Outcomes of pregnant women hospitalized with unrepaired congenital heart disease: Insights from a multidisciplinary center in Vietnam

Abstract

Background

In developing countries, fewer women have access to multidisciplinary congenital heart disease and reproductive programs staffed by experts. We report pregnancy outcomes of a multidisciplinary healthcare strategy utilizing an in-hospital teamwork approach in Vietnam.

Methods

This retrospective cohort study included pregnant women with unrepaired congenital heart disease managed at a referral cardiovascular center.

Results

Undiagnosed congenital heart disease before pregnancy, a lack of pre-pregnancy cardiology counseling, and modified World Health Organization class III/IV were common. Under the multispecialty healthcare strategy, although the rate of maternal death was 8.2% in the modified World Health Organization class IV group, no deaths occurred in any other group. Fetal/neonatal complications occurred in 54% of pregnancies, and 49.4% of neonates survived. Poor pregnancy outcomes were associated with admission during the first/seconde trimester for fetus/neonates, third trimester for mother, modified World Health Organization class III/IV, cyanosis, and heart failure.

Conclusion

The outcomes of pregnant women with unrepaired congenital heart disease were poor but seemed to improve with a multidisciplinary in-hospital healthcare teamwork strategy.

Keywords

pregnancy complications cardiovascular congenital heart disease multidisciplinary

Introduction

Congenital heart disease (CHD) refers to a diverse set of birth structural abnormalities, ranging from simple to highly complex and severe lesions. Its cumulative incidence is 8 per 1000 live births.¹ With recent medical and surgical advances, most children with CHD survive into adulthood, resulting in approximately 13 million adult cases of CHD worldwide.^2,3 More than half of the adult cases of CHD are women.⁴ As such, the management of pregnant women with CHD is an important emerging health issue.⁵ Women with CHD may tolerate pregnancy-related hemodynamic changes poorly, such as increased blood volume and cardiac output, and are at a high risk of maternal and fetal/neonatal complications.^6,7 Clinical guidelines recommend a high level of multi-professional medical care for women with CHD during pregnancy.^8,9 Such multidisciplinary management will help optimise maternal and infant outcomes in pregnant women with cardiac conditions.¹⁰ However, many healthcare centers from developing countries manage women with CHD clinically, without surgical interventions, while multidisciplinary approaches are limited or unavailable.^11,12 A lack of specialized healthcare programs, such as pre-pregnancy counseling, and insufficient medical management during pregnancy for women with unrepaired CHD, particularly those with Eisenmenger syndrome, may account for the high rate of maternal and fetal/neonatal complications and death in developing countries.^13,14

Vietnam is a developing country in Southeast Asia, which, over the past 30 years, has transformed itself from one of the poorest countries in the world into a lower middle-income country.¹⁵ Concurrent with economic development, the healthcare quality in Vietnam has considerably improved. Care of children with CHD has been an area of focus within the developing healthcare system in Vietnam, with cardiac centers for medical and surgical intervention now established throughout the country. However, challenges remain in the care of pregnancies in women with CHD.^16,17 Healthcare staff are commonly faced with cases of unknown medical and obstetric history or hospitalized pregnant women with unrepaired CHD presenting as an emergency. Data regarding pregnancy outcomes among this clinical population remain inadequate.

To address these challenges, our hospital established the Department of Congenital Heart Disease and Pediatric Cardiology, a specialized care unit for patients with CHD, in 2014. Like other developing countries, we noted hospitalized pregnant women with unrepaired CHD had a markedly increased risk of maternal mortality, according to the modified World Health Organization (mWHO) classification of maternal cardiovascular risk.¹⁸ The efforts of the health system have allowed success in many cases; nevertheless, maternal and fetal/neonatal death remain common. Herein, we report the maternal and fetal/neonatal outcomes of pregnant women with unrepaired CHD hospitalized at our specialized center since its inauguration. Thus, we present the experience of multidisciplinary in-hospital teamwork healthcare activities for women, as well as their fetuses and neonates, and discuss how to optimize this care.

Methods

Study design

This was a retrospective cohort study of pregnant women with unrepaired CHD who were hospitalized between March 2015 and March 2019.

