Downloaded from http://heart.bmj.com/ on March 1, 2015 - Published by group.bmj.com
Heart Online First, published on January 21, 2015 as 10.1136/heartjnl-2014-307228 Editorial
Mode of delivery for pregnant women with heart disease Oktay Tutarel In Western industrialised countries, 0.2%– 4% of all pregnancies are complicated by cardiovascular diseases, and maternal heart disease is the major cause of maternal death during pregnancy.1 While in the Western world, congenital heart disease is the most frequent cardiovascular disease present during pregnancy, in non-Western countries, rheumatic valvular disease dominates.1 As the number of adults with congenital heart disease is increasing due to the great achievements in the treatment of congenital heart defects over the last decades, the prevalence of women with cardiac disease reaching adulthood and contemplating pregnancy is also increasing.2 But, still, cardiac disease in pregnancy remains a relatively ‘evidence-sparse’ field.3 Randomised controlled trials are absent,2 which results in controversy regarding optimum care. One field of intense debate is the mode of delivery, with caesarean section (CS) and vaginal delivery as contenders. Cardiologists and obstetricians often hold very firm views with regard to the superiority of one form of delivery over another.3 The current guidelines of the European Society of Cardiology about pregnancy in cardiac disease recommend that the preferred mode of delivery is vaginal, while generally speaking CS is reserved mainly for obstetric indications,1 with the exception of some maternal cardiac lesions regarded as high risk, like patients on oral anticoagulants in preterm labour, patients with Marfan syndrome and an aortic diameter >45 mm, patients with acute or chronic aortic dissection and those with acute intractable heart failure, in which CS should be considered.1 Despite these recommendations, women with cardiac disease are often more likely to give birth via CS than women without cardiac disease.4 5 Since there are no robust data to support a preference for CS or vaginal delivery, in the world of evidence-based medicine, a randomised controlled trial that elucidates which form of delivery is the best for Correspondence to Dr Oktay Tutarel, Department of Cardiology & Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; [email protected]
both, the maternal and fetal outcome, would be necessary. But such a trial is currently not available and considering all difficulties facing such an endeavour, probably will never be. In such circumstances, data from large registries are our second best bet. One of the largest is the Registry of Pregnancy and Cardiac disease (ROPAC), which was initiated by the European Society of Cardiology and now has enrolled 1321 pregnant women with cardiac disease from a total of 60 hospitals in 28 countries.6 Ruys and colleagues used the data from this registry to investigate the relationship between mode of delivery and pregnancy outcome in 1262 women with cardiac disease.7 In 69% of these patients a vaginal delivery was planned, while in 31% a CS was planned. An emergency CS had to be performed in 16.5% of the patients in the planned vaginal delivery group and in 13.5% of patients in the planned CS group. The authors could not find a difference in the maternal outcome of the patients with planned versus emergency CS. Their most important finding is that there was a similar outcome between the group of patients with planned vaginal delivery in which emergency CS had to be performed and those with a planned and performed CS. Therefore, if patients were not in the highrisk cardiac group and had no obstetric reasons for a CS, an attempt for vaginal delivery was possible, and even if a conversion to emergency CS was necessary, the outcome was not worse than if a CS had been planned right at the outset. But, still, I would be cautious with the assumption made by the authors that ‘planning a caesarean section does not lower the risk of maternal adverse outcome. Therefore, there was no benefit of planned caesarean section over trial vaginal delivery in pregnant patients with cardiac disease’.7 Considering that the planned CS for cardiac reasons group in their study included more high-risk cases with valvular heart disease, cardiomyopathy, worse overall New York Heart Association class and greater anticoagulant use, and also displayed greater maternal mortality, I am not convinced that this group would have the same outcome if vaginal delivery was tried
Tutarel O. Heart Month 2015 Vol 0 No 0
first. Additionally, the design of this study is not adequate to prove the point that there is no benefit of planned CS for patients who are deemed high risk in the current guidelines. But it is reassuring that in patients with cardiac disease without a firm indication (cardiac or obstetric) for CS, a vaginal delivery can safely be attempted, and even if the clinical situation worsens and an emergency CS is required, the outcome is not worse than in patients with a planned CS. This study is—as stated by the authors —primarily hypothesis generating. And its major limitation is the heterogeneity of the data with 60 hospitals in 28 countries contributing to it with different healthcare systems and quite varied rates of CS, even in the general population. But these are limitations that any study based on registries faces. This holds especially true in the field of congenital heart disease, where a meaningful number of cases can often only be achieved by multicentre studies. The most important aspect for a successful pregnancy in women with cardiac disease is still adequate planning. Prepregnancy counselling is of utmost importance. Furthermore, timing and mode of delivery should be discussed in advance in a multidisciplinary team including the patient, and an individualised approach is an absolute necessity. In addition, especially in high-risk lesions, delivery should take place in a tertiary centre with a specialist multidisciplinary team experienced in the care of pregnant women with cardiac disease. Competing interests None. Provenance and peer review Commissioned; internally peer reviewed. To cite Tutarel O. Heart Published Online First: [ please include Day Month Year] doi:10.1136/heartjnl2014-307228
▸ http://dx.doi.org/10.1136/heartjnl-2014-306497 Heart 2015;0:1–2. doi:10.1136/heartjnl-2014-307228
REFERENCES 1
2
3
Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011;32:3147–97. Roos-Hesselink JW, Ruys PT, Johnson MR. Pregnancy in adult congenital heart disease. Curr Cardiol Rep 2013;15:401. Swan L, Lupton M, Anthony J, et al. Controversies in pregnancy and congenital heart disease. Congenit Heart Dis 2006;1:27–34.
