Journal of Perinatology (2014) 34, 901–905 © 2014 Nature America, Inc. All rights reserved 0743-8346/14 www.nature.com/jp

ORIGINAL ARTICLE

Mode of delivery in pregnancies complicated by major fetal congenital heart disease: a retrospective cohort study CA Walsh1, A MacTiernan2, S Farrell2, C Mulcahy1, CJ McMahon3, O Franklin3, D Coleman3, R Mahony1, S Higgins1, S Carroll1, P McParland1 and FM McAuliffe1,2 OBJECTIVE: To determine the mode of delivery in pregnancies complicated by complex fetal congenital heart disease (CHD). STUDY DESIGN: Five-year retrospective cohort study at a tertiary fetal medicine center (2007 to 2011). Cases of complex fetal CHD (n = 126) were compared with 45 069 non-anomalous singleton infants ⩾ 500 g to determine rates of emergency intrapartum cesarean section (CS), preterm delivery and induction of labor. RESULT: Intrapartum CS is significantly higher in fetal CHD than non-anomalous controls (21% vs 13.5%, odds ratio (OR) 1.7, 95% confidence interval (CI): 1.0 to 2.7; P = 0.035), predominantly related to CS for non-reassuring fetal status (OR 2.2, 95% CI: 1.1 to 4.1; P = 0.022). Although fetal CHD did not increase emergency CS rates in nulliparous women, CS was significantly increased in multiparous pregnancies (OR 2.4, 95% CI: 1.8 to 4.6; P = 0.014). Rates of preterm delivery (OR 3.4, 95% CI: 2.0 to 5.4; P o0.0001) and induction of labor (OR 1.9, 95% CI: 1.3 to 2.9; P = 0.001) were higher in the CHD cases. CONCLUSION: Emergency CS is increased in fetal CHD, attributed to a higher rate of CS for non-reassuring fetal status and seen mostly in multiparous women. Journal of Perinatology (2014) 34, 901–905; doi:10.1038/jp.2014.104; published online 29 May 2014

INTRODUCTION Fetal congenital heart disease (CHD) is one of the most commonly diagnosed structural fetal anomalies encountered in routine clinical practice. In contemporary fetal medicine, abnormal findings on fetal echocardiography by experienced providers appear to correlate well with the ultimate postnatal diagnosis.1,2 As such, decisions regarding delivery planning can be reliably made based on the findings of fetal echocardiography. Most experts agree that, in the absence of fetal hydrops or sustained fetal arrhythmia, elective preterm delivery does not confer an advantage.3–5 It is frequently asserted that normal vaginal delivery should be the aim in fetal CHD,5,6 reserving cesarean section (CS) for obstetric indications, with which we would agree. Previous authors have shown that high rates of successful vaginal delivery can be achieved in complex fetal CHD without compromising neonatal outcomes.7–9 Despite this principle, previous work on this issue has tended to focus on outcomes in prenatally diagnosed vs postnatally diagnosed (i.e. undetected) CHD.8,9 The outcome of pregnancies complicated by major fetal CHD compared with healthy nonanomalous pregnancies has been poorly studied. Given the high rates of associated major anomalies in CHD,8,9 and the scope for clinician anxiety in such complex anomalies, it seems reasonable to question whether cases of CHD fare similarly in labor and delivery to healthy controls. We designed a retrospective cohort study over a 5-year study period at a busy tertiary maternal–fetal medicine department, with a high volume of prenatally diagnosed fetal CHD. Our aim was to examine the mode of delivery in cases of fetal CHD vs non-anomalous controls, particularly the rate of emergency intrapartum CS. 1

