Perinatal outcomes and long-term offspring cardiovascular morbidity of women with congenital heart disease

The prevalence of congenital heart disease (CHD) among women of reproductive age is rising. We aimed to investigate the risk of preeclampsia and adverse neonatal outcomes in pregnancies of mothers with CHD compared to pregnancies of mothers without heart disease. In a nationwide cohort of pregnancies in Norway 1994-2014, we retrieved information on maternal heart disease, the course of pregnancy, and neonatal outcomes from national registries. Comparing pregnancies with maternal CHD to pregnancies without maternal heart disease, we used Cox regression to estimate the adjusted hazard ratio (aHR) for preeclampsia and log-binomial regression to estimate the adjusted risk ratio (aRR) for adverse neonatal outcomes. The estimates were adjusted for maternal age and year of childbirth and presented with 95% confidence intervals (CIs). Among 1 218 452 pregnancies, 2425 had mild maternal CHD, and 603 had moderate/severe CHD. Compared to pregnancies without maternal heart disease, the risk of preeclampsia was increased in pregnancies with mild and moderate/severe maternal CHD (aHR1.37, 95% CI 1.14-1.65 and aHR 1.62, 95% CI 1.13-2.32). The risk of preterm birth was increased in pregnancies with mild maternal CHD (aRR 1.33, 95% CI 1.15-1.54) and further increased with moderate/severe CHD (aRR 2.49, 95% CI 2.03-3.07). Maternal CHD was associated with elevated risks of both spontaneous and iatrogenic preterm birth. The risk of infants small-for-gestational-age was slightly increased with mild maternal CHD (aRR 1.12, 95% CI 1.00-1.26) and increased with moderate/severe CHD (aRR 1.63, 95% CI 1.36-1.95). The prevalence of stillbirth was 3.9 per 1000 pregnancies without maternal heart disease, 5.6 per 1000 with mild maternal CHD, and 6.8 per 1000 with moderate/severe maternal CHD. Still, there were too few cases to report a significant difference. There were no maternal deaths in women with CHD. Moderate/severe maternal CHD in pregnancy was associated with increased risks of preeclampsia, preterm birth, and infants small-for-gestational-age. Mild maternal CHD was associated with less increased risks. For women with moderate/severe CHD, their risk of preeclampsia and adverse neonatal outcomes should be evaluated together with their cardiac risk in pregnancy, and follow-up in pregnancy should be ascertained.

IntroductionMore women with congenital heart disease (CHD) are pursuing pregnancy. Their cardiac condition may impact the pregnancy and necessitate interventions during childbirth. We aimed to investigate labor onset and delivery mode in women with CHD relative to women without heart disease and explore the time trends of induced labor and cesarean deliveries.Material and MethodsIn a nationwide cohort in Norway from 1994 to 2014, we compared childbirths of women with mild, moderate/severe, or other CHD to childbirths of women without heart disease. Associations between maternal CHD and labor onset and delivery mode were estimated using log‐binomial regression. Time trends were assessed using Joinpoint regression.ResultsAmong 1 218 452 childbirths, 2425 (20 per 10 000) had mild maternal CHD, 603 (5 per 10 000) moderate/severe maternal CHD, and 522 (4 per 10 000) other maternal CHD. Mild maternal CHD was associated with induced labor (aRR 1.11, 95% CI 1.01–1.22) and cesarean delivery (aRR 1.27, 95% CI 1.18–1.39), and the associations were stronger with moderate/severe CHD (induced labor: aRR 1.34, 95% CI 1.13–1.58; cesarean delivery: aRR 1.80, 95% CI 1.57–2.05) and other CHD (induced labor: aRR 1.39, 95% CI 1.17–1.66; cesarean delivery: aRR 1.62, 95% CI 1.39–1.89). From the first seven years (1994–2000) to the last (2008–2014), the cesarean delivery occurrence rose about 2% per year in childbirths without maternal heart disease and with mild maternal CHD (from 12.4% to 16.4% and from 14.2% to 21.2%, respectively), but remained stable in childbirths with moderate/severe maternal CHD (23.3% to 25.6%). For induced labor, there was a 2% increase per year in childbirths without maternal heart disease, contrasting a 3%–4% increase in those with mild and moderate/severe maternal CHD.ConclusionsMaternal CHD was associated with higher risks of induced labor and cesarean delivery. From 1994 to 2014, the increase in induced labor was steeper in childbirths of women with CHD than in those of women without heart disease. The occurrence of cesarean deliveries rose in childbirths of women with mild CHD but was stable in childbirths of women with moderate/severe CHD.