1
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd (& BCS) under licence.
Downloaded from http://heart.bmj.com/ on March 1, 2015 - Published by group.bmj.com
Editorial 4
5
2
Josefsson A, Kernell K, Nielsen NE, et al. Reproductive patterns and pregnancy outcomes in women with congenital heart disease—a Swedish population-based study. Acta Obstet Gynecol Scand 2011;90:659–65. Karamlou T, Diggs BS, McCrindle BW, et al. A growing problem: maternal death and peripartum complications
6
are higher in women with grown-up congenital heart disease. Ann Thorac Surg 2011;92:2193–8. Roos-Hesselink JW, Ruys TP, Stein JI, et al. Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European
7
Society of Cardiology. Eur Heart J 2013; 34:657–65. Ruys TP, Roos-Hesselink JW, Pijuan-Domènech A, et al. Is a planned caesarean section in women with cardiac disease beneficial? Heart Published Online First: 24 Dec 2014 doi:10.1136/heartjnl-2014-306497
Tutarel O. Heart Month 2015 Vol 0 No 0
Downloaded from http://heart.bmj.com/ on March 1, 2015 - Published by group.bmj.com
Mode of delivery for pregnant women with heart disease Oktay Tutarel Heart published online January 21, 2015
Updated information and services can be found at: http://heart.bmj.com/content/early/2015/01/21/heartjnl-2014-307228
These include:
References Email alerting service
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This article cites 6 articles, 2 of which you can access for free at: http://heart.bmj.com/content/early/2015/01/21/heartjnl-2014-307228 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Drugs: cardiovascular system (8104) Congenital heart disease (674) Epidemiology (3345)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Heart Online First, published on January 21, 2015 as 10.1136/heartjnl-2014-307228 Editorial
Mode of delivery for pregnant women with heart disease Oktay Tutarel In Western industrialised countries, 0.2%– 4% of all pregnancies are complicated by cardiovascular diseases, and maternal heart disease is the major cause of maternal death during pregnancy.1 While in the Western world, congenital heart disease is the most frequent cardiovascular disease present during pregnancy, in non-Western countries, rheumatic valvular disease dominates.1 As the number of adults with congenital heart disease is increasing due to the great achievements in the treatment of congenital heart defects over the last decades, the prevalence of women with cardiac disease reaching adulthood and contemplating pregnancy is also increasing.2 But, still, cardiac disease in pregnancy remains a relatively ‘evidence-sparse’ field.3 Randomised controlled trials are absent,2 which results in controversy regarding optimum care. One field of intense debate is the mode of delivery, with caesarean section (CS) and vaginal delivery as contenders. Cardiologists and obstetricians often hold very firm views with regard to the superiority of one form of delivery over another.3 The current guidelines of the European Society of Cardiology about pregnancy in cardiac disease recommend that the preferred mode of delivery is vaginal, while generally speaking CS is reserved mainly for obstetric indications,1 with the exception of some maternal cardiac lesions regarded as high risk, like patients on oral anticoagulants in preterm labour, patients with Marfan syndrome and an aortic diameter >45 mm, patients with acute or chronic aortic dissection and those with acute intractable heart failure, in which CS should be considered.1 Despite these recommendations, women with cardiac disease are often more likely to give birth via CS than women without cardiac disease.4 5 Since there are no robust data to support a preference for CS or vaginal delivery, in the world of evidence-based medicine, a randomised controlled trial that elucidates which form of delivery is the best for Correspondence to Dr Oktay Tutarel, Department of Cardiology & Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany; [email protected]
both, the maternal and fetal outcome, would be necessary. But such a trial is currently not available and considering all difficulties facing such an endeavour, probably will never be. In such circumstances, data from large registries are our second best bet. One of the largest is the Registry of Pregnancy and Cardiac disease (ROPAC), which was initiated by the European Society of Cardiology and now has enrolled 1321 pregnant women with cardiac disease from a total of 60 hospitals in 28 countries.6 Ruys and colleagues used the data from this registry to investigate the relationship between mode of delivery and pregnancy outcome in 1262 women with cardiac disease.7 In 69% of these patients a vaginal delivery was planned, while in 31% a CS was planned. An emergency CS had to be performed in 16.5% of the patients in the planned vaginal delivery group and in 13.5% of patients in the planned CS group. The authors could not find a difference in the maternal outcome of the patients with planned versus emergency