J Obstet Gynecollnd Vol. 54, No.6: NovemberlDecember 2004 Pg 556-560

Outcome of Pregnancy After Cardiac Surgery - A Comparative Analysis

Datta Ray Chaitali, Saumandal Bijay KumarDepartment of Obstetrics and Gynecology, Institute of Post Graduate Medical Educationand Research, Kolkata.

OBJECTIVE - To assess the effectiveness of cardiac surgery in improving prognosis of antenatal mothers withcardiac diseases. METHODS - Pregnant women with cardiac disease attending antenatal clinic were studied overone year to assess their profiles and compare the outcome of those who had undergone cardiac intervention withthose who had not. RESULTS - The women were mostly between 21 and 30 years old and primigravidas. Thecommonest heart disease was rheumatic mitral valve lesion and the interventions were mostly on these valves. Therewere statistically significant differences in the period of gestation attained, mode of delivery and post-deliveryhospital stay but differences in weight of the babies and Apgar scores were not significant. Mortality was more in thenon-operated group. Ours being a referral hospital the incidence of antenatal cardiac women is more than average.CONCLUSION - The prognosis improved after surgery.

Key words: cardiac surgery, pregnancy with cardiac disease

Introduction

Heart disease is still one of the leading causes ofmaternal death in our country. This is due to a lackof awareness, education, and low socio-economiccondition of most of the women, which leads to adelay in seeking medical attention. With the advancesmade in cardiac surgery, pregnancy associated withcardiac disease is better tolerated and has a betterprognosis for both the mother and the child. The aimof this stu dy was to study the incidence of cardiacdis ease in women attending the antenatal clinic ofour hospital, which is a referral center for cardiacpatients, along with their agc, parity, education,economic profile and the outcome of the pregnancywi th special reference to those women who hadundergone cardiac surgery.

Material and Methods

A comparative analysis was carried out among thean tenatal women with cardiac complaints whoattended our Obstetrics department between the periodof September 2001 and August 2002.

The age of the women, parity, education, socio­economic status, past history of any cardiac surgeryand presence of any other associated complicatingfactors were noted.

Paper received on 0110812003 ; accepted on 12110104

Correspondence :Dr. Datta Ray ChaitaliB.B. 126, Salt Lake City. Kolkata - 700064.Tel. 033-2337-0548, 033-2223-5244, 9830031615Ema il : chaitalidr@rediffmail.com

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Thereafter, the outcome of the pregnancy with regardsto period of gestation at delivery, mode of de livery,duration of post-delivery stay, weight of the baby,Apgar score at birth and any associated morbidity ofthe mother were elicited. Any differences in outcomebetween mothers who had undergone cardiac surgeryand those who had not were studied.

Results

The total number of deliveries in our institutionduring this time period of one year was 1780 and 67of them had cardiac disease (3.764%). Of these 67women 23(34.32%), had undergone some form ofcardiac intervention, 19 before and four during thecurrent pregnancy. Fifty-eight (86.5%) were bookedantenatally.

The age of the women varied from 17 to 42 years withmost belonging to the age group of 21 to 30 years(62.6%) (Table I)

Most of the women were primigravidas (70.14%),while of the multigravid women eight had history ofabortions and two had no living child (Table I).

A mojority of the women and their spouses hadreceived at least secondary education (59.7 males and64.1 females) and a majority came from average incomefamilies (73.1%).

There were certain associated complications with thepregnancy in 10 women (Table III).

Of the types of cardiac diseases, rheumatic heartdisease with mitral stenosis and mitral regurgitationwere most com man (74%), followed by congenital

Table I. Age Distribution

Age (years)

.'S. 2021-3031-40

~40

Table II. Parity Distribution

Gravidity

1

2

>2

Operated

8

11

3

1

23

Operated

146

3

23

Non-Operated

7

316

o44

Non-Operated

33

5

6

44

Outcome of Pregnancy After Cardiac Surgery

Total

1542

9

1

67

Total

4711

9

67

Table III. Associated Complications

Fibroid

Rh nega tive blood group

Breech presentation

Previous cesarean delivery

Postdatism

Loss of previous child

Table IV. Cardiac Lesions

Lesions

Mitral stenosis

Mitral regurgitation

Aortic stenosis

Aortic regurgitation

Pulmonary arterial hypertension

Paroxysmal supraventricular tachycardia

Right bundle branch block

Tricuspid regurgitation

Congeni tal cyanotic

Congenital acyanotic

Others (aortoarterities, interrupted lVC, coarctation,cardiomyopathy, infundibular stenosis, congenital

heart block dextrocardia, bicuspid aortic valve)

