Preventing Complications in Pregnant Women With Cardiac Disease
What is the incidence of serious cardiac events (SCEs) in pregnant women with heart disease, and are these adverse outcomes preventable?
A prospective cohort of 1,315 pregnancies in women with heart disease in Canada was used to assess clinical variables and outcomes. SCEs were defined as cardiac death or cardiac arrest, serious arrhythmias or heart failure requiring intensive care, aortic dissection, myocardial infarction, cerebrovascular events, mechanical valve thrombosis, pulmonary embolism, endocarditis, or urgent cardiac intervention. Preventability was defined as a deviation in standard care that could have led to adverse events, adjudicated using the Harvard Medical Practice Study criteria.
SCEs occurred in 3.6% of pregnancies (47 of 1,315). Nearly half of SCEs (49%) were preventable, and most were related to provider management factors (74%). The most common SCEs were cardiac death or arrest, heart failure, arrhythmias, and urgent interventions. SCEs were more likely to occur in women with acquired heart disease, severe aortic or mitral stenosis, mechanical valves, and women with at least mild systemic ventricular dysfunction. Adverse fetal and neonatal outcomes were more common in pregnancies with SCEs (62% vs. 29%; p < 0.001). Adverse obstetric events (1.7%) were primarily related to pre-eclampsia with severe features.
Pregnant women with heart disease are at risk for serious adverse cardiac events, and approximately half of these events are preventable.
Cardiovascular disease is a leading cause of maternal morbidity and mortality. In this well-defined cohort, pregnant women with heart disease were at increased risk for SCEs, and half of the adverse outcomes were preventable. The majority of the preventable events occurred due to provider management factors, including: failure to identify the condition prior to pregnancy, failure to identify the patient as high risk, late recognition in cardiac deterioration, delay in treatment/intervention, inappropriate treatment, and lack of preconception counseling. Preventable adverse events also occurred when patients failed to seek care, were noncompliant, or lacked access to health care. These findings suggest that provider training, patient education, and health care advocacy are all important interventions to improve outcomes among pregnant women. The development of multidisciplinary cardio-obstetric clinics at tertiary care centers may also be helpful.
Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Valvular Heart Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, CHD and Pediatrics and Arrhythmias, Acute Heart Failure
Keywords: Aortic Valve Stenosis, Arrhythmias, Cardiac, Death, Sudden, Cardiac, Endocarditis, Heart Arrest, Heart Failure, Heart Valve Diseases, Infant, Newborn, Mitral Valve Stenosis, Myocardial Infarction, Pre-Eclampsia, Pregnancy, Secondary Prevention, Thrombosis, Vascular Diseases, Ventricular Dysfunction, Women
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