Modified World Health Organization Classification Research Articles

Against all odds: successful pregnancy in an adult patient with unrepaired coarctation of the aorta.

According to the modified World Health Organization classification, pregnant women with unrepaired aortic coarctation are at very high risk for both maternal and fetal complications and should, therefore, be counselled against pregnancy. The most frequent maternal complications include systemic hypertension, renal failure, preeclampsia, and aortic dissection. Herein, we describe a successful pregnancy in an adult patient with unrepaired aortic coarctation.

Cardiovascular Risk Assessment in Pregnancy: Findings From a Large Urban Academic Medical Center [ID 2683572

INTRODUCTION: The goal of this study is to describe patients who screened positive and had true cardiovascular disease (CVD) identified using a risk assessment tool in pregnancy or postpartum. METHODS: This is a prospective validation study of the CVD screening algorithm proposed by the California Maternal Quality Care Collaborative (CMQCC). The CVD risk assessment tool was embedded in the electronic medical record for use by all prenatal care providers with a goal of at least one CVD risk assessment during pregnancy and/or postpartum period. Patients identified with increased risk of CVD received an echocardiogram, electrocardiogram, and cardiology consultation. We describe the assessment tool responses, timing of assessment, cardiac findings, and subsequent interventions. This study was approved by the IRB at Albert Einstein College of Medicine. RESULTS: A total of 1,877 patients were screened as of September 1, 2023, with 148 screening positive for at risk of CVD. Thirty-two patients were found to be true positives including 2 (6.25%) with systolic and/or diastolic dysfunction, 10 (31.3%) with ventricular dilation or hypertrophy, and 23 (71.9%) with a valvular abnormality. CONCLUSION: All 32 true-positive cases were seen by a multidisciplinary cardio-obstetrics team at least once. Ten patients had multiple visits with the cardio-obstetrics team. Three patients were deemed to be of higher risk for decompensation during labor by modified World Health Organization classification and required detailed plans for intrapartum and postpartum management. Seven patients were started on cardiovascular medications. The cardiovascular risk assessment tool proved valuable for identifying and providing individualized care for cardio-obstetric patients.

Electrocardiographic proarrhythmic changes in pregnancy of women with CHD.

Pregnancy-related physiological adaptations result in increased heart rate as well as electrocardiographic changes such as a mean QTc prolongation of 27 ms. Pregnant women with CHD are at increased risk for cardiovascular complications. The aim of this study was to identify risk factors for abnormally prolonged QTc interval-a risk factor for ventricular arrhythmias-in pregnant women with CHD. Retrospective longitudinal single-centre study. Pre-pregnancy demographic and electrocardiographic risk factors for abnormal QTc duration during pregnancy of (a) > 460 ms and (b) >27 ms increase were analyzed. Eighty-three pregnancies in 63 women were included, of which three had documented arrhythmias. All five Modified World Health Organization Classification of Maternal Cardiovascular Risk (mWHO) classeswere represented, with 15 pregnancies (18.1%) in mWHO class I, 26 (31.3%) in mWHO II, 28 (33.7%) in mWHO II-III, 11 (13.3%) in mWHO III, and three pregnancies (3.6%) in mWHO class IV. Heart rate and QTc interval increased, while QRS duration and PR interval shortened during pregnancy. QTc duration of > 460 ms was associated with increased pre-pregnancy QTc interval, QRS duration, and weight, as well as body mass index. QTc increase of > 27 ms was associated with increased heart rate prior to pregnancy. No significant associations of electrocardiographic changes with mWHO class or CHD type were identified. Increased QTc in pregnant women with CHD was associated with being overweight or having higher heart rate, QRS, or QTc duration prior to pregnancy. These patients should be monitored closely for arrhythmias during pregnancy.

