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 Table of Contents  
ORIGINAL ARTICLE
Year : 2023  |  Volume : 16  |  Issue : 1  |  Page : 119-124

Maternal and fetal outcomes among pregnant women with cardiac disease attending a tertiary care hospital: A prospective observational study


1 Department of OBG, KAHER's J. N. Medical College, Belagavi, Karnataka, India
2 Department of Cardiac Anaesthesiology, KAHER's J. N. Medical College, Belagavi, Karnataka, India

Date of Submission11-May-2022
Date of Acceptance30-Jun-2022
Date of Web Publication21-Jan-2023

Correspondence Address:
Dr. Hema Sharanagouda Patil
Department of OBG, KAHER's J. N. Medical College, Nehru Nagar, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_393_22

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  Abstract 


BACKGROUND: Pregnancy in women with cardiac disease is associated with an increased risk for adverse maternal and neonatal outcomes and the present study evaluated maternal and fetal outcomes of pregnancies complicated by cardiac disease.
MATERIALS AND METHODS: An observational prospective study was conducted among 105 pregnant women with cardiac disease attending a tertiary care hospital from February 1, 2017, to January 31, 2018, and followed 30 days postpartum. Data on maternal and gestational age, nature of the underlying cardiac lesion, comorbidities, cardiac intervention, and medication were recorded. Up until 28 weeks, the patients were checked every 2 weeks by an obstetrician and a cardiologist, then weekly until birth. Age groups, cardiac lesion, and maternal and fetal outcomes were presented as frequency, and proportion was analyzed using coGuide software, V.1.0 was used for statistical analysis BDSS, Bangalore, Karnataka, India.
RESULTS: Out of 101 subjects, 98 (97.03%) were aged 18–35 years, 75 (74.3%) participants had K/C/O cardiac disease, and in 24 (23.8%) subjects, rheumatic heart disease with isolated mitral stenosis was the predominant cardiac problem. Twenty-two (21%) subjects had undergone surgical correction before to pregnancy, and 6 (8%) patients had cardiac complications, among which 1 (2.9%) had pulmonary edema. Maternal death was noted in 4 patients (3.6%). The incidence of cases with small for gestational age was noted in 36 (35.6%) patients, fresh stillbirth in 1 (2.9%), macerated stillbirth in 1 (2.9%), and neonatal death was noted in 1 (2.9%) patients. Twenty-six (25.7%) participants were diagnosed for the first time with cardiac disease.
CONCLUSIONS: Heart disease is linked to an increased risk of severe maternal and perinatal outcomes, such as maternal and fetal death and morbidity, among pregnant women.

Keywords: Cardiac disease, morbidity, mortality, pregnancy, rheumatic heart disease


How to cite this article:
Patil HS, Kotireddy J, Shitole AB, Patil SS. Maternal and fetal outcomes among pregnant women with cardiac disease attending a tertiary care hospital: A prospective observational study. Indian J Health Sci Biomed Res 2023;16:119-24

How to cite this URL:
Patil HS, Kotireddy J, Shitole AB, Patil SS. Maternal and fetal outcomes among pregnant women with cardiac disease attending a tertiary care hospital: A prospective observational study. Indian J Health Sci Biomed Res [serial online] 2023 [cited 2023 Jan 28];16:119-24. Available from: https://www.ijournalhs.org/text.asp?2023/16/1/119/368322




  Introduction Top


Every year, around 287,000 maternal fatalities occur worldwide, with significant differences between wealthy and low/middle-income communities.[1] In middle-income nations, the “obstetric transition” occurs when regions of intermediate income and development begin to exhibit a tendency toward lower maternal mortality and a commensurate increase in indirect causes.[2] The Millennium Development Goal aims to reduce maternal mortality, and India has achieved a 51% drop in maternal mortality ratio (MMR) Since 1990; nevertheless, this decline is still insufficient.[3]

Heart illness affects 0.3%–3.5% of the population, with congenital rheumatic heart disease (RHD) being more frequent in wealthier nations.[4] Cardiac disease encompasses 2%–4% of pregnancies, the rheumatic mitral disease being the most common acquired heart disease resulting in cardiac morbidity and mortality of young mother and/or the fetus.[5]

In India, 50% of pregnancy-related morbidity is due to RHD.[6] Pregnancy changes a woman's cardiovascular system dramatically, yet it is typically reversible.[7] The asymptomatic disease can be diagnosed by proper screening, regular antenatal checkups, a multidisciplinary approach, and follow-up for a better maternal and fetal outcome merely by chance or good hospital care termed maternal near-miss.[8],[9]

A prospective study by Koregol et al.[10] assessed the gestational outcome in females with RHD, but the importance of heart disease as a risk factor in pregnancy is not fully evaluated and remains an important constituent of maternal prepregnancy evaluation and decision-making. With this background, the main aim of the current study was to analyze the clinical profile of cardiac disease during pregnancy and to study the incidence of maternal and fetal outcomes in complicated pregnancies with cardiac disease.


