Maternal Outcomes by Mode of Delivery in Pregnant Patients with Valvular Heart Disease: A Retrospective Cohort Study

- Heather Acuff, MD, PhD; University of Michigan

- Jerome Federspiel, MD, PhD; Duke University

- Johanna Quist-Nelson, MD; University of North Carolina

- Matthew Fuller, MS; Duke University

- Ashraf S Habib, MB, BCh; Duke University

- Marie-Louise Meng, MD; Vanderbilt University

Background & Hypothesis

Background

- Valvular heart disease (VHD) prevalence in pregnancy: ~1%

- Left-sided & stenotic lesions may be less well tolerated

- Vaginal deliveries generally preferred for patients with cardiac disease

Aims

- Compare morbidity outcomes for vaginal vs. cesarean deliveries

in obstetric patients with VHD

Hypothesis

- Trial of labor would not be associated with greater morbidity

Study Design & Methods

Cohort

- Obstetric patients 12-55y

- Delivery 1/1/16 – 9/30/20

- Valvular heart disease

Outcomes

- Severe maternal morbidity

- Blood transfusion

- ICU admission

- 90-day readmission

- Hospitalization duration

Analyses

- Intention-to-treat: intended deliveries

- As-treated: actual deliveries

Results

Outcomes with greater morbidity for scesarean vs. vaginal deliveries

- Adjusted odds ratio (95% CI): severe maternal morbidity, blood transfusion, ICU admission, 90-day readmission

- Mean difference (95% CI): hospitalization duration

Intended Deliveries

- Left stenotic: ICU admission

- Left regurgitant: blood transfusion, ICU admission

- Right regurgitant: ICU admission

Actual Deliveries

- Left stenotic: ICU admission, hospitalization duration

- Left regurgitant: severe maternal morbidity, blood transfusion, ICU admission, 90-day readmission, hospitalization duration

- Right stenotic: hospitalization duration

- Right Regurgitant: severe maternal morbidity, blood transfusion, ICU admission

Conclusions & Discussion

Conclusions

- Greater morbidity: cesarean deliveries > vaginal deliveries, actual cesarean > intended cesarean

- Most common morbidity among all lesions for both analyses: ICU admission

- Morbidity by VHD lesions:

--- Left Regurgitant: severe maternal morbidity, blood transfusion, ICU admission, 90-day readmission, hospitalization duration

--- Right Regurgitant: severe maternal morbidity, blood transfusion, ICU admission

--- Left Stenotic: ICU admission, hospitalization duration

--- Right Stenotic: hospitalization duration

Discussion

- Trial of labor not associated with greater morbidity

- Intrapartum cesarean deliveries at higher risk

- Supports vaginal deliveries for patients with VHD when clinically feasible

- Patients may benefit from delivering in care center with ICU capabilities

- Importance of individualized, lesion-specific delivery planning

References

- Curr Treat Options Cardiovasc Med 2023; 25(10):587-604

- Cardiol Clin 2021; 39:151-61

- Obstet Gynecol 2019; 133(5):e320-56

- Anesth Analg 2023; 136(4):728-37