Pregnancy risk and contraception among reproductive-age women with rheumatic heart disease attending care at a tertiary cardiac center in Tanzania: a hospital-based cross-sectional study

BackgroundRheumatic heart disease (RHD) remains prevalent in the developing world and reproductive-age women are disproportionately affected. It is among the common est cardiac diseases during pregnancy and is associated with poor pregnancy outcomes. Despite its importance among reproductive-age women, there are no local studies that characterize the clinical characteristics, risk of poor pregnancy outcomes and contraception which represents one effective way to prevent unplanned pregnancies in this population.MethodsThis was a hospital-based descriptive cross-sectional study. Non-pregnant reproductive-age women with echocardiographically diagnosed RHD were consecutively recruited from in- and out-patients units of the Jakaya Kikwete Cardiac Institute (JKCI). A clinical research form was used to gather socio-demographic, clinical characteristics, contraception status and echocardiographic information. The maternal/pregnancy risk class was determined using the modified World Health Organization (WHO) classification of maternal risk.ResultsTwo hundred thirty-eight women of reproductive age with RHD were recruited. The median age (range) was 36 years (15–49). Two-thirds were dyspneic on moderate exertion and 17.2% had New York Heart Association class IV heart failure. A quarter had atrial fibrillation/flutter. On echocardiography, mitral regurgitation was the most common valvular lesion (68.1%), followed by mitral stenosis (66.8%), and 12.2% of participants had reduced left ventricular ejection fraction. Two-thirds (66%) had a high pregnancy risk (class IV) based on the modified WHO classification system. The proportion of participants using contraception was 7.1% and common methods were: bilateral tubal ligation 5 of 17 (29.4%) and hormonal implant (4 of 17). The most common reason for the choice of a method was safety, 10 out of 17 (58.8%).ConclusionThe majority of women of reproductive age with RHD in our hospital cohort are at the highest pregnancy risk based on the modified WHO classification and a very small proportion of them are on contraception. These results call for action among clinicians to offer counselling to these patients, educating them on their risk and offering appropriate contraception advice while waiting for definitive interventions.

Mode of delivery and perinatal outcomes by modified World Health Organization classification of maternal cardiovascular risk in pregnancy

Cardiac disease is a leading cause of maternal morbidity and mortality in the United States, and an increasing number of patients with known cardiac disease are reaching childbearing age. Although guidelines indicate that cesarean deliveries should be reserved for obstetrical indications, rates of cesarean delivery among obstetrical patients with cardiovascular disease are higher than those of the general population. This study aimed to evaluate mode of delivery and perinatal outcomes among patients with low-risk and moderate to high-risk cardiac disease as defined by the modified World Health Organization classification of maternal cardiovascular risk. We performed a retrospective cohort study of obstetrical patients with known cardiac disease, as defined by the modified World Health Organization cardiovascular classification categories in pregnancy, who underwent a perinatal transthoracic echocardiogram at a single academic medical center between October 1, 2017 and May 1, 2022. Demographics, clinical characteristics, and perinatal outcomes were collected. Comparisons were made between patients with low- (modified World Health Organization Class I) and moderate to high-risk (modified World Health Organization Class II-IV) cardiac disease using chi-square, Fisher exact, or Student t-tests. Cohen d tests were used to estimate the effect size between group means. Logistic regression models were used to evaluate the odds of vaginal and cesarean delivery in low- and moderate to high-risk groups. A total of 108 participants were eligible for inclusion, with 41 participants in the low-risk cardiac group and 67 in the moderate to high-risk group. Participants had a mean age of 32.1 (±5.5) years at the time of delivery and a mean pregravid body mass index of 29.9 (±7.8) kg/m2. Chronic hypertension (13.9%) and a history of hypertensive disorder of pregnancy (14.9%) were the most common comorbid medical conditions. In total, 17.1% of the sample had a history of a cardiac event (eg, arrhythmia, heart failure, myocardial infarction). Rates of vaginal and cesarean deliveries were similar between the low- and moderate to high-risk cardiac groups. Patients in the moderate to high-risk cardiac group were more likely to be admitted to the intensive care unit during pregnancy (odds ratio, 7.8; P<.05) and experience severe maternal morbidity compared with patients in the low-risk cardiac group (P<.01). Mode of delivery was not associated with severe maternal morbidity in the higher-risk cardiac group (odds ratio, 3.2; P=.12). In addition, infants of mothers with higher-risk disease were more likely to be admitted to the neonatal intensive care unit (odds ratio, 3.6; P=.06) and have longer neonatal intensive care unit stays (P=.005). There was no difference in mode of delivery by modified World Health Organization cardiac classification, and mode of delivery was not associated with risk of severe maternal morbidity. Despite the overall increased risk of morbidity in the higher-risk group, vaginal delivery should be considered as an option for certain patients with well-compensated cardiac disease. However, larger studies are needed to confirm these findings.