Many Patients had a Combination of Conditions

Operated

12

7

1

1

3

3

1

o1

3

3

1

2

2

2

1

2

Non operated

16

15

3

13

14

2

1

2

2

3

Total

28

22

4

14

17

5

2

2

3

6

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Datta Ray Chaitali et al

Table V. Functional Grades

Functional Grade

NYHAI

NYHAII

NYHA III

NYHAN

Total

Table VI. Mode of Delivery

Mode of Delivery

Normal

Forceps

Breech

LSCSPostmortem cesaream

Table VII. Perinatal Outcome

Operated Group

9 (13.4%)

6 (8.9%)

5 (7.4%)

3 (4.4%)

23

Operated23

1 (4.3%)

2 (8.69%)

o19 (82.6%)

1 (4.3%)

Non-operated Group

18 (26.8%)

9 (13.4%)

10 (14.9%)

7 (10.4%)

4

Non-operated44

6 (13.3%) (1 had intrauterine death)

8 (18%)

2 (5%)

25 (57%)

3 (13%)

Perinatal outcome

Number

Mean birth weight

Percent with low birth weight

Mean Apgar score

Perinatal deaths(All Stillbirths)

Operated Non-Operated

23 44

2720 gm 2530 gm

23.80%(5) 45%(18)

8.81 8.45

1 (4.76%)a 4 (10%)b

a Postmortm cesarean sectionb 1 had intrauterine death and 3 had postmortem cesarean section

Table VIII. Maternal Mortality

Cardiac Period of History of Hospital Cause ofdisease gestation Operation stay death

MD Aortic stenosis and regurgitation 26 (weeks) NO 19 days PulmonaryUnbooked edema and CCF

KG Mitral 32 Closed mitral 1 da ys PulmonaryUnbooked stenosis and regugitation commissurotomy edema and CCF

RM Severe mital stenosis 29 NO 1 da y PulmonaryUnbooked edema and CCF

SM Cardio myopathy 33 NO 3 days PulmonaryUnbooked edema and CCF

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lesions (20.8%) and other miscellaneous lesions(19.4%) (Table IV). Many of the women had acombination of lesions. Fifty-eight (86.5%) womenhad their cardiac disease detected prior to th ispregnancy. Of these the maximum number belongedto NYHA I grade while minimum number belonged toNYHA IV grade (Table V).The majority in every grade,were not ope rated .

The op era ti ons included closed mitralcommissurotomy, balloon mitral valvuloplasty, atrialseptal defect corre ction, repair of coarctation of aortaand Fallots tetrology, pacing and ablation ofanoma lous tracts, and valve replacement.

Four women we re admitted in 2nd trimester, 56 in 3rd

trimester and four during labor

The mean period of gestation attained at delivery inthe op erated group was 37.9 ± 1.96 weeks while in thenonoperated group it was only 36.3 ± 4.59 weeks andth is difference w as found to be just significant withp=0.05 (unpaired student t test).

The mode of deli very in the operated group waslower segment cesarean section (LSCS) in 82% (19/23),while in the nonoperated group it was only 57% (25/44) (Table VI). This d ifference was statisticallysignificant with a double sided p value of 0.021(Fischer test). Incidentally at our institution the cesareansection rate is as high as 65%.

The operated group was on an average dischargedby 11.1 days after delivery with those undergoing LSCSa.fter 12.1 days and those having vaginal delivery afterfive days. The non-operated group was discharged onan average by 7.6 days after delivery, with thoseha ving LSCS after 7.76 days and those having vaginaldelivery after 7.4 days. The difference in the averagepost -delivery stay of the two groups (operated andnon ope rated ) was also found to be statisticallysign ificant (p=0.007; stu dent t test).

The mean birth weight of the babies of operatedmothers wa s 2.72 ± 0.33 kg while that of the non­operated mothers was 2.53 ± 0.44 kg . This was notstatistically significant (p=0.086) (Table V). The Apgarat birth in both the groups was similar with means of8.81 (operated) and 8.45 (non-operated) (Table VII).

The complications that developed after admissionincluded congestive cardiac failure in nine (14%) andcerebrovascular accident in one.

