A retrospective cohort analysis of pregnant women with moderate to complex congenital heart disease or pulmonary hypertension
Abstract Number: S-22
Abstract Type: Original Research
Introduction: An increasing number of women with congenital heart disease (CHD) and pulmonary hypertension (PH) are becoming pregnant. Prior case series have focused on obstetric outcomes. The aim of this study was to assess the impact of labor and delivery anesthetic techniques on maternal and neonatal outcomes in women with CHD or PH.
Methods: We performed a retrospective cohort analysis of all pregnant women with moderate to complex CHD or PH treated at Lucile Packard Children’s Hospital from January 1, 2000 to December 31, 2011. We utilized a clinical database to identify patients, combined with high-risk obstetric anesthesia and adult congenital cardiology records to obtain more details and cross-reference outcomes. We collected data on pregnancy, labor and delivery outcomes, anesthetic management, and postpartum maternal and neonatal outcomes.
Results: A cohort of 100 pregnancies in 66 women was identified. The distribution of lesions, mode of delivery and anesthetic utilized are displayed in the Table. The two cesarean deliveries performed under general anesthesia were both for emergent deliveries in unstable patients with PH.
Maternal Outcomes: There were no maternal deaths. Excluding precautionary admissions for monitoring, 7 deliveries (8%) necessitated postpartum maternal ICU admission: 2 involved severe postpartum hemorrhage, 5 involved decompensated heart failure and/or respiratory failure with mechanical ventilation.
Neonatal Outcomes: The preterm delivery rate was 25%. Two very preterm (22 and 25 weeks) neonates died. No other infants required ICU admission. Mean (interquartile range) Apgar scores among survivors were 7.9 (7.25-9) at 1 minute and 8.8 (8-9) at 5 minutes respectively. Five neonates had a 1 minute Apgar less than 7; none had a 5 minute Apgar less than 7.
Conclusions: This cohort analysis shows that the majority of women are successfully managed with neuraxial techniques. While the cesarean delivery rate appears to be driven, in part, by cardiac indications, the majority of women still delivered vaginally. Maternal and neonatal outcomes were better than reported in previous series. This 11-year retrospective study at a tertiary obstetric hospital did not produce a large enough cohort to facilitate optimal outcome analyses. Multi-center studies and registries are required to further delineate risk factors for adverse outcomes and guide best practices for anesthetic management in this complex population.