Vascular malperfusion and abruption are prevalent in placentas from pregnancies with congenital heart disease and not associated with cardiovascular risk

Congenital heart disease (CHD) in pregnancy is associated with an increased risk of adverse maternal, obstetric, and neonatal outcomes, plausibly through mechanisms involving abnormal placental development and function. This retrospective study aims to elucidate how maternal CHD influences placental health. Demographic and clinical information were collected via electronic medical record review, and placentas underwent histopathological evaluation. Fifty-three singleton pregnancies were included: 35 participants (66%) were classified as lower cardiovascular risk (modified World Health Organization Classification (mWHO) I, II, II-III), and 18 (34%) were classified as higher cardiovascular risk (mWHO III, IV). 12 participants (23%) had a fetus with small for gestational age (SGA). Maternal vascular malperfusion (53%) and placental abruption (11.6%) were common in this cohort, with prevalence above baseline risk. Participants at higher cardiovascular risk had higher rates of SGA (p = 0.04), subchorionic hematomas (p = 0.01) and birth weight:placental weight < 10th percentile (p = 0.04), but did not differ in rates of maternal vascular malperfusion (p = 0.15) compared to those at lower cardiovascular risk. In pregnancies with maternal CHD, SGA and histologic evidence of maternal vascular malperfusion and placental abruption were common, though patients at higher cardiovascular risk did not show evidence of worsened placental health compared to those at lower risk.

Impact of Pre-Existing Ischemic Heart Disease on Severe Maternal Morbidity and Mortality During Delivery Hospitalizations

BackgroundThe impact of pre-existing ischemic heart disease (IHD) on pregnancy is incompletely described. ObjectivesThe purpose of this study was to compare adverse pregnancy outcomes between those with IHD and those with a cardiac diagnosis categorized by the modified World Health Organization classification and those without a cardiac diagnosis. MethodsThis retrospective study used the 2015 to 2018 Nationwide Readmissions Database. Delivery hospitalizations, comorbidities, and outcomes were identified using diagnosis and procedure codes. The exposure was isolated IHD. The primary outcome was severe maternal morbidity (SMM) or death during the delivery hospitalization, analyzed using adjusted relative risk (aRR) regression and weighted to account for the Nationwide Readmissions Database's complex survey methods. ResultsOf 11,556,136 delivery hospitalizations, 65,331 had another cardiac diagnosis, and 3,009 had IHD alone. Patients with IHD were older and had higher rates of diabetes and hypertension. In unadjusted analyses, adverse outcomes were more common among patients with IHD alone than among patients with no cardiac disease and modified World Health Organization class I-II disease. After adjustment, patients with IHD alone were associated with a higher risk of SMM or death (aRR: 1.51; 95% CI: 1.19-1.92) than those without a cardiac disease. In comparison, the aRR was 1.90 (95% CI: 1.76-2.06) for WHO class I-II diseases and 5.87 (95% CI: 5.49-6.27) for WHO II/III-IV diseases. Nontransfusion SMM or death (aRR: 1.60; 95% CI: 1.11-2.30) and cardiac SMM or death (aRR: 2.98; 95% CI: 1.75-5.08) were also higher for those with IHD. ConclusionsIsolated IHD in pregnancy is associated with worse outcomes than no cardiac disease during delivery hospitalization and approximates the risk associated with WHO I-II diagnoses.

Severe oral mucositis relating to pain and worse oral condition among patients with solid tumors undergoing treatment with FOLFIRI and 5-FU: a retrospective study.