There were a total of four deaths with one in theoperated group (1/23 or 4.34%) and three in the non-

Outcome of Pregnancy After Cardiac Surgery

operated group (3/44 or 6.81%) (Table VIII). Thisdifference was not statistically significant. The numberof stillbirths wa s 5 (7.46%) of which four were due todeath of the mother and one was an intrau terine death.

Discussion

Normal gestation is associated w it h adaptivecardiovascular ch ange s". To d ay, th ere is aheterogeneous population of young women withcardiovascular diseases (many of which are rareconditions) contemplating pregnancy". Any specificcongenital or acquired cardiovascul ar anomaly andits physiology must be understood. The nature ofprior surgical procedures and the residua andsequelae following therapy are essential considerationsin the management of a pregnant wome n withcardiovascular d isease", Th e availability ofechocardiography provides information about etiologyand anatomic abnorm ality of the heart and greatvessels, gives accurate and non-invasive assessmentof severity and serves as a means of monitoringprogression- .

Cardiac disease during pregnancy has an ove rallincidence of 1% 4 but in our institute, which is atertiary referral center, the incidence is found to bealmost 4%. Most of them (86%) were under the careof cardiologist prior to conception and hence adequateantenatal care could be administered from thebeginning with 90% requiring admission in the 3rd

trimester mainly due to th e associated cardiaccondition, dis tance of residence from the hospital andlack of adequate modes of transpor t. Althou ghrheumatic heart disease (RHD) remains the commonestcause of heart disease during pregnancy' " our 60%incidence of RHD is less than 88% noted in northernIndia? and 73% in southe rn India".

It is seen that cardiac interventi onal surgery enabledthe women to atta in a longer period of gesta tion(mean 38 we eks) and achieve higher newborn birthweight (mean 2.72kg).

Although vaginal delivery is the method of choice inmost women, as seen worldwide, and cesarean sectionis seldom done for cardiac indications', it was notedhere that delivery by LSCS wa s the preferred modeespecially in the operated group (19/23 i.e. 82%), andalso in the non-operated group (25/44 or 57%). Thiswas statistically significant with a double-sided pvalue of 0.0211(Fischer test). Six of these wo men ha dassociated obstetric indications like breech presentation,previous cesarean delivery, post-datism and previousbad obstetric performance. In the other cases, electiveLSCS was preferred due to the presence of expert

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Datta Ray Chaiiali et al

anesthetic care, adequate postoperative set up andthe ability to monitor delivery in a controlled manner.Of note is the fact, that there was no maternal or fetalmortality after abdominal delivery.

The difference in the duration of hospital stayfollowing LSCS in the operated (mean 12.1 days) andnonoperated groups (mean 8.08 days) was statisticallysignificant(p=O.OOOl; student t test), ant: this may beexplained by the fact that women with more severediseases were the ones requiring cardiac surgery andso they were observed for a longer period followingdelivery. In contrast the difference in the duration ofhospital stay following vaginal delivery in theoperated(mean 5 days) and nonoperated(mean 7.44days) groups was not statistically significant.

All the five stillbirths occurred in unbooked womenone of whom came with intrauterine fetal death. Of thefour maternal deaths one occurred in those who hadundergone cardiac surgery (1/23; 4.34%). Suri et al9

reported 2.9%maternal mortality following only valvereplacement surgery. This further goes to emphasizethe need for an interdisciplinary approach betweenthe cardiologist, obstetrician and general practitionerfor the adequate diagnosis of the disease, propertreatment including operative intervention whererequired and regular antenatal care in order to lowerthe maternal mortality and improve the prognosis ofmothers with cardiac disease 10.

References

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Giornale Italiano di Cardiologia 1998; 28: 873-7.

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3. Zuber M, lenni R. Heart valve disease in womenin the reproductive age. Review. TherapeutischeUmschau 1998; 55: 762-6.

4. Seils A, Noujaim SR, Davis K eds. WilliamsObstetrics, 21st ed. New York. McGraw Hill, 1997:1182.

5. Padmavati S. Rheumatic fever and rheumatic heartdisease in developing countries. Bull World HealthOrgan. 1978; 56: 543-50.

6. Vijay Kumar M, Narula I, Reddy KS et al.Incidence of rheumatic fever and prevalence ofrheumatic heart desease in India. Int J Cardiology1994; 43: 221-8.

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10. Kohler F, Fotuhi P, Baumann G. Pregnancy andcongenital heart defects. Review. Zeitschrift furKardiologie. 90 suppl 2001, 4: 30-5.