Study sample

A flowchart of patient selection is shown in Supplemental Material 1. Eligible pregnant women with unrepaired CHD were identified based on the following criterion: confirmation of CHD by transthoracic echocardiography performed on admission and first hospitalization for pregnancy at our center. The exclusion criteria were women with a simple and sole cardiac defect, such as a patent foramen ovale, bicuspid aortic valve, or another valve prolapse; prior total CHD correction; missing echocardiography data; and missing information about fetal/neonatal outcomes during hospitalization. After screening, 87 pregnant women were included in our analysis.

Data collection

Demographic and clinical information concerning pregnancy were obtained by review of the medical records during hospitalization. Demographic data included maternal age, with advanced maternal age defined as over 35 years¹⁹; maternal cardiac history; clinical status; pregnancy trimester at the time of admission; gestational age of the fetus at the time of obstetric intervention; and obstetric history. Clinical data included laboratory results, echocardiography and electrocardiography results, and obstetric interventions and outcomes.

The diagnosis of CHD was based on the International Classification of Disease (10th Revision). Cyanosis was defined as a saturation of peripheral oxygen (SpO₂) of ≤ 90% at rest on room air, with severe cyanosis defined as a SpO₂ of ≤ 85%. Pre-eclampsia was diagnosed based on the 2021 International Society for the Study of Hypertension in Pregnancy guidelines.²⁰ All pregnant women were confirmed to have CHD using transthoracic echocardiography performed by experts in CHD and a cardiologist with experience in cardiac sonography. Left ventricular systolic dysfunction was defined as an ejection fraction of ≤ 40% on transthoracic echocardiography. Echocardiography was also used to diagnose pulmonary arterial hypertension (PAH) as a peak tricuspid regurgitation velocity of > 3.4 m/s.²¹ Standard 12-lead electrocardiogram was recorded to determine the presence of arrhythmias. A plasma NT-proBNP level of > 128 pg/mL was indicative of heart failure. Anemia was defined by a hemoglobin level of ≤ 105 g/L and polycythemia by a hemoglobin concentration of ≥ 165 g/L.

Supplemental Material 2 outlines the strategy of multidisciplinary in-hospital teamwork for cardiac care, as well as the interventions provided to mothers, fetuses, and neonates. At admission, the maternal clinical status was classified based on the mWHO classification as either class I (no detectable risk of maternal mortality or no/middle risk of morbidity), class II (small risk of maternal mortality or moderate risk of morbidity), class III (significant risk of maternal mortality or severe morbidity), or class IV (extremely high risk of maternal mortality or severe mobility, pregnancy contraindicated).¹⁸

Outcome measures

The following maternal factors were collected: obstetric history and status of CHD diagnosis before pregnancy, clinical status at admission, and obstetric interventions performed. The outcomes of the mothers, fetuses, and neonates were collected during pregnancy and at follow-up 4–6 weeks after delivery. Data collected included the rate of maternal, fetal, and neonatal mortality during hospitalization; adverse maternal events, such as transfer to the intensive care unit (ICU) for severe cardiac failure; adverse fetal events, such as miscarriage, fetal death due to maternal death, stillbirths, and fetal loss; and adverse neonatal events, such as neonatal death, neonatal asphyxia (Apgar score <7), and low and very low birth weight (≤ 2500 g and ≤ 1500 g, respectively, at delivery).

Statistical analyses

Continuous data are reported as the mean, standard deviation (SD), and 95% confidence interval (CI) for normally distributed variables and a median and interquartile range (IQR) for non-normally distributed variables. Nominal variables are reported as the absolute number (n) and percentage. Student's t-test was used to evaluate differences in the normally distributed variables, Mann–Whitney U-test for non-normal continuous variables, and the Chi-squared or Fisher's exact tests for nominal variables. Univariable and multivariable logistic regression analyses, using the forward stepwise method, were performed to identify factors related to poor maternal and fetal/neonatal outcomes. All analyses were performed using SPSS (version 22.0, IBM Corp., Armonk, NY, USA), with a two-tailed p-value <0.05 considered significant. Power analysis was performed using Cramer's V effect size and partial Eta squared effect size.