METHODS We conducted a retrospective cohort study of pregnancies with known fetal CHD delivering in a single tertiary obstetric center between 1 January 2007 and 31 December 2011. Ours is a busy free-standing obstetric unit, containing a large maternal–fetal medicine department and a level III neonatal intensive care unit, delivering approximately 9500 infants per annum, including a large number of fetal medicine referrals. The decision for CS is made by a consultant obstetrician (specialist with at least 10 years clinical experience) in every case. The overall rate of cesarean delivery in our institution during the 5-year study period was 20% (9150/45 688). All major fetal cardiac defects in our center are managed by a multidisciplinary team comprising a maternal–fetal medicine specialist, neonatologist, pediatric cardiologist and nurse specialist. Vaginal delivery is generally the aim, with elective CS reserved for obstetric indications or fetal arrhythmias, which would preclude fetal monitoring in labor. Induction of labor is considered from 39 weeks on an individualized basis, depending on the cardiac lesion, Bishop’s score, parity and patient distance from the hospital. Induction is undertaken using vaginal prostaglandin E2 gel (1 to 2 mg for nulliparous women; 1 mg for multiparous women) to a maximum of four doses. Once cervical favorability is achieved, amniotomy is performed and oxytocin infusion commenced; mechanical methods of induction are not used in our institution. Babies born with major CHD are stabilized in the neonatal intensive care unit and a neonatal echocardiogram is performed as soon as possible by a pediatric cardiologist. Following initial management, infants are transferred (approximately 6 km) to our affiliated pediatric cardiology center for definitive intervention. Cases of fetal cardiac disease were identified from an institutional fetal anomaly register, with obstetric outcomes extracted from computerized hospital records. Indications for delivery for all CS are recorded prospectively in this database. All major fetal congenital heart defects in singleton infants ⩾ 500 g were eligible (Figure 1). Isolated ventricular septal defects and premature atrial contractions, which would not be anticipated

Fetal Medicine Unit, National Maternity Hospital, Dublin, Ireland; 2UCD Obstetrics and Gynaecology, University College Dublin, National Maternity Hospital, Dublin, Ireland and Department of Pediatric Cardiology, Our Lady’s Hospital for Sick Children, Crumlin, Dublin, Ireland. Correspondence: Professor FM McAuliffe, UCD Obstetrics and Gynaecology, University College Dublin, National Maternity Hospital, Dublin 2, Ireland. E-mail: fi[email protected] This study was presented in part at the 16th Annual Meeting of the British Maternal–Fetal Medicine Society in Dublin, Ireland, April 2013. Received 20 February 2014; revised 22 April 2014; accepted 24 April 2014; published online 29 May 2014 3

Mode of delivery in fetal heart disease CA Walsh et al

902 January 2007 – December 2011 National Maternity Hospital, Dublin 45,069 singleton infants ≥500g

January 2007 – December 2011 National Maternity Hospital, Dublin 45,069 singleton infants ≥500g

Excluded: Premature atrial contractions Isolated VSD Lethal aneuploidy

Excluded: Lethal congenital fetal anomalies Major fetal CHD

n = 44,931 non-anomalous controls alive at ≥24 weeks

n=138 major fetal congenital heart

Pregnancy losses excluded: Miscarriage6300 fetuses with CHD reported significantly higher rates of meconium aspiration, fetal distress and CS when compared with the general population.13 Additionally, a Japanese study reported higher rates of both abnormal fetal heart rate patterns and intrapartum CS for fetal indications in 116 CHD cases.14 Although we agree that vaginal delivery offers advantages, particularly for the mother, the present study, which found a higher rate of intrapartum CS for NRFHT in cases of major CHD, appears to lend further credence to the hypothesis that major fetal CHD is associated with a higher rate of emergency CS. We acknowledge several limitations with the present study. The retrospective nature of this study introduces the possibility of bias, although demographic data are collected meticulously and published annually in our institution. Second, this was a study in a single obstetric center, which practices a standard protocol of labor management; our total CS rate (20%) and rate of prelabor CS for fetal CHD (12%) were low by international standards. Although we believe this draws the CS rates in CHD cases into sharper focus, it is likely that such pronounced differences would not be demonstrated in units with high baseline cesarean rates. Third, although we have attempted to discriminate between isolated fetal CHD and cases with extracardiac anomalies, this distinction is limited to anomalies identified antenatally or immediately postnatally. Last, while we have provided data on early neonatal outcomes for laboring women with fetal CHD, our study is underpowered to examine the effect of mode of delivery on perinatal outcomes. Nonetheless, this is a large 5-year study that, unlike most previously published work, compares outcomes in fetal CHD with non-anomalous controls. It is reassuring to find no difference in Apgar scores or cord pH in vaginally delivered CHD cases compared with those requiring emergency CS, underscoring the safety of vaginal delivery for these women. The finding that intrapartum CS rates are higher in cases of major fetal CHD should assist clinicians in counseling women faced with this complex situation. © 2014 Nature America, Inc.