ABSTRACTBACKGROUND:There is a need for studies that correlate the severity of oral mucositis (OM) with chemotherapy protocols, transient myelosuppression and oral health.OBJECTIVE:To analyze the severity of OM among individuals with solid tumors during hospitalization and its correlation with the type of chemotherapy, myelosuppression and oral health condition.DESIGN AND SETTING:Retrospective study at a public hospital in Bauru, state of São Paulo, Brazil, that is a regional referral center.METHODS:Individuals diagnosed with solid malignant tumors who received chemotherapy during hospitalization for completion of the antineoplastic treatment cycle or who presented complications resulting from this were assessed.RESULTS:Twenty-eight individuals (24.3%) manifested some degree of OM. The most prevalent degrees of OM according to the World Health Organization (WHO) and modified WHO classification were grades 2 (11.3%) and 5 (4.3%), respectively. It was observed that the higher the OM-WHO (P < 0.001; r = 0.306) and modified OM-WHO (P < 0.001; r = 0.295) classifications were, the greater the oral pain reported by the individuals was. Presence of mucositis in the upper lip and buccal mucosa contributed to increased severity of OM and worsening of swallowing during hospitalization. Thus, severe OM was associated with use of the FOLFIRI protocol (folinic acid, fluorouracil and irinotecan).CONCLUSION:Individuals with tumors who presented severe OM had greater severity of oral pain and worse oral health. Use of the FOLFIRI protocol was associated with higher prevalence of severe OM, while use of 5-fluorouracil (5-FU) was correlated with worse oral condition.

Comparison of severe maternal morbidity in pregnancy by modified World Health Organization Classification of maternal cardiovascular risk

BackgroundTo compare rates of severe maternal morbidity (SMM) for pregnant patients with a cardiac diagnosis classified by the modified World Health Organization (mWHO) classification to those without a cardiac diagnosis. MethodsThis retrospective study using the 2015-2019 Nationwide Readmissions Database identified hospitalizations, comorbidities, and outcomes using diagnosis and procedure codes. The primary exposure was cardiac diagnosis, classified into low-risk (mWHO class I and II) and moderate-to-high-risk (mWHO class II/III, III, or IV). The primary outcome was SMM or death during the delivery hospitalization; secondary outcomes included cardiac-specific SMM during delivery hospitalizations and readmissions after the delivery hospitalization. ResultsA weighted national estimate of 14,995,122 delivery admissions was identified, including 46,541 (0.31%) with mWHO I-II diagnoses and 37,330 (0.25%) with mWHO II/III-IV diagnoses. Patients with mWHO II/III-IV diagnoses experienced SMM at the highest rates (22.8% vs 1.6% for no diagnosis; with adjusted relative risk (aRR) of 5.67 [95% CI: 5.36-6.00]). The risk of death was also highest for patients with mWHO II/III-IV diagnoses (0.3% vs <0.1% for no diagnosis; aRR 18.07 [95% CI: 12.25-26.66]). Elevated risk of SMM and death persisted to 11 months postpartum for those patients with mWHO II/III-IV diagnoses. ConclusionsIn this nationwide database, SMM is highest among individuals with moderate-to-severe cardiac disease based on mWHO classification. This risk persists in the year postpartum. These results can be used to enhance pregnancy counseling.

ONE YEAR REVIEW OF PATIENTS ADMITTED WITH CARDIAC DISEASES IN PREGNANCY IN A TERTIARY CARE HOSPITAL OF PESHAWAR

Objective: To identify the frequency and type of cardiac diseases in pregnant women and their fetal and maternal outcome. Methodology: This observational study was carried out in Unit A, Department of Gynecology and Obstetrics, Lady Reading Hospital, Peshawar from mid January 2019 to mid January 2020. After informed written consent, using non probability consecutive sampling all pregnant women presenting with cardiac diseases were included in this study. Age, parity, mode of delivery, and period of gestation were recorded. Cardiac disease was diagnosed on the basis of symptoms, ECG and echocardiography. Types of different cardiac lesions and maternal risk were noted according to Modified World Health Organization classification of maternal cardiovascular risk. Maternal and fetal outcomes were measured in terms of mortality. Data was analyzed using SPSS version 20. Results: In one year, a total of 10263 pregnant ladies were admitted and among them 43 (0.42%) patients had cardiac disease. It was observed that 79.1% (n=35) were diagnosed for 1st time during pregnancy. Most frequent cardiac disorder was cardiomyopathy, found in 27.9% (n=12) of patients, followed by congenital heart disease in 18.6% (n=8), in the form of mitral and aortic stenosis. Maternal and fetal mortality was 4.7% (n=2) and 9.3% (n=4), respectively. Conclusion: There is a small proportion of pregnant patients with cardiac disease among all pregnancies. Most of the patients were multiparous and cardiomyopathy was found to be the most prevalent cardiac disease.

Pregnancy Outcomes in Women After Arterial Switch Operation for Transposition of the Great Arteries: Results From ROPAC (Registry of Pregnancy and Cardiac Disease) of the European Society of Cardiology EURObservational Research Programme.