Results

Characteristics of the study sample

The relevant characteristics of pregnant women with unrepaired CHD are summarized in Table 1. Among 52 previous fetuses, fetal loss was reported in 20 (38.5%) and preterm birth in 9 (17.3%). Further, the CHD status was not diagnosed before pregnancy in 32 (36.8%) women.

Table 1.

Clinical characteristics in pregnant women with unrepaired congenital heart disease into the mWHO classification of maternal cardiovascular risk.

Clinical characteristic		mWHO class I (N = 12)	mWHO class II (N = 13)	mWHO class III (N = 13)	mWHO class IV (N = 49)	p-value	Effect size
Maternal age at admission (years)	Mean (SD, 95% CI)	29.5 (3.3, 27.4–31.6)	28.2 (6.5, 24.2–32.1)	27.2 (5.8, 23.7–30.7)	27.2 (4.2, 26.0–28.4)	0.461	0.03
	< 20	0	1 (7.7%)	2 (15.4%)	0	0.06	0.263
	20–35	12 (100%)	10 (76.9%)	10 (76.9%)	47 (95.9%)
	> 35	0	2 (15.4%)	1 (7.7%)	2 (4.1%)
Gestational age at admission (weeks’ gestation)	Mean (SD, 95% CI)	31.8 (6.3, 27.8–35.9)	23.6 (13.3, 15.6–31.6)	24.1 (13.1, 16.2–32.0)	25.1 (12.8, 21.5–28.8)	0.301	0.043
	First trimester (n, %)	0	4 (30.8%)	4 (30.8%)	12 (24.5%)	0.493	0.176
	Second trimester (n, %)	3 (25%)	3 (23.1%)	2 (15.4%)	7 (14.3%)
	Third trimester (n, %)	9 (75%)	6 (46.2%)	7 (53.8%)	30 (61.2%)
Total number of pregnancies	One (n, %)	6 (50%)	7 (53.4%)	7 (53.4%)	33 (67.3%)	0.477	0.211
	Two (n, %)	4 (33.3%)	5 (38.5%)	2 (15.4%)	10 (20.4%)
	Three (n, %)	2 (16.7%)	1 (7.7%)	2 (15.4%)	5 (10.2%)
	Four (n, %)	0	0	1 (7.7%)	1 (2%)
	Five (n, %)	0	0	0	0
	Six (n, %)	0	0	1 (7.7%)	0
Fetal outcomes	Total number (n, %)	8 (100%)	7 (100%)	14 (100%)	23 (100%)	–	–
	Surviving infants (n, %)	5 (62.5%)	6 (85.7%)	2 (14.3%)	11 (47.8%)	0.012	0.46
	Term births (n, %)	5 (62.5%)	6 (85.7%)	3 (21.4%)	9 (39.1%)	0.027	0.42
	Preterm births (n, %)	0	1 (14.3%)	4 (28.6%)	4 (17.4%)	0.398	0.239
	Fetal loss (n, %)	3 (37.5%)	0	7 (50%)	10 (43.5%)	0.144	0.323
Unknown CHD before this pregnancy period (n, %)		7 (58.3%)	7 (58.3%)	3 (23.1%)	15 (30.6%)	0.118	0.26
Cyanosis (n, %)		0	0	8 (61.5%)	24 (49%)	<0.001	0.493
Severe cyanosis (n, %)		0	0	3 (23.1%)	20 (40.8%)	0.003	0.405
Anemia (n, %)		2 (16.7%)	3 (23.1%)	0	3 (6.1%)	0.129	0.255
Polycythemia (n, %)		0	0	7 (53.8%)	7 (14.3%)	<0.001	0.463
Left ventricular ejection fraction < 40% (n, %)		0	0	0	0	–	–
NT-proBNP > 128 pg/mL (n,%) (n = 78)		1 (11.1%)	0	0	17 (37%)	0.006	0.402

CHD: congenital heart disease; CI: confidence interval; mWHO: modified World Health Organization; NT-proBNP: N-terminal pro-B-type natriuretic peptide; SD: standard deviation; compared between mWHO class I-IV using the Chi-square test with estimated effect size by Cramer's V and one-way ANOVA test with estimated effect size by partial Eta squared.

