International Journal of Gynecology and Obstetrics 128 (2015) 30–32

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CLINICAL ARTICLE

Congenital heart disease in pregnancy in a low-income country Nalini Arora a,⁎, Hena Kausar b, Narayan Jana c, Sarbeswar Mandal b, Dipankar Mukherjee d, Ranajit Mukherjee e a

Department of Obstetrics and Gynecology, ESI Postgraduate Institute of Medical Sciences and Research, Joka, Kolkata, India Department of Obstetrics and Gynecology, Institute of Postgraduate Medical Education and Research, Kolkata, India c Department of Obstetrics and Gynecology, Burdwan Medical College, Burdwan, India d Department of Cardiology, Institute of Postgraduate Medical Education and Research, Kolkata, India e Department of Neonatology, Institute of Postgraduate Medical Education and Research, Kolkata, India b

a r t i c l e

i n f o

Article history: Received 16 March 2014 Received in revised form 20 July 2014 Accepted 11 September 2014 Keywords: Congenital heart disease Low-income countries Maternal mortality Pregnancy

a b s t r a c t Objective: To assess maternal and perinatal outcomes among pregnant women with congenital heart disease (CHD) in a low-resource country. Methods: A prospective, observational study was conducted at a teaching hospital in Kolkata, India, between January 1, 2008, and December 31, 2010. All pregnant women with CHD were followed up from first prenatal visit to discharge. Both maternal and perinatal outcomes were analyzed. Results: Of 174 pregnant women with heart disease, 27 (16%) had CHD. Mean age was 23.5 ± 3.6 years. Four (15%) patients were diagnosed with CHD during the index pregnancy. Nine (33%) women had undergone surgical correction before conception. Cesarean delivery was performed in 12 (44%) women. Fifteen (56%) neonates weighed less than 2500 g, and 4 (15%) were born preterm. Mean birth weight was slightly higher in women with corrected heart lesions than in those with uncorrected ones (2593 ± 480 g vs 2294 ± 620 g; P = 0.22). Three (11%) neonates died, but no stillbirths occurred. One (4%) woman died after delivery owing to atonic postpartum hemorrhage. Conclusion: Delayed diagnosis, lack of treatment, and unplanned pregnancy are major challenges for women with CHD, which need to be addressed to improve maternal and neonatal outcomes in low-resource countries. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction The number of individuals with congenital heart disease (CHD) who survive to adulthood is growing worldwide [1,2]. The increase is especially apparent in high-income countries as a result of continuing improvement in the medical and surgical management of CHD [3]. In these countries, pregnant women with CHD are commonly encountered by obstetricians [4]. A similar trend has been observed in low-resource countries, though at a slower pace. In India, 12.5%–23.4% of all pregnant women with cardiac problems have CHD [5,6]. Women affected by cardiovascular disease adapt poorly to the physiological hemodynamic changes during pregnancy, which means that the risks of serious maternal or neonatal morbidity and mortality are increased. These risks are increased further in unplanned pregnancies in women with uncorrected cardiac lesions. In a retrospective analysis [6], nearly 88% of pregnant women with CHD in North India had an uncorrected cardiac lesion. Therefore, special attention is required for such women. Few data regarding CHD and pregnancy are available from lowincome countries. Most series have focused on rheumatic heart diseases ⁎ Corresponding author at: Department of Obstetrics and Gynecology, ESI Postgraduate Institute of Medical Sciences and Research, Diamond Harbour Road, Joka, Kolkata 700104, India. Tel.: +91 33 24381382; fax: +91 33 24381176. E-mail address: [email protected] (N. Arora).

in pregnancy. Two large observational studies from northern India [5,6] show maternal and fetal outcomes after pregnancies of women with CHD, but both are retrospective and have inherent limitations. The aim of the present study was to evaluate the maternal and perinatal outcomes among pregnant women with CHD in a lowincome country. 2. Materials and methods The present prospective, observational study was conducted at the Institute of Postgraduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital in Kolkata, India, between January 1, 2008, and December 31, 2010. All pregnant women with CHD were followed up from their first prenatal visit to discharge. Women with acquired heart diseases such as rheumatic heart diseases, cardiomyopathies, hypertension, and ischemic heart diseases were excluded from the study. The study was approved by the institutional ethics committee. The participants provided written informed consent. Baseline data obtained at the first prenatal visit included age, parity, nature of underlying cardiac lesion, cardiac surgery before pregnancy, previous cardiac morbidity, and current cardiac medication if any. For every woman, a complete general physical, cardiovascular, and obstetric examination was performed, and a New York Heart Association (NYHA) class was assigned. Laboratory investigations were undertaken,

http://dx.doi.org/10.1016/j.ijgo.2014.07.033 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

