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Preconception counseling, predicting risk and outcomes in women with mWHO 3 and 4 heart disease
Matthew Cauldwell1, Sarah Ghonim2, Anselm Uebing2
1Academic Department of Obstetrics and Gynaecology, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.
Insights
Preconception counseling (PCC) is crucial for women with severe heart disease (CHD). A higher clinician-quoted risk at PCC best predicted adverse maternal and fetal outcomes in high-risk pregnancies.
Area of Science:
- Cardiology
- Maternal-Fetal Medicine
- Reproductive Health
Background:
- Preconception counseling (PCC) is recommended for women with congenital heart disease (CHD) to manage pregnancy risks.
- Existing risk-scoring systems for pregnancies with maternal heart disease (HD) have not specifically focused on high-risk populations.
Purpose of the Study:
- To evaluate the accuracy of risk prediction for adverse events in high-risk pregnancies (modified WHO [mWHO] 3 and 4) using various scoring systems and clinician assessment.
- To determine the best predictor of adverse maternal or fetal outcomes in this population.
Main Methods:
- Retrospective cohort study of women with mWHO 3 and 4 undergoing pregnancies of at least 20 weeks gestation (1994-2015).
- Assessed the correlation between quoted risk at PCC and actual adverse event rates.
- Calculated NYHA, CARPREG scores, and clinician-assessed percentage risk to predict outcomes.
Main Results:
- 102 pregnancies in 76 women were analyzed; 63 attended PCC.
- Maternal and fetal adverse events were frequent.
- NYHA scores did not predict adverse events; CARPREG >3 predicted heart failure; mWHO 4 predicted maternal death.
- Clinician-quoted risk at PCC was the most accurate predictor of adverse outcomes.
Conclusions:
- Women with higher CARPREG and mWHO scores experience more adverse events during pregnancy.
- Access to preconception counseling (PCC) is essential for women with severe heart disease to improve pregnancy outcomes.
Objective:
All women with CHD, especially those with more severe disease, should be offered preconception counseling (PCC), to discuss the risk of complications and to plan a future pregnancy. Several scoring system have been devised to estimate the risk of adverse events in pregnancies complicated by maternal heart disease (HD) and while comparisons have been made across the whole population, none have focused on the high-risk population.
Methods:
Retrospective cohort study that included women classed as modified WHO (mWHO) 3 and 4 who had a pregnancy from at least 20weeks gestation between 1994 and 2015 managed within our institution. We assessed how well the quoted risk (at PCC) of an adverse event (maternal or fetal) related to the actual rate of occurrence. We calculated NYHA and CARPREG scores for all patients, and the clinician assessment of percentage risk, to predict the occurrence of an adverse outcome.
Results:
We identified 76 mWHO 3 and 4 women who had a total of 102 pregnancies. However, only in 63 pregnancies had the woman attended PCC. Both maternal and fetal adverse events were common. NYHA did not significantly predict any adverse events, whilst a CARPREG score of >3 score predicted heart failure and mWHO4 score predicted maternal death. However, the best prediction of adverse outcomes was a composite quoted risk (percent) given at PCC.
Conclusions:
Women must have access to PCC as those with worse CARPREG and mWHO scores encounter greater adverse events.
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