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Maternal and neonatal outcomes in women with history of coronary artery disease
Matthew Cauldwell1*, Philip J Steer1, Kate von Klemperer2, Fiona Walker2Mandeep Kaler3, Sarah Grixti3 Joanna
Hale4 Josie Evans5, David Warriner6, Stephanie Curtis7, Aarthi R Mohan8, Samuel Dockree9, Lucy Mackillop10,
Cathy Head11, Monique Sterrenburg12, Suzanne Wallace13, Gemma Partridge14, Leisa Freeman15, Jelle
Bateman16, Fionnuala McAuliffe16, Margaret Simpson17, Niki Walker17, Joanna Girling18, Farrah Siddiqui19, Aidan
Bolger20, Foteini Bredkai21, Mark R Johnson2, Anna Roberts23
1. Academic Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, 369 Fulham Road, London,
SW10 9NH, United Kingdom
2. Department of ACHD, Bart’s Health Centre London, United Kingdom
3. Department of Obstetrics, Bart’s Health, London, United Kingdom
4. Department of Obstetrics, Princess Anne Hospital, Southampton.
5. Department of Obstetrics, Queen’s Hospital, Romford,
6. Department of Cardiology, Leeds Teaching Hospitals
7. Adult Congenital Heart Disease Service, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
8. Department of Obstetrics, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
9. Women’s Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
10. Department of Adult Congenital Heart Disease, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
11. Department of Adult Congenital Heart Disease, St Thomas’ Hospital London, United Kingdom
12. Department of Obstetrics, Sheffield Teaching Hospitals, United Kingdom
13. Maternity Department, University Hospitals NHS Trust, Nottingham, United Kingdom
14. Department of Obstetrics, Norfolk and Norwich Hospital, United Kingdom
15. Department of Adult Congenital Heart Disease, Norfolk and Norwich Hospital, United Kingdom
16. Department of Obstetrics
17. Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, United Kingdom
18. Department of Obstetrics, West Middlesex University Hospital, London
19. Department of Obstetrics, Royal Leicester Infirmary, Leicester, United Kingdom
20. Department of Adult Congenital Heart Disease, Glenfield Hospital, Leicester, United Kingdom
21. Department of Obstetrics, University College Hospital, London, United Kingdom
22. Department of Adult Congenital Heart Disease, Bart’s Heart Centre, London, United Kingdom
23. Department of Obstetrics, St Mary’s Hospital, Manchester, United Kingdom
Keywords: pregnancy, ischaemic heart disease
Conflict of Interest: None
Word count:
*Corresponding author
Acknowledgements: None
Funding: Nil
Conflict of Interest: None declared
Keywords: pregnancy, coronary artery disease.
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Abstract
Objective
Pregnancy outcomes in women with pre-existing coronary artery disease are poorly
described. There is therefore a paucity of data therefore on which to base clinical
management and to counsel women with regard to both maternal and neonatal outcomes.
Methods
We conducted a retrospective multicentre study from 16 UK centre specialised cardiac
obstetric clinics of women with an established diagnosis of coronary artery disease. We
included only pregnancies from of 24 weeks gestation or more delivered between January
1998 to October 2018. Data wereas collected on adverse maternal cardiovascular, obstetric
and neonatal events. The study period was January 1998 to October 2018.
Results
A total of 79 women who had 92 pregnancies (94 babies including two sets of twins) were
identified. 35.9% were obese and 24.3% were current smokers. 18/79 (22.8%) had a history
of diabetes, 27/79 (34.2%) had dyslipidaemia and 21/79 (26.2%) had hypertension. CAD was
due to atherosclerosis in 52/79 (65.8%), of women had atherosclerotic disease,
spontaneous coronary artery dissection (SCAD) in 11/17(13.9) had prior spontaneous
coronary artery dissection(SCAD), 11/79 (13.9%) had prior coronary spasm in 11/79 (13.9%)
and 9/79 (11.4%) had prior coronary thrombus in 9/79 (11.4%). 74/79 (93.7%) of women
had previous coronary angiography with 43/79 (56.6%) having coronary stenting performed.
