News from ESC 2018: Is it safe for women with heart disease to become pregnant?

Br J Cardiol 2018;25:135–7 Leave a comment
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First published online 24th October 2018

“Usually”, appears to be the answer according to 10-year results from the Registry Of Pregnancy And Cardiac disease (ROPAC) a worldwide, prospective registry which was set up in 2007 by co-chairs Professor Roos-Hesselink (Erasmus Medical Centre, Rotterdam, the Netherlands) and Professor Roger Hall (University of East Anglia, Norwich, UK).

European Society of Cardiology congress 2018, held in Munich
European Society of Cardiology congress 2018, held in Munich

Professor Jolien Roos-Hesselink, said: “Pregnancy is safe for most women with heart disease but for some it is too risky. Our study shows that fewer women with heart disease die or have heart failure during pregnancy than 10 years ago. However, nearly one in 10 women with pulmonary arterial hypertension died during pregnancy or early post-partum.”

She added that pre-pregnancy counselling is crucial to identify women who should be advised against pregnancy, for instance in those with severe valvular heart disease, and to discuss the risks, options and to initiate timely treatment.

While other causes of maternal mortality, such as blood loss or infection are declining, the burden of maternal heart disease is rising. Pregnancy has a major impact on the mother’s circulation. The heart has to pump up to 50% more blood and heart rate rises by 10–20%, which can be risky in women with heart disease. Heart disease is the top reason women die during pregnancy in developed countries. Worldwide, it causes up to 15% of maternal deaths during pregnancy or in the early post-partum period.

The ROPAC researchers presented outcomes of 5,739 pregnant women with heart disease enrolled in 53 countries during 2007 to 2018. The average age of the mothers was 29.5 years and 45% had never delivered before.

More than half of the women (57%) had been born with congenital heart disease, and the majority had surgical correction at a young age. Other diagnoses were valvular heart disease (29%), cardiomyopathy (8%), aortic disease (4%), ischaemic heart disease (2%), and pulmonary arterial hypertension (1%).

Professor Roos-Hesselink said: “The proportion of women with conditions considered very high risk by the World Health Organization increased from around 1% in 2007 to 10% in 2018. This suggests that more women with very high-risk heart diseases are becoming pregnant than in the past. This is probably because corrective surgery has improved survival and more women reach reproductive age, and perhaps doctors are becoming more selective in who they advise to avoid pregnancy.”

Overall, less than 1% of women died during pregnancy or the early post-partum period. Women with pulmonary arterial hypertension, had the highest rate of death (9%). Rates of foetal and neonatal death were both 1%.

Delivery was by Caesarean section in 44% of the women, of which more than one-third were for cardiac reasons (16% of all deliveries). Regarding complications, heart failure, supraventricular and ventricular arrhythmias occurred in 11%, 2% and 2% of women, respectively. Women were more likely to have complications during pregnancy if they had any of the following prior to becoming pregnant: heart failure, diminished exercise capacity, reduced ejection fraction, or use of anticoagulants.

Professor Roos-Hesselink said: “After an initial increase in maternal mortality and new diagnoses of heart failure during pregnancy between 2007 and 2010, these rates have been declining. This occurred despite the presence of more very high risk women with heart disease being included in our registry as time went by.” She noted that the fall in adverse outcomes over the years might indicate greater awareness of the specific problems and better management of pregnant women with heart disease.

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COMMANDER HF: rivaroxaban in heart failure…
…and in VTE in the MARINER trial
European Society of Cardiology 2018 Congress in briefs