  Materials and Methods Top


Study design

An observational prospective study.

Source population

Pregnant women with cardiovascular disease attending the outpatient department and labor room of the gynecology and endocrinology department of a tertiary care hospital.

Study population

Pregnant females with cardiovascular disease.

Sample size

One hundred and five pregnant women with known cardiovascular disease were selected.

Sampling technique

A convenient sampling method was employed.

Ethical and informed consent

Before the study began, the ethical committee review board of the pertinent tertiary care hospital granted authorization, and signed informed consent was acquired from individuals. The subjects' confidentiality was respected. EC reference No.- MDC/DOME/109 dated 06.01.2017.

Study period

From February 1, 2017, to January 31, 2018, for a period of 1 year and followed until 30-day postpartum.

Inclusion criteria

Antenatal cases with complicated cardiac disease and who had completed 28 weeks of gestation been included in the study.

Exclusion criteria

Cases with incomplete records and therapeutic abortion for noncardiac reasons were excluded from the study.

Data collection

We identified 105 pregnant women diagnosed with cardiovascular disease. Maternal age, parity status, gestational age, nature of the underlying cardiac lesion, New York Heart Association (NYHA) functional class, and incidence of hypertension, cardiac intervention before to pregnancy, cardiac suppository, and anticoagulants were all recorded as baseline data in all patients. Laboratory analysis included blood grouping, blood counts, urine analysis, serum biochemistry, and Venereal Disease Research Laboratory, HIV, and Hepatitis B surface antigen were entered in medical records, electrocardiography and echocardiography were done for all women suspected to have heart disease. Up until 28 weeks, the registered prenatal patients were checked every 2 weeks by an obstetrician and a cardiologist, then weekly until birth. The hazards were explained to all of the patients. The cases were followed pre- and postdelivery fetal outcomes were analyzed based on intrauterine fetal complications, prematurity, etc. the effect of NYHA functional class on the prognosis of maternal and fetal outcomes was also assessed.

Maternal (obstetric), cardiac, and perinatal problems were defined as adverse outcomes throughout the antepartum, peripartum, and postpartum periods.

Maternal complications were anemia (hemoglobin <10 g/dL), pregnancy-induced hypertension (defined as systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg), postpartum hemorrhage (defined as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section), cardiac complications were defined as pulmonary edema (a chest radiograph or the presence of crackles more than a third of the posterior lung areas are heard), sustained symptomatic tachyarrhythmia requiring treatment, cardiac arrest or cardiac death. Preterm delivery (37 weeks gestation), tiny for gestational age, stillbirth, and intrauterine death were all considered perinatal problems. Each patient's maternal (NYHA class worsening, maternal morbidity, and death) and perinatal (birth weight, preterm, Apgar score, neonatal intensive care unit [NICU] hospitalization) outcomes were recorded.

Statistical analysis

Study variables

The key outcome variables were maternal and fetal outcomes. The key explanatory variables were gestation weeks and other comorbidities. For quantitative variables, mean and standard deviation were used, whereas, for categorical variables, frequency and percentage were used. By comparing mean values, the link between categorical explanatory factors and the quantitative outcome was determined. Independent samples t-test was used to assess the statistical significance of normally distributed variables. Cross tabulation and percentage comparisons were used to investigate the relationship between category outcomes. To determine statistical significance, the Chi-square test was performed. Statistical significance was defined as a P < 0.05. For statistical analysis, coGuide version V.1.0 (BDSS, Bangalore, Karnataka, India) was utilized.[11]


  Results Top


A total of 101 subjects were included in the final analysis. Four subjects were lost to follow-up or shifted to another hospital.