Postpartum readmissions among patients with adult congenital heart disease.

Background: Neonatal outcomes are directly affected by maternal heart disease, which remains one of the leading causes of preventable pregnancy-related deaths in the United States. Limited data compares maternal and neonatal outcomes among this high-risk population. We describe neonatal outcomes among pregnancies with and without heart disease in a tertiary care center with coordinated multidisciplinary care. Methods: This was a cohort study of pregnancies affected by maternal cardiac diseases that received multidisciplinary care (maternal-fetal-medicine, obstetrics, cardiology, anesthesiology, genetics) in a single tertiary center between 2012 and 2024. Study groups consisted of pregnancies with maternal acquired heart disease (AHD) (n = 242), maternal congenital heart disease (CHD) (n = 224), and a comparison group of pregnancies without maternal heart disease from November 2020 through April 2021 (n = 183). Neonatal outcomes including birth weight, gestational age, Apgar scores, and NICU admissions, were compared by Pearson Chi-Square, Fisher Exact, and Kruskal-Wallis rank sum tests. A pairwise comparison was conducted for significant differences. A sensitivity analysis was performed by logistic and linear regression to adjust for beta-blocker use during pregnancy. Significance was set at alpha = 0.05. Results: Maternal heart disease, particularly CHD, was associated with increased adverse neonatal outcomes compared to the comparison cohort. Infants born to people with CHD or AHD had lower birth weights, shorter gestational ages, lower Apgar scores, and higher NICU admission rates compared to those without heart disease (Table 1) (p < 0.01 for all comparisons). The proportion of small for gestational age infants born to people with CHD was significantly higher than those born to people with AHD (p = 0.007). After adjusting for beta-blocker exposure during pregnancy, the odds for small for gestational age in neonates of patients with CHD were 2.29 times higher than in those with AHD (p = 0.006). All other outcomes were similar in the CHD and AHD cohorts. Conclusion: Maternal heart disease is associated with increased risk of adverse neonatal outcomes, necessitating a multidisciplinary approach in prenatal care. Infants born to individuals with CHD had a higher risk for small for gestational age compared to those with AHD. Further studies are needed to better understand this biological difference.

The aim of this study was to evaluate perinatal outcome and long-term offspring gastrointestinal morbidity of women with celiac disease. Perinatal outcomes, as well as long-term gastrointestinal morbidity of offspring of mothers with and without celiac disease were assessed. The study groups were followed until 18 years of age for gastrointestinal-related morbidity. For perinatal outcomes, generalized estimation equation (GEE) models were used. A Kaplan–Meier survival curve was used to compare cumulative incidence of long-term gastrointestinal morbidity, and Cox proportional hazards models were constructed to control for confounders. During the study period, 243,682 deliveries met the inclusion criteria, of which 212 (0.08%) were to mothers with celiac disease. Using GEE models, maternal celiac disease was noted as an independent risk factor for low birth weight and cesarean delivery. Offspring born to mothers with celiac disease had higher rates of gastrointestinal related morbidity (Kaplan–Meier log rank test p < 0.001). Using a Cox proportional hazards model, being born to a mother with celiac disease was found to be an independent risk factor for long-term gastrointestinal morbidity of the offspring. Pregnancy of women with celiac disease is independently associated with adverse perinatal outcome as well as higher risk for long-term gastrointestinal morbidity of offspring.