The CHD malformations identified are reported in Table 2, with the most common malformations being shunt lesions: atrial septal defect (13.8%), ventricular septal defect (23.0%), and patent ductus arteriosus (13.8%). However, the incidence of pregnant women with shunt lesions combined with PAH was very high (58.6%, n = 51).

Table 2.

Types of congenital heart disease in pregnant women.

Anatomical defect, n (%)	N = 87 (100%)
Isolated VSD	20 (23.0%)
Isolated ASD	12 (13.8%)
Isolated PDA	12 (13.8%)
Isolated PS	4 (4.6%)
CAVc	1 (1.1%)
Truncus arteriosus	1 (1.1%)
VSD + PDA	5 (5.7%)
VSD + ASD	3 (3.4%)
VSD + Truncus arteriosus	1 (1.1%)
VSD + CoA	1 (1.1%)
VSD + PDA + CoA	2 (2.3%)
ASD + PS	3 (3.4%)
PDA + PS	2 (2.3%)
PDA + AS	2 (2.3%)
Coronary artery fistula	2 (2.3%)
Ebstein's anatomy	2 (2.3%)
Tetralogy of Fallot	2 (2.3%)
DORV	1 (1.1%)
DORV + VSD + PDA	1 (1.1%)
DORV + CAVc + PDA	1 (1.1%)
PA/IVS	1 (1.1%)
PA/IVS + PDA	2 (2.3%)
PA/IVS + TGA	1 (1.1%)
TGA + VSD + PS	1 (1.1%)
Tricuspid atresia	1 (1.1%)
Single ventricle + PS	1 (1.1%)
Lutembacher syndrome	1 (1.1%)
Heterotaxy syndrome	1 (1.1%)

ASD: atrial septal defect; CAVc: complete atrioventricular septal defect; CoA: coarctation of aorta; DORV: double outlet right ventricle; PA/IVS: pulmonary atresia with intact ventricular septum; PDA: patent ductus arteriosus; PS: pulmonary stenosis; TGA: transposition of great arteries; VSD: ventricular septal defect.

We noted that 45 (51.7%) women did not receive pre-pregnancy counseling. The distribution of mWHO classification of maternal cardiovascular risk among the women without pre-pregnancy cardiology counseling versus those with counseling was as follows: class I, 17.8% versus 9.5% (n = 8 vs. 4); class II, 20% versus 9.5% (n = 9 vs. 4); class III, 8.9% versus 21.4% (n = 4 vs. 9); and class IV, 53.3% versus 59.5% (n = 24 vs. 25).

Obstetric interventions

During hospitalization, 74 (86.2%) women had obstetric interventions (Supplemental Material 1). These included surgical termination of pregnancy during the first trimester (19.5%), medical termination of pregnancy during the first trimester (1.1%), intervention for ectopic pregnancy (1.1%), subtotal hysterectomy (5.7%), vaginal delivery (4.6%), and cesarean delivery (52.9%). We noted that 20 women (23%) required acute obstetric interventions, with these performed within the first 24 h after admission in 12 (13.8%).

Maternal and fetal/neonatal outcomes

Maternal, fetal, and neonatal outcomes are described in Figure 1. In total, 14 (16.1%) women developed significant heart failure requiring transfer to the ICU, and 4 (4.6%) maternal deaths were reported. No maternal death among women with mWHO class I-III was reported, whereas 4 (8.2%) maternal deaths among women with mWHO class IV occurred.

Figure 1.

Maternal, fetal, and neonatal outcomes in pregnant women with unrepaired congenital heart disease based on the modified World Health Organization (mWHO) classification of maternal cardiovascular risk.

Fetal/neonatal complications occurred in 47 (54%) cases, but there were 43 (49.4%) surviving neonates who were discharged, including those of 6 (100%) pregnant women with mWHO class I, 5 (62.5%) with mWHO class II, 5 (41.7%) with mWHO class III, and 27 (55.1%) with mWHO class IV.

Factors related to poor maternal and fetal/neonatal outcomes

The results of the stratified logistic regression analysis for predicting poor maternal and fetal/neonatal outcomes are summarized in Table 3. On multivariable analysis, the following were identified as predictive factors of poor maternal outcomes: admission during the third trimester of pregnancy, severe cyanosis, heart failure, and anemia. Predictive factors of poor fetal/neonatal outcomes were associated with admission during the first/second trimester, cyanosis, heart failure, and mWHO class III/IV.