BackgroundIn the past 3 decades, the arterial switch procedure has replaced the atrial switch procedure as treatment of choice for transposition of the great arteries. Although survival is superior after the arterial switch procedure, data on pregnancy outcomes are scarce and transposition of the great arteries after arterial switch is not yet included in the modified World Health Organization classification of maternal cardiovascular risk.Methods and ResultsThe ROPAC (Registry of Pregnancy and Cardiac disease) is an international prospective registry of pregnant women with cardiac disease, part of the European Society of Cardiology EURObservational Research Programme. Pregnancy outcomes in all women after an arterial switch procedure for transposition of the great arteries are described. The primary end point was a major adverse cardiovascular event, defined as combined end point of maternal death, supraventricular or ventricular arrhythmias requiring treatment, heart failure, aortic dissection, endocarditis, ischemic coronary events, and thromboembolic events. Altogether, 41 pregnant women (mean age, 26.7±3.9 years) were included, and there was no maternal mortality. A major adverse cardiovascular event occurred in 2 women (4.9%): heart failure in one (2.4%) and ventricular tachycardia in another (2.4%). One woman experienced fetal loss, whereas no neonatal mortality was observed.ConclusionsWomen after an arterial switch procedure for transposition of the great arteries tolerate pregnancy well, with a favorable maternal and fetal outcome. During counseling, most women should be reassured that the risk of pregnancy is low. Classification as modified World Health Organization risk class II seems appropriate.

Anesthesia for Cesarean Section and Postpartum Cardiovascular Events in Congenital Heart Disease: A Retrospective Cohort Study

To clarify the association between anesthetic technique and maternal and neonatal outcomes in parturients with congenital heart disease (CHD). Retrospective, observational cohort study. An academic hospital. A total of 263 consecutive parturients with CHD who underwent cesarean section from 1994 to 2019. None. The authors compared postpartum cardiovascular events (composite of heart failure, pulmonary hypertension, arrhythmia, and thromboembolic complications) and neonatal outcomes (intubation and Apgar score <7 at one or five minutes) by anesthetic technique. Among 263 cesarean sections, general anesthesia was performed in 47 (17.9%) parturients and neuraxial anesthesia in 214 (81.3%) parturients. Cardiovascular events were more common in the general anesthesia group (n = 7; 14.9%) than in the neuraxial anesthesia group (n = 17; 7.9%). Generalized linear mixed models assuming a binomial distribution (ie, mixed-effects logistic regression), with a random intercept for each modified World Health Organization classification for maternal cardiovascular risk, revealed that general anesthesia was not significantly associated with cardiovascular events (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.30-3.29). In addition, general anesthesia was associated with composite neonatal outcomes (Apgar score <7 at one or five minutes or need for neonatal intubation; OR, 13.3; 95% CI, 5.52-32.0). Anesthetic technique is not significantly associated with postpartum composite cardiovascular events. General anesthesia is significantly associated with increased need for neonatal intubation and lower Apgar scores.

