The importance of heart disease in pregnancy

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 http://www.ncbi.nlm.nih.gov/pubmed/22968232

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).

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