Monthly Archives: September 2012

This post refers to

‘Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology’ by Jolien Roos-Hesselink, Titia Ruys, Jörg Stein and others on behalf of the ROPAC Investigators published online in the European Heart Journal on September 11th 2012

I’ve posted previously about the importance of heart disease in pregnancy. Even in developed countries like our own, where maternal mortality rates are extremely low, cardiac disease remains the single most common cause of indirect maternal mortality* in many series.

Many countries do not have a strategic approach to the delivery of cardiac care to pregnant patients and Australia is no different. Cardiac symptoms are not uncommonly overlooked in pregnant women where the confounding effects of normal pregnancy must be taken into account (shortness of breath, ankle swelling and palpitations are common ‘symptoms’ of ‘normal’ pregnancy but equally may be the first indication of a cardiac problem). Where problems are suspected access to appropriate investigations may be difficult and there are few teams specialising in the management of cardiac disease in pregnancy. Perhaps for similar reasons the 2011 UK report ‘Saving Mothers Lives’ concerning maternal deaths between 2006 and 2008 found that

‘The assessors considered that some degree of substandard care was present in 27 of the 53 (51%) deaths…’

and that…

‘In 13 deaths, there were major lessons to be learnt, and, if the care had been better, the outcome may have been different.’

Despite the rarity of the combination of pregnancy and heart disease this publication in the European Heart Journal emphasises that it is not a problem that should be ignored. In the largely European ROPAC registry the overall maternal mortality of women with heart disease was 1% compared with 0.007% of a comparable population. So whilst in the developed world maternal deaths are very rare, pregnancy remains a significant risk for women with pre-exisiting heart disease or for those who are diagnosed with heart disease during pregnancy.

One other observation is of note. The first is the dramatic change in the profile of maternal heart disease. In the last substantial description of maternal heart disease in Australia from the Royal Women’s Hospital, Melbourne and concerning women and pregnancies between 1950 and 1975 over 80% of the case concerned rheumatic heart disease and only 13% had relatively uncomplicated congenital lesions. By contrast, our own registry recently presented at the 2012 European Society of Cardiology now reveals congenital disease to be overwhelmingly the most common cause of presentation to the clinic – with complex lesions such as repaired Tetralogy of Fallot and Transposition of the great arteries fairly common. This observation is shared by the European registry.

The 2011 report of the Queensland Maternal and Perinatal Quality Council included the recommendation that…

‘When pregnant women present with common symptoms such as chest pain, palpitations, syncope and shortness of breath, there should be a low threshold for considering significant cardiovascular disease and referral for specialist opinion and investigation within a clinically appropriate time frame.’

Which only make sense if those services are available. The UK report goes further…

‘Women with a known history of cardiac disease must be referred for consultant-led obstetric care in a maternity unit where there is a joint obstetric/cardiology clinic or a cardiologist with expertise in the care of women with heart dis- ease in pregnancy.’

Advice, it seems, we should take heed of…



* Indirect maternal mortality refers to women dying during pregnancy or within 42 days of the end of pregnancy due to causes other than those directly related to the pregnancy itself. So, for example, postpartum haemorrhage would be considered a direct cause but pulmonary embolus or heart failure due to mitral stenosis indirect. Maternal mortality rates are usually expressed as deaths per 100000 live births or per 100000 maternities (which includes live births and stillbirths).

When I started blogging about a year ago I made the un-bold decision that I would keep by blog and the associate twitter account anonymous. It wasn’t a real attempt at anonymity and in fact has become a bit of a joke. The identity of @LastCardiology is one of the worst kept secrets amongst my peers!

That being said, the decision not to link my name to the blog did have some basis.

Firstly, I was at the time responsible for convening a large medical scientific meeting – probably the largest in the country in terms of attendance and budget. The meeting, its brand and its outcome – whilst a matter of great interest to me – really belong to the learned society of which I am a member. Consequently, whilst wanting to help promote the merits of the meeting I had no desire to use that as a cheap source of publicity for my own online activity and even less desire to see something that I might write have a negative impact on the outcome of the meeting.

Secondly, I was at the time somewhat taken by the multitude of blogposts on the risks of social media to the practice medical professionals and being new to the game, it was not my desire to run the gauntlet of this potentially perilous activity.

So almost a year on, with the meeting successfully out of the way and a considerably better feel for the risks and benefits of ‘the social media’ I was just about to lower my guard and formally blow the (laughably transparent) veil of anonymity away from my blog.

And then this…

‘Preliminary Consultation Paper on Social Media Policy’ from the Australian Health Practitioner Regulation Authority (AHPRA).

Above all, as a researcher as well as a clinician, I had begun to feel that the the social media had a compelling role in the future dissemination, promotion and integration of research activity. And there’s the rub. If as a clinician/researcher I am ‘out there’ promoting the merits of the clinical research of our group, cross blogging positive editorial comment, extolling the virtue of translating the findings of our work into daily clinical practice – will I fall foul of the law as interpreted by AHPRA?

After all…

‘The definition of advertising under the Advertising Guidelines is broad…’


A person advertising a regulated health service may contravene the National Law even if they are not themselves a registered health practitioner. As a result, a person may be found to have ‘advertised’ a health service even though they did not intend to advertise or promote their health service.’

Above all,

‘Testimonials, or comments that may amount to testimonials, made on social media sites by patients or other people may contravene the National Law and expose the registered health practitioner and/or the holder of the social networking account to liability.’

To me, the document appears uniformly negative, short-sighted, misguided and even somewhat paranoid. The sort of thing that one might have read in the tabloid press concerning the perils of the ‘information super highway’… about 15 years ago.

I’d be most interested others comments and advice on this matter either here or through my blog at but please be careful not to saying anything positive about me!



For additional commentary see and


…is how it feels during the last couple of weeks running into the large scientific meeting that you have been organizing for 18 months.


For a clinician used to being in control of situations this has been an interesting experience indeed.


The jigsaw pieces required to fit into place to create a scientific meeting of >2200 attendees, 25 overseas speakers, three-and-a-half days of eight parallel sessions, over 700 scientific abstracts, >$1M in commercial sponsorship are many and varied. Thank heavens for professional conference organizers. Nevertheless, even excellent ones can’t entirely remove the sense of overall responsibility for the outcome and the overwhelming desire for everyone to go away either enlightened, inspired or perhaps just entertained.


I hope that we delivered and left the meeting in as healthy, or healthier state, than we found it.


Best of luck to the organisers of the CSANZ 2013 meeting (