Out of 101, most of the participants, 98 (97.03%), were aged between 18 and 35 years, and 51 (50.5%) women were primigravida, and 43 (49.5%) women were multigravida. 26 (25.7%) were diagnosed for the first time with cardiac disease, and 75 (74.3%) participants had a history of cardiac disease in which 43 (42.6%) had a history of <10 years, 46 (45.5%) had a history of 10–30 years, and 12 (11.9%) participants had a history of >20 years. Most of them were NYHA Class I 58 (57.4%), 23 (22.8%) were Class II, and 20 (19.8%) were Class III [Table 1].
Table 1: Summary of baseline characteristics (n=101)

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The majority of the subjects with congenital heart disease, 19 (18.8%) had an atrial septal defect (ASD), followed by 9 (8.9%) having a ventricular septal defect, and 3 (3%) had other congenital problems. In subjects with acquired heart disease, 24 (23.8%) had mitral stenosis, and 27 (26.7%) had mitral stenosis and mitral regurgitation. Eight (7.9%) subjects were treated with a prosthetic valve, 14 (13.9%) were treated with postballoon mitral valvotomy, and 23 (22.8%) with other surgical interventions. Among the subjects with associated medical conditions, 33 (32.7%) had anemia, 3 (3%) had chronic hypertension, 10 (9.9%) had hypothyroidism, 12 (11.9%) had gestational hypertension, 4 (4%) had gestational diabetes, and 1 (1%) had renal disease [Table 2].
Table 2: Summary of the cardiac parameter (n=101)

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The majority of the women, 45 (44.6%) had assisted vaginal delivery, followed by 43 (42.6%) who had lower segment cesarean section. The majority of the subjects, 14.9%, were admitted to the intensive care unit after delivery due to cardiac disease, followed by 9.9% who had a change in NYHA class, and 2% of subjects died during the course as maternal complications due to cardiac disease. After postpartum, 1 (1%) had pulmonary edema, 1 (1%) postpartum hemorrhage, 1 (1%) postpartum collapse, and 1 (1%) sepsis as postpartum complications [Table 3].
Table 3: Summary of obstetric and postpartum complications, type of delivery, and maternal outcome parameter (n=101)

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Thirty-six participants (35.6%) showed intrauterine growth restriction (IUGR) of the fetus, 12 (11.9%) participants had oligohydramnios, and 3 (3%) participants had the intrauterine demise of the fetus. There were 99 (98%) live births and 1 (1%) fresh and macerated stillbirth. Among the study population, 20 (20%) were gestational aged between 32 and 37 weeks, and 81 (81%) were gestational aged ≥37 weeks. Most of the newborns, 80 (80.81%) had an Apgar score of 7–10 min, and 18 (18.18%) had a 4–6 min score. Twenty-two (21.8%) newborns required NICU care. The majority of the newborns 56 (55.4%) were in between 2.5 and 3.5 kg weight, followed by 44 (43.6%) newborns who were '<2.5 kg in weight. Out of 101 participants, 1 (1%) newborn had a neonatal death [Table 4].
Table 4: Summary of fetal outcome parameter

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  Discussion Top


A prospective observational study was carried out on 105 pregnant women who were above 28 weeks of gestation visiting a tertiary care hospital in India from February 2017 to January 2018 and were recruited and followed 30 days postpartum. Out of 105, 101 were considered for final analysis as four subjects lost to follow-up. Ninety-eight (97.03%) participants were aged 18–35 years 75 (74.3%) participants had K/C/O cardiac disease RHD with isolated mitral stenosis in 24 (23.8%) subjects was the predominant cardiac problem. Twenty-two Before pregnancy, 21% of the patients had received the surgical correction. Six patients (8%) suffered cardiac problems, one of whom had pulmonary edema. Four cases had maternal mortality (3.6%). A total of 36 (35.6%) patients were found to be small for gestational age, with 1 (2.9%) fresh macerated stillbirth and neonatal mortality.

Despite the availability of earlier prospective studies[10] of cardiac diseases with related maternal morbidity and death, to the best of our knowledge, this is the first research to employ the latest World Health Organization (WHO) standardized definitions and criteria for different degrees of morbidity. The revised WHO recommendations included a four-category risk assessment system, ranging from low risk to pregnant contraindications. These standards encourage personalized treatment plans and are thought to be among the most reliable in predicting morbidity.[12]

In the present study majority of subjects, 98 (97.03%) were in the age group of 18–35 years. Our findings were in comparison to a study done by Hossinzadeh et al.[13] where the mean age of the females in the study was 28 ± 9.5 years, which is adequate with respect to the increased age of marriage, on the one hand, and the high number of pregnancies and abortions, on the other hand. The most frequent cause of congenital heart disease was ASD 19 (18.8%), and in acquired heart disease, the most common cause was mitral stenosis and regurgitation, both 27 (30%). This is in comparison to a study done by Küçükoğlu et al.[14] were, the congenital heart defects (CHD) rate was 27.6%. ASD was the most common congenital anomaly among CHD (n = 8/900; 0.88%).