During pregnancy tThere were 6 cardiac events, including one NSTEMI at 23 weeks of’
gestation , and one SCAD recurrence at 9 weeks postpartum, . Oone symptomatic
deterioration in woman with severely impaired LV function developed symptomatic
deterioration and three women with established history ofworsening angina had ongoing
episodes of angina. Preterm birth complicated over a quarter of pregnancies and 14% of
women developed pre-eclampsia, 25% delivered preterm and 25% of. Furthermore, over a
quarter of babies were born small for gestational age.
Conclusion
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Women with established CAD have relatively low rates of serious cardiac events in
pregnancy. Nevertheless, but rates of adverse obstetric and neonatal events are much
greater, highlighting the importance of receiving care within from a specialised
multidisciplinary teams.
Keywords:
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Introduction
The number of pregnancies complicated by coronary artery (CAD) is increasing in developed
countries. The increase is probably related to greater rates of coronary atheroma, caused by
the increase prevalence of medical co-morbidities, most strikingly diabetes and
hypertension, in the pregnant population. These in turn are increased due to the tendency
to delay pregnancy until later life and the higher rates of obesity (1, 2). Despite this, there
are very few studies on the subject of CAD and pregnancy (2, 3); those that exist suggest
that CAD is associated with a higher risk of an adverse maternal outcome (4); although a
more recent series reported a more favourable maternal outcome (5). Neonatal outcomes
also appear to be adversely affected by maternal CAD, with the Registry on Pregnancy and
Cardiac Disease (ROPAC) reporting that the babies of women with CAD (n=25) had the
lowest birthweight and highest mortality when compared to babies of women with other
forms of heart disease (2). Similarly, our group has reported that women with CAD had
babies with lower birthweights than healthy controls (6). These poor outcomes may be due
to the higher incidence of obstetric complications including gestational diabetes,
hypertension and pre-eclampsia (PET). TCertainly, the risk of CAD doubles after one
pregnancy complicated by PET (7), but it remains unclear whether women with CAD have an
increased risk of developing PET. Women with underlying heart disease are also more likely
to take cardiac medications during pregnancy (8), which may exert negative effects on
birthweight for example, in the case of beta-blockers (9) Further, while there are data
suggesting that the use of many cardiac medications is safe during pregnancy, the impact of
some of the newer agents used in the management of CAD, such as antiplatelet agents, is
unknown (10).
In order to address these questions and to provide more data on the outcome of
pregnancy, we conducted a retrospective multicentre study examining maternal and fetal
outcomes in pregnancies in women with known CAD.
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Methods
UK centres that provide joint specialist clinics for pregnant women with heart disease were
invited by email in June 2018 to participate in a joint study. Participating centres identified
pregnancies in women with an established diagnosis of CAD or acute coronary syndrome
including myocardial infarction prior to pregnancy. Pregnancies ending before 24 weeks of
gestation were excluded. Cases were identified from January 1st 1998 until September 30th
2018 and data were collected from detailed review of the medical and obstetric notes.
Pseudo-anonymised data (all personal identifiers omitted) were amalgamated into a single
dataset. The study protocol was approved by the local research governance team at
Imperial College Healthcare.
Demographic data collected included maternal age, race/ethnicity, New York Heart
Association class (NYHA), height, pre-pregnancy weight and body mass index. Data were
obtained on the interval between the diagnosis of CAD and pregnancy, and the incidence of
known cardiovascular risk factors such as smoking, diabetes, hypertension, inherited
thrombophilias and family history of cardiovascular disease. We also recorded whether
cardiac catherization had occurred prior to pregnancy and whether coronary stents were in
situ. Left ventricular (LV) function ejection fraction (EF) (normal LVEF >55%, mild LVEF
impairment 45-55%; moderate LVEF impairment 30-44%; severe impairment <30%) was
assessed prior to pregnancy. Data were also collected on medications used during
pregnancy and whether there was documented evidence of pre-conception counselling.