CS. Their most important finding is that there was a similar outcome between the group of patients with planned vaginal delivery in which emergency CS had to be performed and those with a planned and performed CS. Therefore, if patients were not in the highrisk cardiac group and had no obstetric reasons for a CS, an attempt for vaginal delivery was possible, and even if a conversion to emergency CS was necessary, the outcome was not worse than if a CS had been planned right at the outset. But, still, I would be cautious with the assumption made by the authors that ‘planning a caesarean section does not lower the risk of maternal adverse outcome. Therefore, there was no benefit of planned caesarean section over trial vaginal delivery in pregnant patients with cardiac disease’.7 Considering that the planned CS for cardiac reasons group in their study included more high-risk cases with valvular heart disease, cardiomyopathy, worse overall New York Heart Association class and greater anticoagulant use, and also displayed greater maternal mortality, I am not convinced that this group would have the same outcome if vaginal delivery was tried
Tutarel O. Heart Month 2015 Vol 0 No 0
first. Additionally, the design of this study is not adequate to prove the point that there is no benefit of planned CS for patients who are deemed high risk in the current guidelines. But it is reassuring that in patients with cardiac disease without a firm indication (cardiac or obstetric) for CS, a vaginal delivery can safely be attempted, and even if the clinical situation worsens and an emergency CS is required, the outcome is not worse than in patients with a planned CS. This study is—as stated by the authors —primarily hypothesis generating. And its major limitation is the heterogeneity of the data with 60 hospitals in 28 countries contributing to it with different healthcare systems and quite varied rates of CS, even in the general population. But these are limitations that any study based on registries faces. This holds especially true in the field of congenital heart disease, where a meaningful number of cases can often only be achieved by multicentre studies. The most important aspect for a successful pregnancy in women with cardiac disease is still adequate planning. Prepregnancy counselling is of utmost importance. Furthermore, timing and mode of delivery should be discussed in advance in a multidisciplinary team including the patient, and an individualised approach is an absolute necessity. In addition, especially in high-risk lesions, delivery should take place in a tertiary centre with a specialist multidisciplinary team experienced in the care of pregnant women with cardiac disease. Competing interests None. Provenance and peer review Commissioned; internally peer reviewed. To cite Tutarel O. Heart Published Online First: [ please include Day Month Year] doi:10.1136/heartjnl2014-307228
▸ http://dx.doi.org/10.1136/heartjnl-2014-306497 Heart 2015;0:1–2. doi:10.1136/heartjnl-2014-307228
REFERENCES 1
2
3
Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011;32:3147–97. Roos-Hesselink JW, Ruys PT, Johnson MR. Pregnancy in adult congenital heart disease. Curr Cardiol Rep 2013;15:401. Swan L, Lupton M, Anthony J, et al. Controversies in pregnancy and congenital heart disease. Congenit Heart Dis 2006;1:27–34.
1
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd (& BCS) under licence.
Downloaded from http://heart.bmj.com/ on March 1, 2015 - Published by group.bmj.com
Editorial 4
5
2
Josefsson A, Kernell K, Nielsen NE, et al. Reproductive patterns and pregnancy outcomes in women with congenital heart disease—a Swedish population-based study. Acta Obstet Gynecol Scand 2011;90:659–65. Karamlou T, Diggs BS, McCrindle BW, et al. A growing problem: maternal death and peripartum complications
6
are higher in women with grown-up congenital heart disease. Ann Thorac Surg 2011;92:2193–8. Roos-Hesselink JW, Ruys TP, Stein JI, et al. Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European
7
Society of Cardiology. Eur Heart J 2013; 34:657–65. Ruys TP, Roos-Hesselink JW, Pijuan-Domènech A, et al. Is a planned caesarean section in women with cardiac disease beneficial? Heart Published Online First: 24 Dec 2014 doi:10.1136/heartjnl-2014-306497
Tutarel O. Heart Month 2015 Vol 0 No 0
Downloaded from http://heart.bmj.com/ on March 1, 2015 - Published by group.bmj.com
Mode of delivery for pregnant women with heart disease Oktay Tutarel Heart published online January 21, 2015
Updated information and services can be found at: http://heart.bmj.com/content/early/2015/01/21/heartjnl-2014-307228
These include:
References Email alerting service
Topic Collections
This article cites 6 articles, 2 of which you can access for free at: http://heart.bmj.com/content/early/2015/01/21/heartjnl-2014-307228 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Drugs: cardiovascular system (8104) Congenital heart disease (674) Epidemiology (3345)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