N. Arora et al. / International Journal of Gynecology and Obstetrics 128 (2015) 30–32

including hemograms, blood typing, urine analysis, and screening for HbsAg and HIV. Obstetric sonography and maternal electrocardiography were done for all women. These women were followed up by both obstetricians and cardiologists throughout the pregnancy. Induction of labor and lower-segment cesarean delivery were undertaken only when indicated. Maternal outcomes included any cardiac morbidity in the form of pulmonary edema or arrhythmia during pregnancy or the immediate postpartum period; obstetric complications during prenatal and postnatal periods; and mode of delivery. Perinatal outcomes included birth weight, gestational age at delivery, Apgar score, need for immediate neonatal intensive care, and stillbirth or neonatal death. All neonates were examined by neonatologists, and neonatal echocardiography was planned only on clinical suspicion of heart disease. Results were analyzed by unpaired t test using Stata 7.0 (Stata Corporation, College Station, TX, USA). P b 0.05 was considered statistically significant. 3. Results During the study period, 174 pregnant women with different types of heart disease delivered at the study center, of whom 27 (16%) had CHD. All 27 participants were younger than 30 years (mean age 23.5 ± 3.6 years) and 14 (52%) were primigravidas. CHD had been diagnosed before pregnancy in 23 (85%) women, all of whom had been referred to the prenatal clinic either directly by the department of cardiology and cardiovascular surgery at the Institute of Postgraduate Medical Education and Research or from other hospitals. In the other 4 (15%) women, the underlying cardiac disease was suspected by obstetricians on the basis of symptoms in the current pregnancy; the diagnosis of CHD was confirmed by cardiologists. All four women had atrial septal defects. One case was diagnosed late in the third trimester owing to a delay in seeking healthcare services. All women with CHD were under joint care of an obstetrician and a cardiologist. The most common cardiac lesions encountered were atrial septal defects, which affected 11 (41%), including 1 (4%) case of a reversal of intracardiac shunt with Eisenmenger syndrome and 2 (7%) of pulmonary hypertension (Table 1). Surgical correction had been performed before the index pregnancy in 9 (33%) women (Table 1). No residual defects were recorded in these nine women, although one woman who had had double outlet right ventricle developed pulmonary regurgitation after surgery. The length of pregnancy by the time of the first prenatal visit was 18.2 ± 7.6 weeks. At the first prenatal visit, 16 (59%) women were in NYHA class I, 8 (30%) were in class II, and 3 (11%) were class III/IV. All women who had previously undergone surgical correction were NYHA class I, except one who was class II. Fetal echocardiography was performed in only 4 (15%) women, because this service was not available in our hospital. The reports were normal.

Table 1 Congenital heart disease among pregnant women (n = 27). Type of cardiac defect

No. (%)

No. who underwent surgical correction before the index pregnancy (%)

Atrial septal defect Atrial septal defect plus Eisenmenger syndrome Tetralogy of Fallot Patent ductus ateriosus Pulmonary stenosis Ebstein anomaly Ventricular septal defect with pulmonary stenosis Mitral valve prolapse with mitral regurgitation Congenital heart block Aortic stenosis Double outlet right ventricle

10 (37) 1 (4) 3 (11) 3 (11) 3 (11) 2 (7) 1 (4) 1 (4) 1 (4) 1 (4) 1 (4)

3 (11) 0 1 (4) 1 (4) 2 (7) 1 (4) 0 0 0 0 1 (4)

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Table 2 Labor and delivery outcomes (n = 27).a Outcomes

Women with congenital heart disease

Cesarean delivery Mean length of pregnancy, wk Mean birth weight, g Low birth weightb Preterm birth Stillbirth Care in the neonatal intensive care unit Neonatal deaths

12 (44) 37.5 ± 1.5 2394 ± 575 15 (56) 4 (15) 0 6 (22) 3 (11)

a b

Values are given as number (percentage) or mean ± SD. b2500 g.

