Most mothers born with heart defects can develop


image: Overview of the main results of the study. The results illustrate a significantly increased risk of maternal and neonatal complications as well as a significantly increased risk of recurrence of congenital heart disease in children of mothers with congenital heart disease.
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Credit: European Heart Journal

According to a study published in European Heart Journal today (Wednesday). [1]

In recent decades, advances in heart surgery have meant that more babies born with congenital heart disease (CHD) have survived and reached childbearing age, but so far the risks for women with CC to become pregnant and give birth have not been cleared. Doctors often advised them against attempting pregnancy because of the risk of death and other health problems for mothers and babies.

The current study of 7,512 pregnancies in 4,015 women with coronary artery disease in Germany is the largest to investigate the problem and shows that no woman has died, although there have been more health complications for her. these mothers and babies compared to a control group of 11,225 pregnancies in 6,502 women without CHD. There was a low but increased risk of stillbirth or death of babies in the first month of life in people born to mothers with coronary heart disease, and these children had a six times higher risk of coronary heart disease than in the group. witness.

“The most important finding of our study is that many women born with a congenital heart defect are able to go through their pregnancies and give birth safely. This is important because only a few decades ago many women would not even have reached adulthood themselves. It is very encouraging to see that so many mothers with congenital heart defects can give birth to healthy children, ”said Dr. Astrid Lammers, who is the study’s lead author and consultant. in pediatric cardiology, currently working in the ward for adults with coronary artery disease at the University Hospital in Münster, Germany.

“We report health issues around the time of birth that are relevant and important. However, with advanced neonatal support and techniques, the majority of these problems can be overcome with medical support, albeit with surgery and prolonged hospitalization.

An accompanying editorial by experts not involved in the research [2] describes the result of zero deaths among mothers in the ‘well done’ study as ‘unexpected and fantastic news’.

Dr Lammers and colleagues analyzed all pregnancies of women with coronary artery disease between 2005 and 2018 with one of the largest German health insurance companies, which insures around nine million people (around one ninth of the German population). ). They matched them with women of the same age who did not have coronary artery disease.

They found no women in the CHD group who died during pregnancy and up to 90 days after childbirth; a woman in the non-CHD group died. Although the complications were low overall, women with congenital heart disease had a significantly higher rate of stroke (1.13% vs. 0.17%), heart failure (0.84% ​​vs. 0, 03%) and abnormal heart rhythm problems (0.82% vs. 0.12%) compared to women without coronary artery disease. . Cesarean deliveries were also more common in coronary heart patients: 40.5% versus 31.5%.

Among babies born to mothers with coronary heart disease, there was an increased risk of stillbirth (1.4% vs. 0.4%), death in the first month of life (0.83% vs. 0.22% ), of low and extremely low birth weight (1000-2499g or less than 1000g), born prematurely, requiring mechanical ventilation, showing major visible abnormalities and exhibiting Down syndrome or other genetic syndromes. Eighteen percent of babies born to mothers with coronary artery disease themselves had coronary artery disease, compared with 3% of babies to mothers without coronary artery disease, and 6% versus 0.4% required assisted heart surgery heart-lung machine before the age of six.

The researchers found that the complexity of the mother’s heart defect, high blood pressure, heart failure, anticoagulant therapy with vitamin K antagonists in the year before pregnancy, and previous fertility treatment were all significant predictors of medical problems in the newborn.

In their article, the researchers point out that the mothers studied were managed jointly by pediatric and adult cardiologists, gynecologists and general practitioners, as well as regional and national adult CHD centers, in a decentralized and well-funded health system where they would have had access to appropriate advice. The same results would be unlikely in less wealthy countries.

“Our findings should help inform expectant mothers with congenital heart disease what to expect in terms of neonatal complications and refer them to the appropriate care providers if they wish to start a family. Counseling is a very important part of the care of every woman with a congenital heart defect and should begin at a young age. It seems to work in developed countries like Germany, as suggested by the lack of maternal deaths. This is probably due to avoiding very high risk pregnancies and proper management of the pregnancy, ”said Dr Lammers.

“Health issues seem to occur primarily in children, so counseling should focus on potential health issues for them. For some women whose heart defects put them at a very high risk of death or serious complications, the risks associated with pregnancy should be discussed during counseling and these women should be discouraged from becoming pregnant. Sometimes the desire to have a child outweighs these risks, and women always choose to get pregnant. It remains an individual decision for the woman and her partner. In this case, it is important to ensure close medical supervision by all specialists involved throughout the pregnancy. [3]

In the accompanying editorial, Prof Jolien Roos-Hesselink and Dr Karishma Ramlakhan, Erasmus University Medical Center Rotterdam (The Netherlands) write that the study is an important contribution to knowledge on the subject. “Not only is this the largest study, but it includes all women with ADHD [adult congenital heart disease], without possible bias to include only patients seen in a tertiary center or to include patients with other types of heart disease. In addition, given that it is carried out in a western country with an optimal health system, the results are applicable to other western countries with comparable care organization systems with appropriate counseling in place and a good collaboration between cardiac and obstetric care. Pregnancy outcomes in studies with a global perspective, including patients from developing countries, show less favorable outcomes. . . These differences illustrate how a women’s health system and environment have a huge impact on the outcome of their pregnancy and show that we still need to work to improve these outcomes for all women around the world.

They point out that the fact that no woman with coronary heart disease has died “reassures the vast majority of patients with coronary heart disease about the risk of pregnancy mortality. This is an important message that should lead to a policy change from a potentially very dangerous approach to pregnancy to considering pregnancy relatively safe and an explanation of possible risks, provided that WHOM IV women [the very highest risk group] should not get pregnant.

Remarks:

[1] “Maternal and neonatal complications in women with congenital heart disease: a national analysis”, by Astrid Elisabeth Lammers et al. European Heart Journal. doi: 10.1093 / eurheartj / ehab571

[2] “Promising Perspectives on Pregnancy in Women with Congenital Heart Disease”, by Karishma P. Ramlakhan and Jolien W. Roos-Hesselink. European Heart Journal. doi: 10.1093 / eurheartj / ehab692

[3] heart defects complex severity includes univentricular hearts, in which there is one chamber rather than two, transposition of large arteries, and cyanotic congenital heart disease, which is any heart defect that results in deoxygenated blood bypassing the lungs and entering the circulation, resulting in a lack of oxygen reaching other tissues of the body. Average heart defects include tetralogy of Fallot (pulmonary stenosis, interventricular communication, aortic overlap, thick right ventricle) and narrowing of the largest artery, the aorta. Simple Heart defects include defects in the atrial “collecting” chambers or defects in the wall (the septum) that divides the left and right ventricles in the heart.