The primary maternal cardiac outcome was the occurrence of cardiac arrest, cardiac death,
need for percutaneous intervention (PCI) or cardiac surgery, ventricular arrhythmia, heart
failure, new onset/worsening angina, acute coronary syndrome (ACS) or myocardial
infarction (MI) in pregnancy or up to 6 months postpartum. Obstetric outcomes included
gestational hypertension (GH; ≥140 mm Hg systolic or ≥90 mm Hg diastolic after 20 weeks’
gestation), PET (GH with proteinuria ≥0.3 g/24 hours), preterm delivery (delivery at <37
completed weeks of gestation) and post-partum haemorrhage (PPH, blood loss ≥500 mL at
vaginal delivery and ≥1000mL at caesarean). Neonatal outcomes were small for gestational
age (SGA, defined as birth weight (BW) <10th centile for sex and gestational age by the
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Aberdeen centiles), stillbirth (fetal demise ≥24 weeks’ gestation) and neonatal unit
admission.
Statistics
Data were analysed using SPSS V.23/25 for Windows. Categorical data are presented as
frequencies (numbers) and percentages. Data are presented as medians with inter-quartile
range. Correlations were calculated using Pearson’s product moment if variables were
continuous and Spearman’s rank-order correlation if either of the variables was ordinal.
Differences between continuous variables were assessed with the Mann Whitney U test if
they were not normally distributed. All tests were two tailed and p<0.05 was considered
statistically significant.
Results
Sixteen centres provided data on a total of 79 women who had 92 pregnancies (94 babies
including two sets of twins). 66 (85.3%) were white European and 12 (15.2%) were South
Asian and one (1.3%) black African. Table One shows the demographic detailss of the study
population at in their first pregnancy post diagnosis. 28/78 (35.9%) were obese (BMI not
available in one case). 18/74 women (24.3%) were current smokers, 26/74 (35.1%) were ex-
smokers and 30/74 (40.5%) had never smoked (smoking status was not recorded for 5
women). The majority of the women (57/79, 72.2%) in the study were parous at the time of
the first post event pregnancy post event (para 0, 24 (30.4%), para 1, 32 (40.5%), para 2 or
greater 23 (29.1%). The underlying CAD aetiology was atherosclerosistic in 52/79 (65.8%),
coronary artery dissection in 11/79 (13.9%), coronary spasm in 11/79 (13.9%) and coronary
thrombus in 9/79 (11.4%). 74/79 (93.7%) had had previous coronary angiography with
43/79 (56.6%) having had a coronary stent inserting performed. One woman had had
previous coronary artery bypass surgery prior to pregnancy. 18/79 (22.8%) had a history of
diabetes, 27/79 (34.2%) of dyslipidaemia and 21/79 (26.2%) hypertension. 18/79 (22.8%)
women had impaired ventricular function (left ventricular systolic dysfunction, LVSD) with
10/18 (55.6%) having mild, 7/18 (38.9%) moderate and 1/18 (5.6%) severe impairment. In
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the first pregnancy post event, 67/79 (84.8%) were NYHA class 1 and 12/79 (15.2%) NYHA
class 2, cf 12/13. (92.3%) vs 1/13 (7.7%) in the second pregnancy. Only 22/79 (27.8%)
women in their first pregnancy post event had received preconception counselling.