One woman with an atrial septal defect and pulmonary arterial hypertension developed atrial fibrillations at 36 weeks of pregnancy. She required digoxin and aspirin. No women required oral anticoagulants. Cesarean delivery was performed in 12 (44%) women; the remaining 15 (56%) delivered vaginally. One primigravida with uncorrected tetralogy of Fallot (NYHA class II) had intrauterine growth restriction. She went into labor at 39 weeks of pregnancy and the cardiotocograph was pathological. An emergency cesarean was performed under general anesthesia. She developed primary postpartum hemorrhage, for which a subtotal hysterectomy was performed because bleeding could not be controlled with other measures. She died in the critical-care unit 6 hours after surgery. Postpartum hemorrhage was the direct cause of this maternal death. Table 2 shows the labor and delivery outcomes. The nine neonates whose mothers had undergone surgical correction had a higher mean birth weight than the 18 whose mothers had uncorrected heart lesions (2593 ± 480 g vs 2294 ± 620 g), although the difference was not significant (P = 0.22). Mean gestational age was similar for both neonates whose mothers had undergone corrections and those whose mothers had not (37.2 ± 1.3 vs 37.7 ± 1.6 weeks; P = 0.42). Six (22%) neonates required intensive care and 3 (11%) died in the neonatal period. The causes of death were sepsis with heart failure, birth asphyxia with pulmonary hemorrhage, and intracranial hemorrhage. On clinical examination, the neonatologists did not suspect CHD in any of these newborns. Therefore, neonatal echocardiography was not performed. 4. Discussion In the present study, CHD contributed to 16% of all pregnancies complicated by heart diseases. CHD was diagnosed for the first time during pregnancy in 15% of these women. Only one third had previously undergone surgical correction after diagnosis in early childhood. More than half the neonates had a low birth weight (b2500 g), and more than one fifth required neonatal intensive care. In low-resource countries, a significant number of the women with CHD both treated and untreated contemplate pregnancy and their number is expected to increase in future because of gradual, albeit slow addition of more cardiac care centers. In the current study, the proportion of pregnant women with heart diseases who had CHD is similar to that reported for 1994–2000 in northern India (12%) [5], but lower than that in a later study from the same region (24%) [6]. The difference between the current study and the previous one [6] may be attributed to the difference in geographical location and referral pattern of cardiac patients. In addition to the increasing number of pregnant women with CHD, delayed diagnosis and lack of treatment are the other two major challenges for obstetricians treating these women in low-resource countries. The diagnosis of CHD in low-income countries is often late [7,8]. Age at diagnosis varies from first day of life to almost 80 years [9–11]. Illiteracy, poverty, and poor awareness and access to basic medical care are common factors leading to late diagnosis [12]. In the present series, 15% of women affected by CHD were diagnosed in the index

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pregnancy. The proportion of women who were diagnosed during the index pregnancy in the present study (15%) is lower than that in an earlier series [13], in which 26.1% of women were diagnosed during pregnancy. This difference could be due to increased availability and easier access to medical care over the past 15 years or to a different geographic location. To provide adequate health care to the increasing number of pregnant women with CHD, providers need to focus on early diagnosis and treatment along with antecedent complications that can occur because of hemodynamic changes of pregnancy. Such a focus could reduce the maternal and perinatal morbidity and mortality associated with CHD among pregnant women. Dissemination of information and a high index of suspicion for CHD among health workers could prevent misdiagnosis and facilitate early diagnosis [9]. In addition, a mandatory formal health check-up by a doctor at the time of vaccination or before school admission could help to diagnose asymptomatic heart lesions early in low-resource countries where most births are not attended by a pediatrician. Availability and access to timely treatment is also a prerequisite to reduce the disease-related morbidity and mortality. Women whose cardiac anomaly remains uncorrected but who survive to adulthood might develop many secondary changes in the heart and other organs (e.g. pulmonary hypertension) that make them further vulnerable to the hemodynamic changes of pregnancy. The proportion of pregnant women who had corrected congenital cardiac lesions in a previous study [6] was identical to that in the present series (33%). Although these proportions are higher than the 22% reported previously [13], it is still low. Ignorance and scarce resources appear to be the major reasons why these women had remained without treatment. Therefore, the number of cardiac centers in low-income countries needs to increase, as previously suggested [8]. Because women with CHD do not understand the implications of becoming pregnant, their pregnancies are often unplanned. If pediatricians and cardiologists provided information and education about the risk of pregnancy at the time of the initial CHD diagnosis, women would know to seek health care before or immediately after conception, which could provide a window of opportunity for timely action. The fact that many first prenatal visits occurred fairly late in the present study is a concern. In addition, with a growing number of pregnant women with medical disorders, prepregnancy counseling clinics with a specialist multidisciplinary team should be established [14], at least at tertiary care centers, because such clinics are rare in low-resource countries. In the present study, many newborns had low birth weight, and some required intensive care. Besides developing early neonatal morbidity, these newborns are likely to have delayed health sequelae during adulthood, which places a further burden on the already limited health resources. Previous studies [6,13] have indicated that the incidence of prematurity and the number of newborns who are small-forgestational-age improves if the mother’s lesion had been surgically corrected before conception [6,13]. In the present study, mean birth weight was 299 g higher in women with corrected heart lesions than