Objective To evaluate the impact of cesarean delivery (CD) on offspring risk for long-term cardiovascular morbidity. Study design A population-based cohort analysis was performed, including all singleton term deliveries occurring between 1991 and 2014 at a single tertiary medical center. A comparison was performed between children delivered via CD and those delivered vaginally. Fetuses with cardiac or other congenital malformations were excluded, as were cases of urgent CD and pregnancies involving preeclampsia, gestational diabetes, placenta previa, labor induction, fetal growth restriction, preterm PROM, and instrumental deliveries. Hospitalizations of the offspring up to 18 years of age involving cardiovascular morbidity were compared between the two study groups. A Kaplan–Meier survival curve compared cumulative cardiovascular morbidity incidence and a Cox regression model controlled for confounders. Results Of the 132,054 term deliveries who met the inclusion criteria; 8.9% were CDs (n = 11,746) and 91.1% (n = 120,308) were vaginal deliveries. Cardiovascular hospitalization incidence per 1000 person follow up years was 0.742 in the CD group and 0.054 in the comparison group (HR = 1.3, 95%CI 1.051–1.710, p = .018). The Kaplan–Meier survival curve demonstrated a significantly higher cumulative incidence of cardiovascular morbidity following CD (log rank p = .018). In the Cox proportional hazards model, CD was noted as an independent risk factor for offspring long-term pediatric cardiovascular morbidity (adjusted HR = 1.295, CI 1.005–1.668, p = .04) when controlling for maternal age, obesity, ethnicity, gestational age, newborn gender, low birthweight, maternal preexisting cardiovascular disease, and deliveries occurring after 2008. Conclusion Singletons delivered by CD at term have an increased risk of long-term cardiovascular morbidity.

IntroductionFetal echocardiograms (F-echo) are recommended in all pregnancies when maternal congenital heart disease (CHD) is present, even if there was a prior level II ultrasound (LII-US) that was normal. The goal of this study was to evaluate if any diagnosis of a critical CHD was missed in a fetus with maternal CHD who had a normal LII-US.MethodsA retrospective chart review of all F-echoes where the indication was maternal CHD between 1/1/2015 to 12/31/2022 was performed. Fetuses were included if they had a LII-US that was read as normal and had an F-echo. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age.ResultsA total of 296 F-echoes on fetuses with maternal CHD were evaluated, of which 175 met inclusion criteria. LII-US was performed at 19.8 ± 2.9 weeks gestational age and F-echo was performed at 24.2 ± 2.8 weeks gestational age. No patient with a normal LII-US had a diagnosis of a critical CHD by F-echo (negative predictive value = 100%). Evaluating those patients that had a negative LII-US, ten patients were diagnosed with non-critical CHD postnatally (negative predictive value = 94.3%). F-echo correctly diagnosed two of the ten missed LII-US CHD.ConclusionsCritical CHD was not missed with a normal LII-US in this at risk population. F-echo also missed the majority of CHD when a LII-US was read as normal. A cost–benefit analysis of screening F-echo in fetuses with maternal CHD should be conducted if a normal LII-US has been performed.

Association between delivery of a small-for-gestational-age neonate and long-term maternal cardiovascular morbidity

Purpose To characterize temporal trends and outcomes of delivery hospitalization with maternal congenital heart disease (CHD). Materials and methods For this repeated cross-sectional analysis, deliveries to women aged 15–54 years with maternal CHD were identified in the 2000–2018 National Inpatient Sample. Temporal trends in maternal CHD were analyzed using joinpoint regression to estimate the average annual percentage change (AAPC) with 95% CIs. The relationship between maternal CHD and several adverse maternal outcomes was analyzed with log-linear regression models. Risk for adverse outcomes in the setting of maternal CHD was further characterized based on additional diagnoses of cardiac comorbidity including congestive heart failure, arrhythmia, valvular disease, pulmonary disorders, and history of thromboembolism. Results Of 73,109,790 delivery hospitalizations, 51,841 had a diagnosis of maternal CHD (7.1 per 10,000). Maternal CHD rose from 4.2 to 10.9 per 10,000 deliveries (AAPC 4.8%, 95% CI 4.2%, 5.4%). Maternal CHD deliveries with a cardiac comorbidity diagnosis also increased from 0.6 to 2.6 per 10,000 from 2000 to 2018 (AAPC 8.4%, 95% CI 6.3%, 10.6%). Maternal CHD was associated with severe maternal morbidity (adjusted risk ratios [aRR] 4.97, 95% CI 4.75, 5.20), cardiac severe maternal morbidity (aRR 7.65, 95% CI 7.14, 8.19), placental abruption (aRR 1.30, 95% 1.21, 1.38), preterm delivery (aRR 1.47, 95% CI 1.43, 1.51), and transfusion (aRR 2.28, 95% CI 2.14, 2.42). Risk for severe morbidity (AAPC 4.7%, 95% CI 2.5%, 6.9%) and cardiac severe morbidity (AAPC 4.7%, 95% CI 2.5%, 6.9%) increased significantly among women with maternal CHD over the study period. The presence of cardiac comorbidity diagnoses was associated with further increased risk. Conclusion Maternal CHD is becoming more common among US deliveries. Among deliveries with maternal CHD, risk for severe morbidity is increasing. These findings support that an increasing burden of risk from maternal CHD in the obstetric population.