Cardiac outcomes
In total there were 6 recorded cardiac events (Table 2). Whilst there were no cardiac deaths,
there was one case of nNon-ST-elevation myocardial infarction (NSTEMI) at 23 weeks of’
gestation managed medically. One woman had recurrence of spontaneous coronary artery
dissection (SCAD) at 9 weeks postpartum. One womaen, with previous severely impaired LV
function, developed symptomatic deterioration and three women with established history
of angina had ongoing episodesworsening symptoms of angina. NThere were no cases of
symptomatic or sustained ventricular arrhythmia were identified. No women required
cardiac surgery during pregnancy or postpartum. Cardiac events exclusively occurred
exclusively in parous women (6/67 pregnancies in parous women cf 0/25 in nulliparous
womena). Cardiac events were more common in women with atherosclerotic disease,
occurring in 6/61 pregnancies in women with this diagnosis vs 1/31 in all the other
diagnostic groups combined, but this was not statistically significant (p=0.333). Cardiac
events appeared to be more common in women with atherosclerotic disease occurring in
5/46 women vs 1/26 in all other diagnostic groups for all other groups but this was not
statistically significant (Fishers exact p=0.65)
Obstetric and Neonatal variables
The main obstetric and neonatal variables are shown in Table 3. Excluding twin pregnancies
and pregnancies with birthweights <500g, preterm birth was common, with 20/75 (26.7%)
babies being born preterm in the first pregnancy post event, and 2/11 (18.2%) in the second
pregnancy post event. Pre-eclampsia occurred in 11/75 (14.7%) of first pregnancies after the
cardiac event cf none of 11 second pregnancies. Pre-eclampsia was significantly associated
with earlier delivery - 7/11 (63.6%) preterm with pre-eclampsia cf 13/64 (20.3%) without
(p=0.006 Fisher’s exact test). Only two of the women developing PET were nulliparous.
Three of 11 (27.2%) of women developing PET had a history of coronary thrombosis
compared with 8 of 68 (11.8%) with no such history, although this was not statistically
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significant (p=0.177 Fisher’s exact test). GH occurred in four women, all in their first
pregnancy post event, two of whom were already on a beta-blocker. 15 of 23 women (65%)
with known hypertension at the beginning of pregnancy were taking a beta-blocker at
booking visit; beta-blockade was used in 42 of the 92 pregnancies (45.6%).
Excluding twin pregnancies, stillbirths, and babies weighing <500g, in first pregnancies post
event 19/74 babies (25.7%) were born weighing less than the tenth centile for gestational
age (5/11 (45.5%) in the second pregnancy post event). Univariate analysis revealed that the
cardiac diagnosis did not impact birthweight, but left ventricular systolic function did, with
all grades of dysfunction being associated with lower birthweight (statistically significant in
relation to mild dysfunction; figure 1). Smoking (figure 2) and PET (figure 3) were both
associated with mothers having babies of lower birthweights, but this was only statistically
significant for PET. 21.6% of babies (19/88 livebirths) were admitted to the neonatal unit,
largely as a result of preterm delivery. There were three stillbirths, all with growth-restricted
babies. No women agreed for a post-mortem to be carried out. The two neonatal deaths
were both associated with extreme prematurity, both infants were born at 24 weeks
gestation.
In first pregnancies post event, 37/79 (46.8%) were vaginal births, 14/79 (17.7%) were
emergency caesarean sections during labour, and 28/79 (35.4%) deliveries were by elective
caesarean section before labour. The corresponding figures in the second pregnancy post
event were 4/13 (30.8%), 2/13 (15.4%) and 7/13 (53.8%), which are not significantly
different from the first pregnancy post event (p=0.209 by MannWhitney U).
The overall rate of postpartum haemorrhage defined as an estimated bloodd loss of 500ml
or more was 50/92 (54.3%) and correlated strongly with mode of delivery – 10/41 (24.4%)
vaginal deliveries, 11/16 (68.8%) emergency caesarean sections and 29/35 (82.9%) of
elective caesarean sections (p<0.001 Kruskal-Wallis test).
Cardiac Medications
Table 2 lists the cardiac medications used before and during pregnancy; at least one of these
was used in 88/92 (95.6%) of pregnancies. 84/92 (91.3%) took aspirin, (71/79 (89.8%) in
first pregnancies post event and; 13/13 (100%) in second. As well as having an antiplatelet
effect Aspirin reduces the incidence of PET (11) and is advocated by many groups for women
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at high risk of developing PET (12). The rate of PET in first pregnancies after the event was
9/71 (12.7%) in women taking aspirin and 3/8 (37.5%) in women not taking aspirin (p=0.098
by Fisher’s exact test).