The occurrence of spinal muscular atrophy was noted in 36 (35.6%) patients, and each 1 (2.9%) fresh macerated stillbirth and neonatal death were noted. In contrast, research by Owens et al.[15] found that newborn problems, such as fetal and inhospital mortality, preterm, small-for-gestational-age birth weight, respiratory distress syndrome, and CHD, were significantly elevated in the children of pregnant women with HD.

Of the 101 women, 51 (50.5%) were primigravida with a mean gestational age of delivery between 32 and 37 weeks in 81 (81%). The vast majority of patients (92.6%) fall within NYHA Classes 1 and 2. NYHA Class 3 and Class 4 were found in 7.4% of the patients, with a bad prognosis. Of the 101 births, 57 (56%) were vaginal deliveries and 43% were cesarean sections. Maternal complications were seen in 27 (25%) of the participants in our research. We had 22 (21.8%) NICU admissions in this research due to preterm, IUGR, birth asphyxia, and meconium-stained amniotic fluid. We experienced three prenatal deaths: one from stillbirth, one from macerated delivery, and one from neonatal death. These all findings are in comparison to a study by Sengodan and Selvaraj.[8]

In the present study, 8 (7.9%) had undergone prosthetic valve, and 14 (13.9%) had postballoon mitral valvotomy as surgical intervention. These findings are similar to Khan et al.[16] where a total of 10/55 (18.18%) patients had undergone corrective cardiac surgery, and ASD closure was the most common corrected heart lesion (9.09%). Our study had 99 (98%) live births and 3% stillbirths. Similar results were concluded by Joshi et al.[17] where the live birth was recorded in 38 out of 42 cases (90.5%) of the 16 (42.1%) were preterm babies. Intrauterine mortality occurred in 4 cases, while 5 babies died in the neonatal period.

Among the subjects with associated medical conditions, 33 (32.7%) had anemia, 3 (3%) had chronic hypertension, 10 (9.9%) had hypothyroidism, 12 (11.9%) had gestational hypertension, 4 (4%) had gestational diabetes, and 1 (1%) had renal disease. These findings were in comparison to Cribbs et al.[18] where maternal age, other comorbidities such as hypertension, diabetes, hypercholesterolemia, and even coronary artery disease have become more common and have increased the incidence of acquired heart disease complicating pregnancy. In the present study, 1 (1%) had pulmonary edema, 1 (1%) postpartum hemorrhage, 1 (1%) postpartum collapse, and 1 (1%) sepsis as a postpartum cardiac complication, which is in contrast to a study by Poli et al.[19] where the study considered heart failure and pulmonary edema as two different cardiac complications.

The maternal mortality was 2% in the present study, and low birth weight babies 44 (43.6%). This is similar to Sharma Koirala[20] where maternal mortality was 1%, and 37.64% low birth weight babies were reported. This contrasts with the findings of Steffie Heemelaar et al.[21] who found that the burden of cardiac-related death is difficult to measure due to a lack of mortality records. In nations with a lower MMR, the proportion of cardiac deaths among all MDs seemed to be greater. This is consistent with the concept of “obstetric transition,” or preexisting medical conditions. Our research found new predictors of poor newborn outcomes, such as overall heart disease and established risk factors including hypertension and obstetric difficulties.

Limitations

Obesity exacerbates a number of morbid diseases that arise during pregnancy. This condition, however, was not reported in the current investigation. The sample size was also small to generalize the findings. Another shortcoming of the survey design is the provider's recollection bias. It was a single-center study, and there was no control group to reduce the confounder bias. There were several components of the patient's history, imaging data, laboratory results, medicines, and long-term follow-up that could not be analyzed. To generalize the findings to a bigger population, prospective studies covering a huge geographical area with a large sample size have to be conducted as further research.


  Conclusions Top


Heart disease in pregnancy has a major impact on maternal and fetal outcome and are multifactorial in origin and include clinical and nonclinical factors. A diagnosis of RHD before to pregnancy may enhance the result. Multidisciplinary cooperation, and proper preconceptional and antenatal care are the key measures to improve the fetal–maternal outcome and can reduce maternal and fetal mortality and morbidity.

Acknowledgment

We acknowledge Dr. N. S. Mahantshetti, Principal, J. N. Medical College, Belagavi.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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