Table 3.

Stratified logistic regressions predicting poor maternal and fetal/neonatal outcomes in pregnant women with unrepaired congenital heart disease.

Independent variables	Beta	Standard error	p-value (Wald statistic)	OR (95% CI)
Univariable logistic regression
Maternal poor outcomes
Pregnancy over the age of 35 years	−19.622	17974.843	0.999	–
Third pregnancy and more	0.17	0.843	0.84	1.19 (0.23–6.18)
Gestational age at admission as the third trimester	2.428	1.064	0.022	11.33 (1.41–91.2)
Cyanosis	1.364	0.612	0.026	3.91 (1.18–12.99)
Severe cyanosis	1.64	0.613	0.007	5.16 (1.55–17.14)
Plasma level of NT-proBNP > 128 pg/mL	2.639	0.7	< 0.001	14.0 (3.55–55.21)
Anemia	1.311	0.799	0.101	3.71 (0.77–17.77)
Polycythemia	−0.166	0.826	0.841	0.85 (0.17–4.28)
PAH	20.231	6698.829	0.998	–
mWHO III-IV	19.971	8038.595	0.998	–
Fetal/neonatal poor outcomes
Pregnancy over the age of 35 years	21.154	17974.842	0.999	–
Third pregnancy and more	0.024	0.648	0.97	1.02 (0.29–3.65)
Gestational age at admission as first/second trimester	1.686	0.493	0.001	5.4 (2.05–14.2)
Cyanosis	1.678	0.509	0.001	5.36 (1.98–14.52)
Severe cyanosis	1.809	0.605	0.003	6.11 (1.87–19.99)
Plasma level of NT-proBNP > 128 pg/mL	1.743	0.683	0.011	5.71 (1.5–21.81)
Anemia	−2.278	1.093	0.037	0.1 (0.01–0.87)
Polycythemia	2.702	1.064	0.011	14.91 (1.85–120.0)
PAH	1.696	0.475	< 0.001	5.46 (2.15–13.83)
mWHO III-IV	2.475	0.611	< 0.001	11.88 (3.59–39.36)
Multivariable logistic regression
Maternal poor outcomes
Step 1
Plasma level of NT-proBNP > 128 pg/mL	2.639	0.7	< 0.001	14.0 (3.55–55.21)
Constant	−2.639	0.518	< 0.001	–
Step 2
Plasma level of NT-proBNP > 128 pg/mL	2.906	0.784	< 0.001	18.29 (3.93–85.04)
Gestational age at admission as the third trimester	2.641	1.167	0.024	14.03 (1.43–138.09)
Constant	−4.778	1.222	< 0.001	–
Step 3
Plasma level of NT-proBNP > 128 pg/mL	3.506	0.939	< 0.001	33.31 (5.28–209.95)
Gestational age at admission as the third trimester	2.846	1.17	0.015	17.22 (1.74–170.63)
Anemia	3.099	1.245	0.013	22.17 (1.93–254.32)
Constant	−5.638	1.336	< 0.001	–
Step 4
Plasma level of NT-proBNP >128 pg/mL	3.587	1.044	0.001	36.12 (4.67–279.34)
Gestational age at admission as the third trimester	2.718	1.223	0.026	15.15 (1.38–166.36)
Anemia	3.509	1.42	0.013	33.41 (2.07–540.26)
Severe cyanosis	2.225	1.006	0.027	9.26 (1.29–66.46)
Constant	−6.374	1.532	< 0.001
Fetal/neonatal poor outcomes
Step 1
mWHO III-IV	2.533	0.688	< 0.001	12.59 (3.27–48.46)
Constant	−1.735	0.626	0.006	−
Step 2
mWHO III-IV	3.367	0.908	< 0.001	28.98 (4.89–171.98)
Gestational age at admission as first/second trimester	2.425	0.794	0.002	11.3 (2.38–53.57)
Constant	−3.197	0.924	0.001	–
Step 3
mWHO III-IV	3.219	0.949	0.001	25.0 (3.89–160.66)
Gestational age at admission as first/second trimester	2.595	0.81	0.001	13.4 (2.74–65.56)
Plasma level of NT-proBNP > 128 pg/mL	1.602	0.743	0.031	4.96 (1.16–21.31)
Constant	−3.518	0.989	< 0.001	–
Step 4
mWHO III-IV	2.553	1.007	0.011	12.84 (1.79–92.42)
Gestational age at admission as first/second trimester	2.88	0.865	0.001	17.81 (3.27–97.08)
Plasma level of NT-proBNP > 128 pg/mL	1.883	0.806	0.02	6.57 (1.35–31.92)
Cyanosis	1.664	0.736	0.024	5.28 (1.25–22.35)
Constant	−3.79	1.057	< 0.001	–