in those who had not undergone correction. This finding is clinically relevant for low-resource countries, where lack of the neonatal intensive care units is a major constraint [15]. Therefore, targeting these girls and women for counseling and early treatment is likely to improve both maternal and perinatal outcomes and will help to improve the distribution of existing health resources in low-income countries. In conclusion, late diagnosis, lack of treatment, and unplanned pregnancy are the major challenges for women with CHD in low-resource countries. Increasing public awareness and generating resources for the management of these patients in early childhood are the key requirements for the prevention of maternal and perinatal complications. In addition, strengthening prenatal services and establishing preconception counseling clinics, at least at tertiary care centers, could further help these women through early risk assessment and allowing them to conceive in a planned manner. Conflict of interest The authors have no conflicts of interest. References [1] Nieminen HP, Jokinen EV, Sairanen HI. Late results of pediatric cardiac surgery in Finland: a population-based study with 96% follow-up. Circulation 2001;104(5): 570–5. [2] Thorne S, Deanfield J. Long-term outlook in treated congenital heart disease. Arch Dis Child 1996;75(1):6–8. [3] Perloff JK. Congenital heart disease in adults. A new cardiovascular subspecialty. Circulation 1991;84(5):1881–90. [4] Pitkin RM, Perloff JK, Koos BJ, Beall MH. Pregnancy and congenital heart disease. Ann Intern Med 1990;112(6):445–54. [5] Bhatla N, Lal S, Behera G, Kriplani A, Mittal S, Agarwal N, et al. Cardiac disease in pregnancy. Int J Gynecol Obstet 2003;82(2):153–9. [6] Aggarwal N, Suri V, Kaur H, Chopra S, Rohila M, Vijayvergiya R. Retrospective analysis of outcome of pregnancy in women with congenital heart disease: single-centre experience from North India. Aust N Z J Obstet Gynaecol 2009;49(4):376–81. [7] Bannerman CH, Mahalu W. Congenital heart disease in Zimbabwean children. Ann Trop Paediatr 1998;18(1):5–12. [8] Saxena A. Congenital heart disease in India: a status report. Indian J Pediatr 2005; 72(7):595–8. [9] Bode-Thomas F, Okolo SN, Ekedigwe JE, Kwache IY, Adewunmi O. Paediatric echocardiography in Jos University Teaching Hospital: problems, prospects and preliminary audit. Niger J Paediatr 2003;30(4):143–9. [10] Mocumbi A, Lameira E, Yaksh A, Paul L, Ferreira MB, Sidi D. Challenges on the management of congenital heart disease in developing countries. Int J Cardiol 2011; 148(3):285–8. [11] Ibadin MO, Sadoh WE, Osarogiagbon W. Congenital heart diseases at the University of Benin Teaching Hospital. Niger J Paediatr 2005;32(2):29–32. [12] Zheleva B. Linked by a common purpose: global efforts for improving pediatric heart health: a report by Children’s HeartLink. http://www.congenitalcardiologytoday. com/index_files/CCT-JUL07-INT.pdf. Published July 2007. Accessed June 14, 2014. [13] Sawhney H, Suri V, Vasishta K, Gupta N, Devi K, Grover A. Pregnancy and congenital heart disease—maternal and fetal outcome. Aust N Z J Obstet Gynaecol 1998;38(3): 266–71. [14] Swan L. Congenital heart disease in pregnancy. Best Pract Res Clin Obstet Gynaecol 2014;28(4):495–506. [15] Sen A, Mahalanabis D, Singh AK, Som TK, Bandyopadhyay S. Development and effects of a neonatal care unit in rural India. Lancet 2005;366(9479):27–8.

Congenital heart disease in pregnancy in a low-income country.

To assess maternal and perinatal outcomes among pregnant women with congenital heart disease (CHD) in a low-resource country...
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