508 Puerperal thrombosis on mitral valve prothesis

Abstract Introduction Replacement of a diseased heart valve with a prosthetic heart valve exchanges the native disease for prosthesis-related complications. Valve thrombosis can occur in mechanical prosthetic valves. The significant morbidity and mortality associated with this condition permits rapid diagnostic evaluation. A combination of transthoracic and transoesophageal echocardiography (TEE) is required to assess the haemodynamic effect of thrombosis, leaflet motion and thrombus size. Mechanical valves offer excellent haemodynamic performance and long-term durability, but the need for anticoagulation increases maternal and foetal mortality and morbidity, and the risk of major cardiac events during pregnancy. Case report A 23-year-old gravida 0 woman was admitted to the emergency obstetric care. At the age of 18 months, she underwent valve replacement surgery in the mitral position (St. Jude Medical Standard size 25mm), this requires use of warfarin after surgery. Although she was advised otherwise; the patient became pregnant. She had an increased risk of maternal cardiovascular complications [Modified World Health Organization classification (mWHO) III] and obstetrics complications. The warfarin treatment was discontinued, and it was started low molecular weight heparin (LMWH) 100IU, twice daily subcutaneously, on gestation 36 week. The last administration was 2 days before the admission (&amp;gt;48h before delivery). So, on gestation week 39, she was admitted to the department of Obstetrics. Then, as cardiotocography showed decreased foetal heart rate, an emergency caesarean section was performed. A healthy baby was delivered. After delivery, we perform an immediate two-dimensional transthoracic echocardiography (2D TTE), as there was a high-risk of valve thrombosis, and it showed an apparent normal prosthetic excursion but a high mean pressure gradient (25mmHg) – elevated transprosthetic gradient. It was not well visualized the occlude motion of the mechanical valve by 2D TTE, so we perform a TEE to answer the clinical question, if there was a dysfunction due to an acute process (i.e. thrombus). It revealed an obstruction – reduced mobility of one disc and elevated velocities by CW doppler (30mmHg), and a presence of thrombus (1.3X0.8mm). The anticoagulation with intravenous UFH was started immediately, but anticoagulation failed, and she underwent valve replacement surgery (St. Jude Medical standard size 27mm. Conclusion Our patient had a very-high risk of complications maternal cardiovascular complications - WHO risk classification III - because the risk of valve thrombosis is markedly increased during pregnancy. The risk is lower with adequate dosing of anticoagulant therapy, but our patient was not which increased the risk of thrombosis. Finally, it is important to notice that it is recommended to manage pregnancy in women with mechanical valves in a centre with a pregnancy heart team. Abstract 508 Figure. Valve thrombosis

P1265 A home for two: a case of a twin pregnancy complicated by twin-to-twin transfusion in a woman with a repaired total anomalous pulmonary venous connection

Abstract BACKGROUND Total anomalous pulmonary venous connection (TAPVC) is a rare correctable congenital heart lesion. According to the modified World Health Organization classification (mWHO) of maternal cardiovascular risk, pregnant patients with successfully repaired TAPVC are at low cardiovascular risk (mWHO class I), but the risk rises to mWHO class III if left ventricular (LV) impairment and ventricular arrhythmias are present. CASE SUMMARY A 34 years old woman with corrected supracardiac TAPVC, pregnant with a spontaneous monochorionic diamniotic twin pregnancy (TP) complicated by twin-to-twin transfusion syndrome (TTTS) was referred to the cardiologist in preparation for fetoscopic laser coagulation (FLC). She was born with a TAPVC to the innominate vein associated with an atrial septal defect (ASD), repaired at the age of 3 months by anastomosing the PVC to the posterolateral wall of the left atrium and closure of the ASD with a pericardial patch. At follow up a few years later she developed asymptomatic mild LV dysfunction and alternating brady and tachyarrhythmias including non-sustained ventricular tachycardias (NSVT). At 17th weeks of gestation she presented mild dyspnoea (NYHA functional class II) and an alternance of sinus bradycardia, atrial fibrillation and NSVT. 2D echocardiography showed moderate LV dilatation and dysfunction (LVEF 47%). She was treated with loop-diuretics, but refused antiarrhythmic and anticoagulant therapy. At 19th weeks, TTTS was diagnosed and successful FLC of placental anastomoses was carried out. Symptomatic worsening of LV function and functional class developed in the ensuing weeks (NYHA III, LVEF 40%). Induction of foetal lung maturity with maternal administration of steroids was carried out at 28 weeks but stopped because of spontaneous preterm labour. After delivery, the arrhythmic burden increased to the point of requiring admission to the intensive care unit (ICU) where pacemaker implant was indicated, but refused by the patient. Diuretics and ACE-inhibitors were titrated, but no beta-blockers nor other antiarrhythmics could be started due to intermittent av block. At discharge, the patient was asymptomatic at rest and there were no clinical signs of heart failure. At 17 months of follow-up, she was still asymptomatic, though LV function remained poor. The 2 newborns were discharged after a stormy 4 months in the neonatal ICU and are still being treated for bronchopulmonary dysplasia and the sequels of intraventricular haemorrages. DISCUSSION We are not aware of other described twin pregnancies in repaired TAPVC with residual LV dysfunction and arrhythmia. As the haemodynamic load of twin pregnancy is more severe and the twin pregnancy itself at high risk both for prematurity and maternal cardiac deterioration, evaluation by a Specialist Multidisciplinary referral Unit should occur before conception especially in mNYHA class III and higher, as per current guidelines. Abstract P1265 Figure. Image 1

Update ESC-Leitlinie: Kardiovaskuläre Erkrankungen während der Schwangerschaft – Worauf kommt es an?