mWHO: modified World Health Organization; NT-proBNP: N-terminal pro-B-type natriuretic peptide PAH: pulmonary artery hypertension; OR: odds ratio; CI: confidence interval. Poor maternal outcomes are defined as maternal death and transfer to the intensive care unit because of severe cardiac failure. Poor fetal outcomes included miscarriage, stillbirths, and fetal loss. Poor neonatal outcomes included neonatal death, neonatal asphyxia, low birth weight, and very low birth weight.

Discussion

Our findings show the current clinical status, factors related to poor obstetric outcomes, and positive results of multidisciplinary in-hospital teamwork activities for pregnant women with unrepaired CHD. This information highlights the significant inadequacies in healthcare for these complex pregnancies in developing countries. A significant proportion of these women reported a history of pregnancy difficulties, had undiagnosed CHD prior to their pregnancy, and had, therefore, not received pre-pregnancy cardiology counseling. Notably, a considerable proportion of pregnant women presented at the time of admission with a severe clinical status as mWHO III/IV risk classification, with PAH and severe cyanosis. Importantly, this demonstrates how some women who had known their medical condition was a contraindication for pregnancy decided to become pregnant nonetheless.

Characteristics of pregnant women with unrepaired CHD

Our report on the characteristics of pregnant women with unrepaired CHD was similar to a recent report in China, where 32.3% presented with PAH and mWHO IV.²² It is likely that in other developing countries, this status could lead to a delay in diagnosis and under-treatment of CHDs during childhood, causing major issues such as PAH in adulthood.²³ Even in developed countries, 10.7% of pregnant women with cardiac conditions presented with mWHO class IV.²⁴ In detail, our study closely reported on the phenomenon of women classified as high risk of maternal mortality with/without cardiology counseling, in whom pregnancy was still desired and occurred. Pregnancy is a common and legitimate desire, despite a poor obstetric history, even in women who understood their cardiac conditions were unsafe or contraindicated for pregnancy. Appropriate pre-pregnancy cardiology counseling regarding risk factors associated with poor pregnancy outcomes is essential for these women. Our study noted that more than half of the pregnant women had not received adequate pre-natal counseling, which underlines the gap in pre-pregnancy counseling in Vietnam, which could further assist women in making the best decisions for themselves regarding their pregnancy. This gap in healthcare is not limited to Vietnam. Another study from China reported that one-third of hospitalized pregnant women with CHD were unaware of their cardiac problem and thus had not received pre-pregnancy cardiology counseling.²⁵ In developed countries, such as the United Kingdom, despite the majority of women with heart disease having a prior discussion about pregnancy, a study reported that fewer than half of the women counseled felt well informed regarding the maternal and fetal/neonatal risks.²⁶ In a study reported in Korea, more than half of pregnant women with CHD did not receive pre-pregnancy cardiology counseling, and the rate of adverse maternal cardiac events among women who received pre-pregnancy cardiology counseling was lower than among women who did not.²⁷

