Pregnancy in Women With Hypertrophic Cardiomyopathy

Study Questions:

What are the maternal and fetal outcomes of pregnant women with hypertrophic cardiomyopathy (HCM)?

Methods:

Data from pregnant women with HCM entered into the worldwide Registry of Pregnancy and Cardiac disease (ROPAC) between 2007 and 2014 were analyzed. Major adverse cardiovascular events (MACE) included death, heart failure, thromboembolic events, and arrhythmia. Outcomes among patients with and without MACE, and patients with obstructive HCM and nonobstructive HCM, were compared.

Results:

Among 60 pregnant women with HCM (mean age 30.4 years), there were no maternal deaths, but 14 (23%) had at least one MACE (15% heart failure, 10% ventricular arrhythmia). The majority of MACE occurred in the third trimester and early postpartum period, but also occurred as early as 5 weeks’ gestation. Women with signs of heart failure or New York Heart Association (NYHA) class >I prior to pregnancy were more likely to have MACE. Fetal loss occurred in 3 (5%) pregnancies and 5 (8.3%) neonates were diagnosed with an inherited cardiomyopathy. Cesarean section was performed in 36 (60%) patients. There were no significant differences between patients with obstructive versus nonobstructive HCM.

Conclusions:

Most women with HCM in this registry tolerated pregnancy and there were no maternal deaths. However, there was a significant rate of MACE, which was more prevalent among women with symptoms of heart failure or decreased functional class before pregnancy.

Perspective:

These findings from ROPAC are consistent with prior studies of HCM during pregnancy. Most women who are asymptomatic from HCM and have good functional status can tolerate pregnancy and the associated increase in plasma volume; however, adverse outcomes can occur. Preconception counseling and close monitoring throughout pregnancy is essential. Although there were no maternal deaths reported in this registry, a significant number of women with HCM developed heart failure and/or ventricular tachyarrhythmias. Women should be carefully assessed prior to pregnancy because symptoms of heart failure or decreased functional status are associated with increased risk during pregnancy. Since most adverse events occur in the third trimester or the first week postpartum, close follow-up by an experienced multidisciplinary team is essential. Additional information about family history, syncope, arrhythmias, and genotype could prove useful in risk stratification, but future research is needed.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, CHD & Pediatrics and Arrhythmias, Acute Heart Failure

Keywords: Arrhythmias, Cardiac, Cardiomyopathies, Cardiomyopathy, Hypertrophic, Cesarean Section, Genotype, Heart Failure, Infant, Newborn, Maternal Death, Patient Care Team, Postpartum Period, Pregnancy, Pregnancy Trimester, Third, Syncope, Tachycardia


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