Mode of delivery in fetal heart disease CA Walsh et al

CONFLICT OF INTEREST The authors declare no conflict of interest.

ACKNOWLEDGEMENTS We are grateful to Ms Fionnuala Byrne, Information Officer, National Maternity Hospital for her help with data collection and retrieval.

REFERENCES 1 Berkley EM, Goens MB, Karr S, Rappaport V. Utility of fetal echocardiography in postnatal management of infants with prenatally diagnosed congenital heart disease. Prenat Diagn 2009; 29: 654–658. 2 Yeu BK, Chalmers R, Shekleton P, Grimwade J, Menahem S. Fetal cardiac diagnosis and its influence on the pregnancy and newborn—a tertiary center experience. Fetal Diagn Ther 2008; 24: 241–245. 3 Donofrio MT, Levy RJ, Schuette JJ, Skurow-Todd K, Sten MB, Stallings C et al. Specialized delivery room planning for fetuses with critical congenital heart disease. Am J Cardiol 2013; 111: 737–747. 4 Craigo SD. Indicated preterm birth for fetal anomalies. Semin Perinatol 2011; 35: 270–276. 5 Colby CE, Carey WA, Blumenfeld YJ, Hintz SR. Infants with prenatally diagnosed anomalies: special approaches to preparation and resuscitation. Clin Perinatol 2012; 39: 871–887.

© 2014 Nature America, Inc.

905 6 Mellander M. Perinatal management, counselling and outcome of fetuses with congenital heart disease. Semin Fetal Neonat Med 2005; 10: 586–593. 7 Peterson AL, Quartermain MD, Ades A, Khalek N, Johnson MP, Rychik J. Impact of mode of delivery on markers of perinatal hemodynamics in infants with hypoplastic left heart syndrome. J Pediatr 2011; 159: 64–69. 8 Trento LU, Pruetz JD, Chang RK, Detterich J, Sklansky MS. Prenatal diagnosis of congenital heart disease: impact of mode of delivery on neonatal outcome. Prenat Diagn 2012; 32: 1250–1255. 9 Landis BJ, Levey A, Levasseur SM, Glickstein JS, Kleinman CS, Simpson LL et al. Prenatal diagnosis of congenital heart disease and birth outcomes. Pediatr Cardiol 2013; 34: 597–605. 10 Anagnostou K, Messenger L, Yates R, Kelsall W. Outcome of infants with prenatally diagnosed congenital heart disease delivered outside specialist pediatric cardiac centers. Arch Dis Childhood Fetal Neonat Ed 2013; 98: F218–F221. 11 Ray Chaudhuri Bhatta S, Keriakos R. Review of the recent literature on the mode of delivery for singleton vertex preterm babies. J Preg 2011; 2011: 186560. 12 Alfirevic Z, Milan SJ, Livio S. Cesarean section versus vaginal delivery for preterm birth in singletons. Cochrane Database System Rev 2012; 6: CD000078. 13 Cedergren MI, Kallen BA. Obstetric outcome of 6346 pregnancies with infants affected by congenital heart defects. Eur J Obstet Gynecol Reprod Biol 2006; 125: 211–216. 14 Ueda K, Ikeda T, Iwanaga N, Katsuragi S, Yamanaka K, Neki R et al. Intrapartum fetal heart rate monitoring in cases of congenital heart disease. Am J Obstet Gynecol 2009; 201: e1–e6.

Journal of Perinatology (2014), 901 – 905

Mode of delivery in pregnancies complicated by major fetal congenital heart disease: a retrospective cohort study.

To determine the mode of delivery in pregnancies complicated by complex fetal congenital heart disease (CHD)...
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