Maternal and fetal/neonatal outcomes

Our study had a considerable number of pregnant women who were transferred to the ICU related to heart failure, which might reflect the high incidence of PAH and/or cyanosis. A previous study reported a heart failure rate of 21.1% among pregnant women with Eisenmenger syndrome and 18.9% among those with cyanosis.²⁸ Our study noted the rate of maternal death as 4.6%, all of whom had PAH. A recent study also reported a high rate of maternal mortality among pregnant women with CHD.²⁹ Notably, the need for acute obstetric interventions was also high in our study sample. A recent study in Sweden reported a rate of emergency cesarean section delivery of 10.4% among pregnant women with CHD.³⁰ Another study noted that cesarean delivery was performed in 46.6% of pregnant women with CHD.³¹ Among pregnant women with CHD, the choice of delivery mode exerts potential risks and benefits. A vaginal delivery could be planned for women with an NYHA (New York Heart Association) class I/II to minimize complications related to hemorrhage and blood loss. However, women with PAH and/or an mWHO III/IV classification are at high risk of hemodynamic instability during pregnancy and delivery, and, therefore, planned cesarean section may be a more appropriate approach in some women.^31–33 The rate of adverse fetal/neonatal events in our study was consistent with recent reports.^25,28,34 The high rate of neonatal asphyxia and very low birth weight are important burdens to the healthcare system in developing countries, such as Vietnam, owing to limited health sources.

Factors related to poor maternal and fetal/neonatal outcomes

On multivariate logistic analysis, the likelihood of poor maternal outcomes was greater for women admitted during their third trimester. This may be related to the significant hemodynamic changes and fetal weight during the third trimester, which increases the burden on the maternal cardiovascular system. Furthermore, obstetric interventions are more difficult and riskier to perform during the third trimester than during the first/second trimester.

In our study, severe cyanosis was associated with poor maternal and fetal/neonatal outcomes. Pregnant women with CHD presenting with cyanosis have a 2.8- and 3.78-fold higher risk of cardiac complications,³⁵ and fetal/neonatal complications,²² respectively, than women without CHD. According to the recent European Society of Cardiology guideline, cyanosis is a predictor of maternal cardiovascular events among pregnant women with cardiovascular diseases.¹⁸

Similarly, anemia is a risk factor for adverse maternal outcomes,^36,37 further aggravating heart failure resulting from an increased preload and reduced afterload. Among individuals with CHD, anemia has been associated with a higher 5-year mortality risk (17.7%) compared to those without anemia (6.0%).³⁸ Therefore, anemia should be carefully managed in pregnant women with CHD. The negative effect of a high plasma level of NT-proBNP, as a marker of heart failure, on poor maternal and fetal/neonatal outcomes that we observed was also consistent with previous findings.^39–41

Lastly, an mWHO III/IV classification was identified as a high-risk factor for poor fetal/neonatal poor outcomes. A recent study in Thailand reported a significant increase in the rates of neonatal death, preterm birth, low birth weight, small for gestational age, neonatal asphyxia, and neonatal ICU admission among pregnant women with an mWHO III/IV classification.⁴² Therefore, pregnant women with an mWHO III/IV classification should be monitored carefully during hospitalization.

Pregnant women with severe CHD present a challenge for healthcare systems, with a maternal cardiac event rate of 19–27% (mWHO class III) and 40–100% (mWHO class IV).¹⁸ Thanks to multidisciplinary in-hospital teamwork healthcare activities, in our study, the outcomes of pregnant women with an mWHO class of III/IV seemed not to be pessimistic, approaching the prognosis achieved in Europe.²⁴ A proactive approach for maternal risk stratification, multidisciplinary delivery planning, and neonatal care could be useful in improving the opportunity of maternal, fetal, and neonatal surveillance for moderate- and high-risk pregnant women with cardiac conditions.^18,43 We noted that in developing countries, the strategy of multidisciplinary management with inter-professional collaboration practice for women with heart diseases has started to trend towards improving the quality of obstetric care.⁴⁴