Congenital heart disease, socioeconomic position and risk of preterm birth

824: Maternal congenital heart defects and long-term cardiovascular morbidity of the offspring

168: Does elective cesarean delivery affect long-term cardiovascular morbidity of the offspring?

There is no established consensus on the safest or most beneficial delivery mode for preterm twins. We assessed the associations between how premature twins were delivered and their long-term cardiovascular morbidity during childhood. A retrospective cohort study was conducted at the Soroka University Medical Center, the only tertiary hospital in southern Israel, which provides obstetric services to the whole country. Twins born between 1991 and 2021 were included, and their cardiovascular morbidity was followed up until 18 years of age. Data was collected from the hospital's databases. A Kaplan-Meier survival curve compared cumulative cardiovascular morbidity between the groups, and a Cox proportional hazard model adjusted the data for confounders. The study comprised 6856 premature twins: 3986 (58.1%) were born via Caesarean delivery and the other 2870 (41.9%) were born by vaginal delivery. Long-term cardiovascular morbidity rates were comparable between twins born vaginally and via Cesarean delivery. Likewise, the cumulative incidence of long-term cardiovascular morbidity did not differ. The Cox proportional hazard model, which controlled for maternal age, diabetes mellitus and hypertensive disorders, showed no associations with the two delivery groups. No associations were documented between delivery mode in preterm twins and childhood cardiovascular morbidity.

While placental abruption is often associated with short-term adverse pregnancy outcomes, we sought to assess whether placental abruption increases the risk for long-term cardiovascular morbidity of the offspring. To study the long-term cardiovascular hospitalizations of offspring of patients with and without placental abruption, cardiovascular morbidity was assessed up to the age of 18years according to a predefined set of ICD-9 codes associated with hospitalization of the offspring. Our data consist of deliveries which occurred between the years 1991 and 2014 in a tertiary medical center. Pregnancies following fertility treatments, multifetal pregnancies, and pregnancies with offspring with congenital anomalies, lack of prenatal care, and perinatal mortality were excluded from the study. We used Kaplan-Meier curve to compare cumulative morbidity incidence and Cox proportional hazards model to control for confounder. During the study period, we examined 217,910 deliveries, out of which 0.46% (n = 1003) were effected by placental abruption. Compared to normal birth children, children born to mothers with placental abruption did not show a significantly higher cumulative incidence of long-term cardiovascular morbidity (1.0% vs. 0.6%; p = 0.127). Placental abruption was not noted as an independent risk factor for long-term cardiovascular morbidity of offspring in the Cox regression analysis, which adjusted for confounders. Our study does not support the association between placental abruption and risk for long-term cardiovascular morbidity of the offspring.

Women with maternal congenital heart disease have a higher risk of preterm birth (PTB) and giving birth to a small for gestational age (SGA) infant. Advanced maternal age (≥35years) likewise increases the risk of PTB and SGA, probably explained by poorer cardiovascular status. It is likely that advanced maternal age is particularly detrimental in women with congenital heart disease. We aimed to determine whether the pattern of higher risk of PTB and SGA with higher maternal age varied among women with and without congenital heart disease. We hypothesised that the effect of age is higher among women with congenital heart disease. We did a cohort study using Danish nationwide registers. Births from 1997 to 2014 were included. Cox regressions were used to estimate hazard ratios (HRs) for PTB and SGA. Universal and congenital heart disease-specific references were used for comparison. We included 932772 births among 548314 women. HRs of PTB and SGA were 1.55 (95% confidence interval [CI] 1.37, 1.77) and 1.43 (95% CI 1.29, 1.58) in women with congenital heart disease as compared to women without. For both PTB and SGA, HRs were higher for women ≥35years as compared to women aged 25-29years. HRs of PTB and SGA were higher among women with congenital heart disease within all strata of maternal age as compared to women without (eg 3.71, 95% CI 1.80, 7.63 vs 1.63, 95% CI 1.56, 1.70) for SGA for women aged 40-44years). The pattern of higher risk of PTB and SGA with higher maternal age was, however, similar among women with and without congenital heart disease. Women with congenital heart disease had a higher risk of PTB and giving birth to an SGA infant at all maternal ages. These two risk factors did not, however, seem to potentiate each other.