Beta blocker use was also very common; 42/92 (45.7%) overall, 38/79 (48.1% in first and
4/13 (30.8%) in second pregnancies after the event, as was the use of low molecular weight
heparin, 17/79 (21.5%) in first pregnancies and 5/13 (38.5%) in second pregnancies after the
event. Only 7/92 (7.6%) used GTN, the same proportion in first and second pregnancies post
event. Clopidogrel was also rarely used; 8/79 (8.7%) in first pregnancies only. Excluding
twins and birthweights <500g, there was no significant correlation of drug usage with
birthweight or birthweight centile, except with low molecular weight heparin (p=0.03 for
birthweight and 0.009 for birthweight centile, Mann-Whitney U) (see figures 4 & 5). None of
the drugs used had any significant correlation with blood loss at delivery.
Discussion
The primary findings from this study suggest that maternal cardiac outcomes for women
with CAD are relatively favourable compared to outcomes for women with other forms of
acquired heart disease (13, 14). In contrast, the rate of obstetric and neonatal complications
is relatively high compared to healthy women. Of particular note, there were no maternal
deaths in this series and only one woman had a serious cardiac event during pregnancy
(NSTEMI), but even she went on to have a livebirth near term (35 weeks). These data
suggest that a pre-existing diagnosis of CAD is not associated with a marked increase in
cardiac events during a subsequent pregnancy. However, whether pregnancy has a negative
effect in the long term on the prognosis of women with CAD this cohort will have a worse
long term prognosis compared to women with a diagnosis of CAD who did not have a
pregnancy was not examined in this study. andHowever, older women embarking on
pregnancy have been shown to experience a higher rate of later cardiovascular events (15),
suggesting that pregnancy may have an adverse cardiovascular impact.
The absence of maternal deaths in our study contrasts to findings from the UK Confidential
Enquiry (MBBRACE UK) which consistently reports thating cardiac disease is the single
biggest cause of indirect maternal death and that CAD is one of the most important causes
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(16). In their 2016 review, over a five year period they reported 153 cardiac maternal deaths
with over a fifth of cases being attributable to ischaemic heart disease (16). Equally, In their
review Burchill et al only reported a single maternal death in a group of women with known
CAD (3). We surmise that the relatively good outcomes observed in both our study and the
study of Burchill et al ;is we hypothesise, as they do, that because women had anwith
known CAD have often identified diagnosis and because most women had undergone
coronary revascularisation and wewere also taking appropriate medical therapy then
maternal mortality remains very low.
Women in our study that experienced cardiovascular events were more likely to have
underlying atherosclerotic disease rather than any other aetiology. This is likelymay be
because this was the most common aetiology encountered. Interestingly two of the women
who experienced worsening angina had a prior diagnosis of dyslipidaemia (all 3 women had
>1 risk factor for cardiac disease) with one stopping her statin during pregnancy. Studies
have shown that during pregnancy LDL particles may become more atherogenic as they
appear to be denser in size (17). However, there is a paucity of data to recommendwhether
the safety of statins are safe in pregnancy is not clear ;(18), but in selected cases women
may benefit from their use as there is no clear link with increased risk of teratogenicity (19)
and women may benefit from their use in selected cases.
The majority of women in our study, as with the MBBRACE UK report, had more than one
risk factor for CAD, with over half of women continuing to smoke or having a past history of
cigarette use and a third of women being obese. Moreover, the median age of women in
pregnancy was 35 years demonstrating that advanced maternal age is a clear risk factor for
CAD. These risk factors-smoking, obesity and age, are the same as those in the general
population; in England a 2015 report from the UK Health and Social Care Information
Centre, showed that in the general population, 20% of mothers were 35 or older, 21% of
women were obese and 13% of women continued to smoke in pregnancy. Whether
screening for these factors in the antenatal population and then performing exercise testing
on screen positive women would impact rates of ACS and CAD-related death during
pregnancy remains unclear, but at an individual level this approach has the potential to
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identify women at high risk of future coronary events. Nevertheless, at present the costs for
undertaking such screening are likely to remain prohibitive.