The treatment of pregnant patients with a cardiovascular disease is a special challenge to deal with. Before getting pregnant all cardiac patients should get medical advice accordingly to their risk profile in the modified World Health Organization classification of maternal cardiovascular risk. This article has the aim to give an overview of the new or changed recommendations of the new ESC-Guideline for the management of cardiovascular diseases during pregnancy.

346. Pregnant with Marfan syndrome and aortic root aneurism: Dissection case report for the third quarter

Introduction The main cardiovascular complications of Marfan Syndrome (MS) are valvar disease, heart failure and aortic dissection. Pregnancy in a patient with MS presents greater risk of aortic complications. Aortic root diameter greater than 45 mm is a class IV of modified World Health Organization classification of maternal pregnancy risk (high risk of maternal death or severe morbidity). We discuss a case of aortic dissection in the third trimester in a MS patient with aortic dilation previous to pregnancy. Method Review of medical charts. Case description Patient 40 years old, with MS, previous echocardiogram with aortic root of 54 mm, ascending aorta of 56 mm, and normal aortic arch. She refused therapeutic abortion. During prenatal she remained asymptomatic, under use of metoprolol for 75 mg. A new echocardiogram was made in the second trimester, without alterations. At 30 weeks of gestation, she presented with aortic dissection type Stanford A. A cesarean section was performed under general anesthesia, followed by subtotal hysterectomy, during which the patient remained stable. Subsequently, correction of dissection of the ascending aorta was initiated, with a Benton procedure and right coronary artery bypass. An intraoperative myocardial infarction caused cardiorespiratory arrest reversed during surgery, but a new episode during anesthetic lead to death. The 1370 g live neonate had a good outcome. Discussion Aortic dissection is a severe condition with high rates of mortality. Pregnancy in a patient with aortic dilation is a reason to pregnancy termination, refused by this patient. Even with medical treatment with beta-blocker, she presented a type A aortic dissection, with immediate indication of premature therapeutic cesarean section followed by surgery. Despite prompt diagnosis and treatment, an intraoperative myocardial infarction was the cause of maternal death. This case shows that in spite of optimal care, pregnancy in Marfan syndrome patient with aortic dilation may have a fatal outcome.

Validation of modified World Health Organization classification for pregnant women with heart disease in a tertiary care center in southern Thailand.

PurposeTo validate the modified World Health Organization (WHO) classification in pregnant women with congenital and acquired heart diseases.Patients and methodsThe database of pregnant women with heart disease, who delivered at Songklanagarind Hospital between January 1995 and December 2016, was retrieved from the Statistical Unit, Department of Obstetrics and Gynecology, along with the Hospital Information System of Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University. Each patient was retrospectively classified according to the modified WHO classification of maternal cardiovascular risk. Comparison of maternal and fetal outcomes among the modified WHO classes were analyzed using the chi-square test or Fisher’s exact test and one-way ANOVA test. A p-value of <0.05 was considered statistically significant.ResultsA total of 331 cases were studied: 157 cases with congenital heart disease and 174 cases with acquired heart disease. There were 48, 173, 32 and 78 cases in the modified WHO class I, II, III and IV, respectively. Congestive heart failure was the most common complication. The overall maternal mortality rate was 3.6%, all of which were in the modified WHO class IV. Maternal cardiovascular events occurred in 24.2% of cases, increasing rates with higher modified WHO class: 4.2%, 15.0%, 25.0% and 56.4% in class I, II, III and IV, respectively (p<0.001). Adverse fetal outcomes including preterm delivery, low birth weight, small for gestational age and neonatal intensive care unit admission were also significantly increased in class III and IV (p<0.05).ConclusionThe modified WHO classification is useful not only for obtaining a cardiovascular risk assessment in pregnant women with heart disease but also for predicting adverse fetal outcomes. It must, therefore, be implemented into routine care service at all levels of health care systems.

Increased Grade in Neuroendocrine Tumor Metastases Negatively Impacts Survival.

