Simona Pesce and Luisiana Stolfi. Pregnancy in CHD: Delivery Decisions, Complications, and Length of Stay. Cardiology in the Young. 2026;36:221-222. doi:10.1017/S1047951125110573.
Pubmed: https://pubmed.ncbi.nlm.nih.gov/41703948/
Take-Home Points
- This editorial reviews a case-control study comparing 162 deliveries in women with congenital heart disease (CHD) versus 321 matched controls without CHD and highlights important contemporary cardio-obstetric lessons.
- Women with CHD experienced a significantly higher rate of maternal cardiac events (8.6% vs 3.4%), corresponding to a relative risk of approximately 2.5-fold compared with controls.
- Operative and assisted delivery were more common in women with CHD, and hospital length of stay was approximately doubled.
- Modified WHO pregnancy risk class correlated with resource utilization and length of stay, but not necessarily with discrete short-term cardiac events.
- Maternal age emerged as an independent predictor of maternal cardiac events within the CHD cohort.
- The authors advocate structured cardio-obstetric programs with first-trimester risk assessment, multidisciplinary delivery planning, and routine postpartum follow-up through 6 to 12 weeks after delivery.
Commentary from Dr. Varun Aggarwal (Wilmington, DE, USA), editor-in-chief of Congenital Heart Disease Journal Watch:
Few developments have transformed adult congenital cardiology more profoundly than the success of pediatric congenital heart care itself. As survival into adulthood has become the norm rather than the exception, a growing number of women with congenital heart disease are pursuing pregnancy. Consequently, cardio-obstetrics has evolved from a niche discipline into a central component of congenital heart disease management.
In this editorial, Pesce and Stolfi discuss findings from a contemporary case-control study evaluating pregnancy outcomes among women with CHD. Although the editorial itself is brief, it highlights several issues that continue to define modern cardio-obstetric care.
The first message is both reassuring and cautionary.
Pregnancy is increasingly successful for most women with congenital heart disease, but it remains a physiologic stress test capable of exposing underlying hemodynamic limitations, ventricular dysfunction, and arrhythmia susceptibility. In the study discussed, maternal cardiac events occurred approximately 2.5 times more frequently among women with CHD than among women without heart disease. Despite overall favorable outcomes, congenital heart disease continues to confer measurable maternal risk.
Importantly, the excess risk was not driven solely by the most complex forms of congenital heart disease. The findings reinforce a principle familiar to ACHD specialists: pregnancy risk exists on a continuum. Even patients considered lower risk by traditional classifications may require increased monitoring and careful multidisciplinary planning.
One particularly interesting observation involved the modified World Health Organization (mWHO) classification system.
The mWHO framework remains one of the most widely used tools for pregnancy risk stratification in women with heart disease. However, in this analysis, mWHO class showed a stronger relationship with hospital length of stay than with individual maternal cardiac events. This suggests that mWHO classification may provide important information regarding anticipated resource utilization and monitoring needs, even when its ability to predict relatively infrequent short-term complications is less robust.
For healthcare systems increasingly focused on value-based care and resource planning, this may be a particularly useful application of risk stratification.
The study also identified maternal age as an independent predictor of maternal cardiac complications. As women with CHD increasingly delay childbirth into later reproductive years, this finding carries growing relevance. Age-related cardiovascular changes may compound congenital cardiac physiology, further emphasizing the need for individualized counseling and risk assessment.
The editorial strongly supports what has become a cornerstone of contemporary cardio-obstetrics: early multidisciplinary evaluation.
Rather than waiting until late pregnancy, women with congenital heart disease benefit from preconception counseling whenever possible and early first-trimester assessment when pregnancy occurs. Such evaluation allows clinicians to develop lesion-specific plans addressing arrhythmia management, anticoagulation, ventricular function surveillance, and delivery planning.
Notably, the authors emphasize that vaginal delivery remains appropriate for most women with congenital heart disease.
Despite persistent misconceptions among patients and sometimes providers, planned cesarean delivery is not routinely associated with superior maternal cardiac outcomes. Instead, cesarean delivery should generally be reserved for obstetric indications or specific cardiac circumstances where hemodynamic concerns justify an operative approach.
This remains a critical counseling point.
Many women understandably assume that surgical delivery represents the “safer” cardiac option. However, available evidence continues to support carefully planned vaginal delivery with appropriate anesthetic and hemodynamic management for most patients. The challenge lies not in choosing cesarean versus vaginal delivery, but in creating a coordinated delivery strategy that minimizes maternal stress and avoids emergency decision-making.
The editorial also highlights the value of standardized cardio-obstetric pathways.
Programs with predefined protocols for labor induction, neuraxial analgesia, vasopressor use, telemetry monitoring, and postpartum surveillance may reduce variability in care and facilitate more reliable outcomes. As ACHD programs increasingly develop formal cardio-obstetric teams, such protocols are becoming an essential component of quality improvement efforts.
Another important point is the emphasis on postpartum care.
Historically, much of the clinical focus has been directed toward antenatal management and delivery. Yet the postpartum period carries substantial cardiovascular risk due to dramatic shifts in preload, afterload, volume status, and neurohormonal physiology. The authors appropriately advocate routine reassessment between 6 and 12 weeks postpartum, including rhythm evaluation and optimization of cardiovascular therapy when needed.
For ACHD practitioners, this recommendation is particularly relevant because postpartum decompensation may occur after apparent intrapartum stability.
The study also raises an interesting observation regarding preeclampsia, which appeared less common among women with congenital heart disease. However, the authors appropriately caution against overinterpretation. Differences in surveillance intensity, patient selection, body mass index, and unmeasured confounders may explain this finding. Additional studies will be required before drawing firm conclusions.
Ultimately, this editorial reflects the ongoing evolution of cardio-obstetrics from individualized expert opinion toward system-based multidisciplinary care.
Modern pregnancy management in women with congenital heart disease increasingly depends on coordinated teams involving ACHD specialists, maternal-fetal medicine physicians, anesthesiologists, obstetricians, neonatologists, and nursing staff. The challenge is no longer simply determining whether pregnancy is possible but rather ensuring that care pathways exist to support women safely through pregnancy, delivery, and the postpartum period.
Clinical Perspective
Pregnancy outcomes for women with congenital heart disease continue to improve, but maternal cardiac complications remain significantly more common than in women without CHD. Early risk stratification, multidisciplinary cardio-obstetric care, standardized delivery planning, and structured postpartum follow-up are key strategies for minimizing risk. Modified WHO classification appears useful not only for risk assessment but also for anticipating healthcare resource utilization and monitoring needs.