It was notable that ten women developed PET, the majority of whom were parous and
delivered prior to 37 weeks (preterm-PET). This rate of PET is approximately three times
greater than the background rate in western Europe (20). Furthermore, the majority of
women were taking aAspirin during pregnancy, usually 75mg, which from a prior systematic
review has been shown to have a 15% reduction in risk of developing PET (21). A recent
study by Rolnik et al demonstrated a 60% in preterm PET in women who took Aspirin 150mg
compared to placebo (22), given the higher than expected rate of PET observed in this
study, the data from Rolnik et al suggest that women with CAD may benefit from 150mg of
aAspirin, because in terms ofof the reducing the risk of of PET. Identifying relatively high
rates of PET in women with CAD might support the view of Melchiorre et al, that PET occurs
as a consequence of cardiovascular maladaptation to pregnancy (23), however it would also
be consistent with PET being a consequence of a more widespread endothelial dysfunction
or metabolic syndrome. If this is the case, then the recognised relationship between PET and
increased risk of later cardiovascular disease may actually not be causal, but only different
facets features of a common underlying disorder. PET was also associated in our study with
earlier delivery and having a baby born small for gestational age, both of which are known
to have long term consequence for the neonate (24).
Impaired fetal growth was a common feature of our study. Median birthweight in first
recorded pregnancies in our study was 2920g which is approximately 150g lower than that
reported by the ROPAC authors in their study (2). Importantly though, when correcting for
gestation at delivery, fetal sex and parity, we found that 29% of infants were SGA, this is a
similar finding to Gelson et al who examined birthweights in a cohort of women with
congenital heart disease (25). A more recent, larger publication from our group (n=1053)
(6), of women with heart disease, identified 15 women with CAD who had babies with a
lower birthweight centile than normal controls (6). We and other authors have also
reported a significant reduction in birthweight in women with cardiac disease taking beta-
blockers (26, 27), whereas although this was not apparent in the current study. Impaired left
ventricular systolic function may also have significantly impaired on fetal birthweight
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growth suggesting these women may havedue to an impaired cardiovascular adaptation to
pregnancy (28).
A high proportion (94%) of women took at least one cardiac medication during pregnancy; t.
This being was almost three times greater than the ROPAC study assddressing cardiac
medication use during pregnancy (8). The reasons for this are multifactorial, but all the
women in our study were managed through specialist clinics having joint care from an
obstetrician and cardiologist. Furthermore, because this cohort had a greater number of
established cardiac risk factors namely hypertension, diabetes and dyslipidaemia, and
wouldthey are likely to have been on cardiac medication for several years. Two women
continued on the antiplatelet drug Ticagrelor without having any adverse fetal or maternal
effect. Importantly, there was no association with maternal haemorrhage (PPH) at delivery
with the use of antiplatelet agents or LMWH during pregnancy, although it was routine
practice to halt Clopidogrel and LWMH (but not aAspirin prior to cases of planned delivery
at 7 days and 12 hours respectively. High. rates of PPH (>50%) may have been higher due to
the use of lower dose of syntocinon and the avoidance ergometrine for the management of
the third stage of labour as t. The combination of ergometrine and syntocinon has been
shown to be more effective than syntocinon alone in the prevention of PPH, but
ergometrine can cause hypertension and myocardial ischaemia (29).
We were not able to identify any risk factors demonstrate with an accuracy which were
more likely to havefor cardiac events during pregnancy, as such events the time course of
the study because they were rare. This was similar to the experience reported by the ROPAC
group, who reported found that out of the 20 women with a prior history of ischemic heart
disease, only one women experienced a new episode of ACS (30). In our study, Out of of the
11 women with SCAD, we saw only one woman hadve a recurrent eventce associated with
pregnancy. This recurrence rate of (9%), which appears lower to be than that reported by
Tweet et al (15%)(31);, although however, we acknowledge their series had included a
larger number of women and our follow up period was shorter. It was noteworthy that just
over a quarter of women received preconception counselling, this maybe explained by lack
of easy access to professionals with the expertise to provide such counselling.