Tumor grade is an important predictor of survival in gastroenteropancreatic (GEP) neuroendocrine tumors (NETs), as determined by Ki-67 expression and mitotic rate. NETs generally grow indolently, but some cells may acquire traits facilitating metastasis. It is unclear how frequently metastases differ in grade from their primary tumors, and whether increasing grade in metastases affects prognosis. Ki-67 immunohistochemistry was performed on resected GEPNET specimens and cases with results for both primary tumors and concurrent metastases were identified. Grade was determined using a modified World Health Organization classification (Ki-67: G1=0-2%; G2>2-20%; G3>20%). Ki-67 was performed on both the primary tumor and metastases in 103 patients. Tumor grade was higher in metastases from 25 (24%) patients, 24 increased from G1 to G2, and 1 increased from G2 to G3; 68 (66%) patients had no change in grade (42 G1 and 26 G2), and 10 (10%) decreased from G2 to G1. No clinicopathologic factors were predictive of higher grade in metastases. The 5-year progression-free survival (PFS) was 55% for patients with stable grade versus 8% of patients with increased grade, while 5-year overall survival (OS) was 92 and 54%, respectively. The 5-year OS of patients who had stable grade with G1 and G2 primaries was 92 and 64%, respectively. Nearly one-third of patients had metastases with a different grade than their primary, and, when grade increased, both PFS and OS significantly decreased. Determining the grade in both the primary tumor and a metastasis is important for estimating prognosis and to help inform decisions regarding additional therapies.

Predictors of obstetric complications in women with heart disease

Objectives: The objective of this study is to evaluate obstetric outcomes in women with heart disease and determine whether current multidisciplinary management approaches adversely affect the mother, the neonate, or both. Also to compare the accuracy of several risk scores (RS) including the modified World Health Organization classification (mWHO) and CARPREG to predict obstetric and neonatal complications and to study the addition value of Uteroplacental-Doppler flow (UDF) parameters to predict obstetric complications. Methods: A prospective cohort study examined outcomes in women with heart disease (HD), the majority of whom had corrective surgery and delivered between January 2007 and March 2012. Results: One hundred and seventy-four patients with 179 pregnancies were included in the study. Obstetric complications, including premature labor, arose in 87 patients (48.6%). Neonatal complications were observed in 11 cases (7%). On multivariate analysis, maternal heart disease was predictive of adverse perinatal events (46 cases, 25.7%) and mode of delivery (Thierry’s spatula) of third- or fourth-degree perineal tears (six cases, 3.2%). mWHO classification predicted obstetric complications (p = 0.0001) better than the CARPREG study. Impaired UDF (uterine artery pulsatility index-20 weeks and umbilical artery pulsatility index-32 weeks in HD versus healthy women: 20w 1.12 versus 1.34, p = 0.005; 32w 0.87 versus 1.09, p = 0.008) was associated with adverse obstetric and offspring outcome in the group of HD pregnant women. Conclusions: Nearly 50% of pregnancies were associated with an adverse obstetric outcome, particularly IUGR. mWHO was better at predicting obstetric and neonatal complications that CARPREG in all cathegories. Furthermore, compromised UDF combined with mWHO improved the prediction of obstetric and offspring complications in this population.

Morphometry of non-inflammatory arteriolar changes in lupus nephritis: a study of 40 cases.

Vascular changes in lupus nephritis (LN) may be the cause of renal function derangement without obvious changes in activity or chronicity indices. Although a few morphological studies of renal vasculature exist, arteriolar morphometric parameters in LN have not been evaluated. For this study, 40 patients with LN and 40 age-matched patients with minimal change disease (controls) were included. Their clinical features were noted, renal biopsy changes classified according to the modified World Health Organization classification of LN and activity and chronicity indices were calculated. Arteriolar morphometric parameters were obtained using manual tracing and an image analysis software. Appropriate statistical tests were applied to assess significance of difference between various groups. Arteriolar wall thickness as well as circumference was significantly higher in all classes of LN as compared with controls (P <0.05). However, no difference was observed in the wall-to-lumen ratio between the two groups (P >0.05). An inter-class analysis of LN did not show any significant difference for any of the arteriolar morphometric parameters (P >0.05). No correlation was found between activity or chronicity indices and the various arteriolar morphometric parameters. This study demonstrates morphometric evidence of arteriolar wall changes in LN. Although no correlation was found with the histological features, further studies are required in this area.