Pregnancy correlates with increased long-term cardiac outcom
Among women with congenital heart disease, pregnancy was associated with an increase in adverse long-term cardiac outcomes, according to a retrospective longitudinal cohort study.

As early life interventions for congenital heart disease (CHD) improve, more patients are living to adulthood and considering pregnancy. Scoring and classification systems predict maternal cardiovascular risk of pregnancy in the context of congenital heart disease but these scoring systems do not assess the potential subsequent risks following pregnancy. Data on long-term cardiac outcomes after pregnancy are unknown for most lesion types. This limits healthcare practitioners’ ability to thoroughly counsel patients considering pregnancy in the setting of congenital heart disease.

This study aimed to evaluate the association between pregnancy and subsequent long-term cardiovascular health of women with congenital heart disease (CHD).

Retrospective longitudinal cohort of women receiving care in two adult CHD centers from 2014-2019. Data were abstracted longitudinally from 15 years of age (or time of entry into the healthcare system) until conclusion of the study, death or exit from the healthcare system. The primary endpoint, a composite adverse cardiac outcome (death, stroke, heart failure, unanticipated cardiac surgery, or requirement of catheterized procedure), was compared between parous (at least one delivery more than 20 weeks) and nulliparous women.

Accounting for differential follow-up, the effect of pregnancy was estimated based on time to composite adverse outcome in a proportional hazards regression model adjusted for WHO class, baseline cardiac medications, and number of prior sternotomies. Participants were also categorized by lesion type including septal defects (VSD, ASD, AVSD, AVCD), right-sided valvular lesions, left-sided valvular lesions, complex cardiac anomalies, and aortopathies to evaluate for a differential effect of pregnancy on the primary outcome when adjusting for lesion type in a sensitivity analysis.

-- Overall 711 women were eligible for inclusion; 209 were parous and 502 nulliparous.

-- Women were classified by World Health Organization (WHO) class with 86 (12.3%) who were WHO Class I, 76 (10.9%) Class II, 272 (38.9%) Class II-III, 155 (22.1%) Class III, and 26 (3.7%) Class IV.

-- Aortic stenosis, bicuspid aortic valve, dilated ascending aorta/aortic root, aortic regurgitation, and pulmonary insufficiency were more common in parous women whereas, dextro transposition of the great arteries (dTGA), Turner syndrome, hypoplastic right heart, left superior vena cava (LSVC), and “other” cardiac diagnoses were more common in nulliparous women.

-- In multivariable modeling, pregnancy was associated with the composite adverse cardiac outcome.

-- Parous women were more likely to have unanticipated cardiac surgery.

-- No other individual components of the primary outcome were statistically different between parous versus nulliparous women in cross-sectional comparisons.

-- The association between pregnancy and the primary outcome was similar in a sensitivity analysis adjusting for cardiac lesion type.

Conclusively, among women with CHD, pregnancy was associated with an increase in subsequent adverse long-term cardiac outcomes. These data may inform counseling of women with CHD considering pregnancy.