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Our data show that women with underlying CAD generally have favourable cardiovascular
outcomes in pregnancy. However, Given there are high rates of adverse obstetric and
neonatal complications events and we would advocateensure that antenatal care for of
these women should be optimised, including encompasses the routine use of aAspirin in
order to reduce early onset pre-eclampsia and . We would also advocate regular fetal
surveillance with of fetal growth, scans given the large proportion of babies born SGA. The
relatively favourable outcome reported in our study may be because the majority of women
continued to take their cardiac medications. Furthermore, we would advocate that the
majority of cardiovascular medications are safe and should be continued in pregnancy and
the continued usage of many of these medications may contribute to more favourable
maternal outcomes.
This study is limited by several factors; it is retrospective in nature and only captures data
from women managed in specialist clinics therefore increasing the chance of referral bias.
Furthermore, we do not have a matched control group so we can compare outcomes.
Whilst this study is relatively small in size we believe it is the largest study to date describing
outcomes for women with known CAD to date.
Conclusion
Women with existing CAD under specialist review tend to have favourable maternal
outcomes during pregnancy and the postpartum period. Women with CAD appear to be
older, parous and have multiple cardiovascular risk factors. Fetal outcomes are less
reassuring with high rates of late fetal loss, preterm delivery and babies born small for
gestational age. Rates of preconception counselling are poor and require improvement
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Table 1 Baseline maternal characteristics at first recorded pregnancy
Demographics (n=72) N (%) unless
otherwise stated
Age in years, median (interquartile range) 35 (31-39)
(minimum and maximum) (23-43
Body Mass Index (median and interquartile range) 26 (22-31)
(minimum and maximum) (19-42)
Nulliparous 22(31)
Parous 50(69)
White European 60(83.3)
South Asian 11(15.3)
Black African 1(1.4)
Functional status
NYHA Class 1 64(89)
NYHA Class 2 8(11)
NYHA Class 3 and 4 0
Cardiac Diagnosis
Atherosclerotic Disease 46 (64)
Previous Spontaneous Coronary Artery Dissection 11 (15)
Coronary Thrombus 8 (11)
Coronary Spasm 7 (10)
Underlying cardiovascular risk factors
Current Smoker/ExSmoker 16(22)/23(32)
Hypertension 21(29)
Obesity 24(33)
Diabetes 15(14)
Dyslipidaemia 22(31)
Thrombophilia 6(8)
Family history 23(32)
Prior cardiac catherization 67(93)
Coronary stents in situ 38(53)
LV Systolic Function
Normal 55(76)
Mild Impairment 10(14)
Moderate Impairment 6(8)
Severe Impairment 1(1)
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Table 2- Cardiac Medication used prior to and during pregnancy
Pre-Pregnancy
Aspirin
Clopidogrel
Beta blockers
Nitrates
ACE Inhibitor
Angiotensin Receptor Blocker
Statin
Ticagrelor
Medication during Pregnancy
Aspirin 76(90)
Clopidogrel 6 (7)
Low Molecular Weight Heparin 20(24)
Beta Blockers 36(43)
Nitrates
Ticagrelor
Statin
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Table 3 Details of cardiac events during pregnancy and postpartum
Age Event Type Cardiac History Timing ManagementPre-pregnancy
Patient A 29 NSTEMI AtheroscleroticPrevious NSTEMI 23weeks Aspirin and Clopidogrel
Patient B 43 Deterioration LV AtheroscleroticFunction Previous STEMI 30 weeks Medical management
Patient C 34 SCAD recurrence Prior SCAD intramural 9 weeks Haematoma RCA* postpartum
Patient D 39 Progressive Atherosclerotic Began Medical managementAngina Previous STEMI second trimester
Patient E 39 Progressive Atherosclerotic Began Medical managementAngina Previous STEMI 31 weeks