Limitations

This study has several limitations. Foremost, this was a retrospective study and, as such, follow-up, outcome assessment, and treatment strategies were not standardized. Further, a detailed description of the multidisciplinary in-hospital teamwork healthcare activities could not be obtained, and the effect of this strategy could not be confirmed. The possibility of bias cannot be eliminated as not all cardiac complications among pregnant women with CHD will result in hospitalization. Moreover, studies such as ours, which are based on hospital admission or administrative data, capture for complications at the time of hospital admission or delivery, underestimating the overall pregnancy risks. In our study, some cardiac complications, such as pulmonary edema and arrhythmias, were not recorded. Pre-pregnancy clinical information was also lacking, such as the NYHA functional classification which could influence pregnancy outcomes. None of the pregnant women with suspected PAH underwent right heart catheterization. We believe that this may have been due to safety concerns and barriers to access during pregnancy. Owing to the cross-sectional design used, causality between poor maternal and fetal/neonatal outcomes and clinical status cannot be proven. Third, our study was conducted at a single hospital with cardiovascular specialization in Vietnam, with a higher rate of admissions of pregnant women with a severe clinical status than that of general pregnancies among women with CHD in obstetric hospitals. This possible sampling bias limits the generalizability of our findings. Fourth, we only collected short-term pregnancy outcomes at 4–6 weeks after delivery; this means that complications that could have occurred in the medium- and long-term might have been missed. Finally, because of the small sample size and low rate of adverse complications, our study only met the minimum number of participants for a reliable comparison of outcomes between the two subgroups.

Conclusion

Our study provides important evidence on poor maternal and fetal/neonatal outcomes and factors related to these outcomes among pregnant women with unrepaired CHD in Vietnam. Indeed, our findings suggest that pre-pregnancy screening for CHD, provision of healthcare counseling and careful management during pregnancy, and multidisciplinary teamwork could be useful to improve pregnancy outcomes during hospitalization.

Supplemental Material

sj-doc-1-obm-10.1177_1753495X221148819 - Supplemental material for Outcomes of pregnant women hospitalized with unrepaired congenital heart disease: Insights from a multidisciplinary center in Vietnam

Supplemental material, sj-doc-1-obm-10.1177_1753495X221148819 for Outcomes of pregnant women hospitalized with unrepaired congenital heart disease: Insights from a multidisciplinary center in Vietnam by Thanh-Huong Truong, Ngoc-Thanh Kim and Dinh-Phuc Nguyen, Mai-Ngoc Thi Nguyen, Doan-Loi Do, Thanh-Tung Le, Hong-An Le in Obstetric Medicine

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sj-doc-2-obm-10.1177_1753495X221148819 - Supplemental material for Outcomes of pregnant women hospitalized with unrepaired congenital heart disease: Insights from a multidisciplinary center in Vietnam

Supplemental material, sj-doc-2-obm-10.1177_1753495X221148819 for Outcomes of pregnant women hospitalized with unrepaired congenital heart disease: Insights from a multidisciplinary center in Vietnam by Thanh-Huong Truong, Ngoc-Thanh Kim and Dinh-Phuc Nguyen, Mai-Ngoc Thi Nguyen, Doan-Loi Do, Thanh-Tung Le, Hong-An Le in Obstetric Medicine

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sj-sav-3-obm-10.1177_1753495X221148819 - Supplemental material for Outcomes of pregnant women hospitalized with unrepaired congenital heart disease: Insights from a multidisciplinary center in Vietnam

Supplemental material, sj-sav-3-obm-10.1177_1753495X221148819 for Outcomes of pregnant women hospitalized with unrepaired congenital heart disease: Insights from a multidisciplinary center in Vietnam by Thanh-Huong Truong, Ngoc-Thanh Kim and Dinh-Phuc Nguyen, Mai-Ngoc Thi Nguyen, Doan-Loi Do, Thanh-Tung Le, Hong-An Le in Obstetric Medicine

Footnotes

Acknowledgments

We thank all medics and nurses from Bach Mai Hospital for their effort and support in caring for pregnant women with CHD at Vietnam National Heart Institute, Bach Mai Hospital.

Contributorship

THT initiated the study, designed data collection tools, monitored data collection, performed data analysis, and drafted and revised the paper. NTK monitored data collection, performed data analysis, and drafted and revised the paper. DPN monitored the data collection, performed data analysis, and revised the draft paper. MNTN, DLD, TTL, and HAL monitored data collection and revised the draft paper. All authors have read and approved the final manuscript.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

Ethical approval for this study was obtained from the Science Board and Ethics Committee of the Department of Cardiology, Hanoi Medical University (no: 4280/QĐ-ĐHYHN).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Guarantor

THT

Informed consent

Informed consent was not sought for the present study because this retrospective study is based on recorded data which was analyzed anonymously.

ORCID iD

Thanh-Huong Truong

Supplemental material

Supplemental material for this article is available online.

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