Timing of Delivery in Women with Cardiac Disease
Rouse CE, Easter SR, Duarte VE, Drakely S, Wu FM, Valente AM, Economy KE.Am J Perinatol. 2022 Aug;39(11):1196-1203. doi: 10.1055/s-0040-1721716. Epub 2020 Dec 22.PMID: 33352586
Take Home message:
- Women with Cardiovascular Disease (CVD) in pregnancy have a high rate of delivering prematurely or in the early term period.
- Women who deliver in the early term period are more likely than those delivering after 39 weeks to have a c-section.
- There is no maternal benefit of an early term delivery in otherwise healthy women with CVD.
Commentary from Dr. Anna Tsirka (Hartford, CT, USA), section editor of Pediatric and Fetal Cardiology Journal Watch
Introduction:
Advances in therapies for women with CVD have led to larger numbers of women with heart conditions desiring pregnancy. Pregnancy management however remains a challenge and CVD remains the leading cause of indirect maternal mortality.
The benefit of a term delivery for the fetus is well established. The American College of Obstetricians and Gynecologists (ACOG) recommends against early term delivery in the absence of a medical indication. There is little guidance with respect to delivery timing in stable, asymptomatic women with CVD. This study examines maternal outcomes in women with CVD who delivered in the early term period compared with those who delivered later.
Materials and Methods:
The Standardized Outcomes for Reproductive Cardiovascular Care (STORCC) trial prospectively enrolled pregnant women
with CVD who were receiving care at Brigham and Women’s Hospital. Women who experienced a miscarriage before
20 weeks gestation were excluded. Cardiac conditions were assigned a level of complexity (mild, moderate, and severe). Women with CVD delivering infants at or beyond 37 weeks’ gestation between January 2011 and December 2016 were included. Women were then classified into two groups according to the gestational age at which they delivered: “early term (delivering at 370/7 through 386/7 weeks)” and “term (390/7 weeks and up)”.
The primary outcome of this study was peripartum cardiovascular morbidity. Secondary outcomes included mode of delivery, a composite outcome of obstetric morbidity, maternal ICU admission, the occurrence of severe maternal morbidity, admission to the NICU, and a composite outcome of neonatal morbidity.
Results:
226 women were included in the initial cohort, with 225 delivering after 37 0/7 weeks. 42 (16%) women delivered prematurely. 83 (37%) delivered in the early term period and 142 (63%). Of the eraly term deliveries, 14% were deemed elective. The type of CVD is described in figure 1.
The maternal characteristics and baseline severity of disease were similar in the two groups with the exception of hypertension. More mothers delivered early had a c section compared to the late term group (43 vs. 25%, p = 0.004). More mothers who delivered early had hypertension and more fetuses with early term delivery had IUGR. There were no statistically significant differences in any of the other outcomes measured. 4% of the cohort had cardiovascular complications during the pregnancy, including arrhythmia and CHF.
3/225 women suffered thromboembolism, 1 was admitted to the ICU and 6 were readmitted.3 newborns required NICU admission. There were no differences in neonatal outcomes, including neonatal malformation syndromes or multiple gestation.
Discussion:
This study found no benefit in maternal or neonatal outcomes from early term delivery. While no differences were found in adverse neonatal events, this study was underpowered for these outcomes. Prior studies in large populations have found that delivery after 39 weeks is optimal for neonatal outcomes.
A limitation of the study is that the comparison of the two obstetrical groups is problematic, given that the recommendation for early delivery may be related to higher risk factors.
Another limitation of the study is the low rate of occurrence of the adverse outcomes. Larger, collaborative studies are needed to find any potentially significant differences in maternal or neonatal adverse outcomes.