Patient F29 Progressive Atherosclerotic Began Medical managementAngina Previous NSTEMI first trimester
*RCA= Right circumflex artery
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Table 4 Obstetric and Neonatal Complications
Obstetric Complications (total pregnancies n=84C) N (% to nearest whole number)*
Postpartum Haemorrhage
Pre-eclampsia
Gestational hypertension )
Mode of Delivery
Spontaneous Vaginal
Assisted vaginal
Elective CS
Emergency CS
No record
Neonatal complications (total births n=84 ) (% to nearest whole number)
Intrauterine death
Neonatal death
SGA (<10th Centile) )
Preterm Prelabour Rupture of Membranes
Preterm delivery
Neonatal Unit Admission
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References
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and Ireland Confidential Enquiries into Maternal Deathsand Morbidity 2009–14. 2016.17. Belo L, Caslake M, Gaffney D, Santos-Silva A, Pereira-Leite L, Quintanilha A, et al. Changes in LDL size and HDL concentration in normal and preeclamptic pregnancies. Atherosclerosis. 2002;162(2):425-32.18. Winterfeld U, Allignol A, Panchaud A, Rothuizen LE, Merlob P, Cuppers-Maarschalkerweerd B, et al. Pregnancy outcome following maternal exposure to statins: a multicentre prospective study. Bjog. 2013;120(4):463-71.19. Kusters DM, Hassani Lahsinoui H, van de Post JA, Wiegman A, Wijburg FA, Kastelein JJ, et al. Statin use during pregnancy: a systematic review and meta-analysis. Expert review of cardiovascular therapy. 2012;10(3):363-78.20. Roberts CL, Ford JB, Algert CS, Antonsen S, Chalmers J, Cnattingius S, et al. Population-based trends in pregnancy hypertension and pre-eclampsia: an international comparative study. BMJ open. 2011;1(1):e000101.21. Duley L, Henderson-Smart D, Knight M, King J. Antiplatelet drugs for prevention of pre-eclampsia and its consequences: systematic review. BMJ (Clinical research ed). 2001;322(7282):329-33.22. Rolnik DL, Wright D, Poon LC, O'Gorman N, Syngelaki A, de Paco Matallana C, et al. Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia. The New England journal of medicine. 2017;377(7):613-22.23. Melchiorre K, Sharma R, Thilaganathan B. Cardiovascular implications in preeclampsia: an overview. Circulation. 2014;130(8):703-14.24. Chan PY, Morris JM, Leslie GI, Kelly PJ, Gallery ED. The long-term effects of prematurity and intrauterine growth restriction on cardiovascular, renal, and metabolic function. International journal of pediatrics. 2010;2010:280402.25. Gelson E, Curry R, Gatzoulis MA, Swan L, Lupton M, Steer PJ, et al. Maternal cardiac and obstetric performance in consecutive pregnancies in women with heart disease. Bjog. 2015;122(11):1552-9.26. Ersboll AS, Hedegaard M, Sondergaard L, Ersboll M, Johansen M. Treatment with oral beta-blockers during pregnancy complicated by maternal heart disease increases the risk of fetal growth restriction. Bjog. 2014;121(5):618-26.27. Gelson E, Curry R, Gatzoulis MA, Swan L, Lupton M, Steer P, et al. Effect of maternal heart disease on fetal growth. Obstetrics and gynecology. 2011;117(4):886-91.28. Melchiorre K, Sutherland GR, Liberati M, Thilaganathan B. Maternal cardiovascular impairment in pregnancies complicated by severe fetal growth restriction. Hypertension (Dallas, Tex : 1979). 2012;60(2):437-43.29. Tsui BC, Stewart B, Fitzmaurice A, Williams R. Cardiac arrest and myocardial infarction induced by postpartum intravenous ergonovine administration. Anesthesiology. 2001;94(2):363-4.30. Greutmann M, Silversides CK. The ROPAC registry: a multicentre collaboration on pregnancy outcomes in women with heart disease. European heart journal. 2013;34(9):634-5.31. Tweet MS, Hayes SN, Codsi E, Gulati R, Rose CH, Best PJM. Spontaneous Coronary Artery Dissection Associated With Pregnancy. J Am Coll Cardiol. 2017;70(4):426-35.
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