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Pregnancy Outcomes in Women With Heart Disease
Quick Takes
- The Madras Medical College Pregnancy and Cardiac (M-PAC) registry in India reveals high rates of maternal morbidity and mortality.
- Independent predictors of adverse maternal outcomes included: LV systolic dysfunction, severe mitral stenosis, prosthetic heart valves, and pulmonary hypertension.
- The majority of pregnant women did not know about their diagnosis of heart disease prior to their pregnancy.
Study Questions:
What are the feto-maternal outcomes, adverse outcome predictors, and applicability of the modified World Health Organization (mWHO) classification in pregnant women with heart disease in India?
Methods:
The Madras Medical College Pregnancy and Cardiac (M-PAC) registry prospectively enrolled pregnant women (2016-2019). Demographic and clinical data and outcomes were collected and analyzed. Primary outcomes were maternal mortality and composite maternal cardiac events. Secondary outcomes were fetal loss and composite adverse fetal events.
Results:
The cohort included 1,005 women (mean age 26 ± 4 years) with 1,029 consecutive pregnancies. Most women had a new diagnosis of heart disease during pregnancy (60%). The most common diagnosis was rheumatic heart disease (42%) and one third had pulmonary hypertension. Maternal cardiac events occurred in 15% of pregnancies, with heart failure being the most common (66%). Independent predictors of adverse cardiac events included left ventricular (LV) systolic dysfunction, severe mitral stenosis, prosthetic heart valves, and pulmonary hypertension. Maternal mortality was 2%, with the highest rates in patients with prosthetic heart valves (9%). The adverse fetal event rate was 34%. The c-statistic of mWHO classification for prediction of maternal cardiac events was 0.794 (95% confidence interval, 0.763-0.826).
Conclusions:
Pregnant women with heart disease in India have high rates of maternal mortality, especially among those with prosthetic heart valves, pulmonary hypertension, or LV dysfunction. The mWHO classification method was only moderately accurate for predicting adverse outcomes in this cohort and may need further adaptation and validation in India.
Perspective:
Compared with other registries of patients with heart disease (e.g., ROPAC, CARPREG), the maternal morbidity and mortality is significantly higher in this M-PAC registry from India. Rheumatic heart disease, prosthetic valves, cardiomyopathy, and pulmonary hypertension are prevalent and associated with increased maternal risks. Further studies to determine effective methods to improve outcomes are needed. The mWHO classification system, described by the European Society of Cardiology pregnancy guidelines, is frequently used to predict risk; however, this classification system relies on the cardiac diagnosis without accounting for many other factors (management, severity, geography, access to care, etc.) that influence outcomes. Additional tools for assessing and reducing maternal and fetal risk while accounting for global variations are needed.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Vascular Medicine, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Pulmonary Hypertension, Hypertension
Keywords: Cardiomyopathies, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Hypertension, Pulmonary, Maternal Mortality, Mitral Valve Stenosis, Pregnancy, Pregnancy Outcome, Rheumatic Heart Disease, Ventricular Dysfunction, Left, Women
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