changes, with the abrupt cessation of the increased utero-placental blood flow at delivery with the return of 500–700 mls into the systemic circulation, make the postpartum period high risk for the development of heart failure [2,3]. The impact of pregnancy on the cardiovascular system may explain why cardiac disease is the leading cause of maternal mortality in high income countries and why women with pre-existing cardiac disease, including congenital heart disease (CHD), are at particular risk [4,5]
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