Pregnancy and Congenital Heart Disease: Moving Beyond the Current Risk Stratification Tools

Q: What is the clinical evidence from this study?

Study design: Review. Population: Adult congenital heart disease (ACHD) in pregnancy. Intervention: Comprehensive multidisciplinary pre-pregnancy and early pregnancy counseling and risk stratification (CARPREG, CARPREG II, ZAHARA, mWHO). Primary outcome: Maternal cardiovascular, obstetric, and fetal adverse events.

Ajitha Kulasekaran; Lorna Swan

doi:10.15420/usc.2022.16

May 25, 2023US Cardiology ReviewOpen Access

Pregnancy and Congenital Heart Disease: Moving Beyond the Current Risk Stratification Tools

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Key result

Pre-pregnancy counseling in congenital heart disease requires expanding beyond cardiac scores to obstetric and fetal risks.

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Why the study?

Women with congenital heart disease have increased risks of complications during pregnancy, but comprehensive pre-pregnancy or early pregnancy counseling needs to go beyond existing risk scoring tools.

Key Points

To review the capabilities and limitations of existing risk stratification tools for pregnant women with congenital heart disease and emphasize the necessity of comprehensive, multidisciplinary counseling.
Narrative review evaluating maternal cardiac risk tools including CARPREG, CARPREG II, ZAHARA, and modified World Health Organization (mWHO) classifications.
Analysis of cardiac, non-cardiac, obstetric, and neonatal factors influencing outcomes in adult congenital heart disease (ACHD) pregnancies.
Risk assessment tools showed discrepancies between predicted and observed risks: CARPREG predicted 10.1% versus 4.0% observed, CARPREG II predicted 8.6% versus 5.0%, ZAHARA predicted 11.1% versus 8.0%, and mWHO predicted 12.4% versus 8.0%.
Existing scoring models focus strictly on short-term maternal cardiac outcomes and omit vital non-cardiac risks, including maternal obesity, age, smoking, and socioeconomic access barriers.
Traditional scores fail to address long-term maternal risks such as ventricular decline, pulmonary artery pressure elevation, or antibody sensitization affecting future heart transplantation.

Structured PICO

P

Population

Pregnant women or women contemplating pregnancy with adult congenital heart disease (ACHD) undergoing pre-pregnancy or early pregnancy risk stratification and counseling.

I

Intervention

Comprehensive multidisciplinary pre-pregnancy or early pregnancy counseling incorporating cardiac risk stratification tools (CARPREG, CARPREG II, ZAHARA, modified WHO) alongside non-cardiac, obstetric, and fetal risk assessments

O

Outcome

Maternal cardiovascular adverse events, obstetric complications, and fetal/neonatal morbidity and mortality

Limitations

Traditional risk scores tend to overestimate risk in more complex patients and are often derived from data sourced from expert centers in high-income countries.
Risk scores lack the granularity to assess individual physiological subtleties (such as Ebstein's anomaly) or how to combine multiple lesions.
Most recognized non-cardiac risk factors (such as maternal obesity, smoking, age, and socioeconomic or logistical barriers) are excluded from existing risk scores.
Existing risk scores tend to overestimate risk in complex patients and are primarily derived from expert centers in high-income countries.
Risk tools lack the granularity needed to assess individual physiological variations or rare conditions (e.g., Ebstein's anomaly) and do not clarify how to combine multiple risk lesions.
Most recognized non-cardiac risk factors (maternal obesity, smoking, ethnicity, age, and access to care) and long-term cardiac implications are excluded from current scoring systems.

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Implication

Traditional cardiac risk scores (CARPREG, CARPREG II, ZAHARA, mWHO) are only a starting point for women with congenital heart disease contemplating pregnancy, requiring supplementation with multidisciplinary counseling addressing non-cardiac, obstetric, and fetal risks.

Abstract

Women with congenital heart disease have increased risks of complications during pregnancy. Several risk scoring tools have been developed to quantify the likelihood of adverse cardiac outcomes during pregnancy. This article describes how comprehensive pre-pregnancy or early pregnancy counseling needs to go well beyond these risk scores. Non-cardiac risk factors and adverse obstetric and fetal outcomes are vital components of the dialogue between the multidisciplinary team and the patient embarking on, or contemplating, pregnancy.

Discussion

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Cite This Study

Kulasekaran et al. (2023) conducted a review in Adult congenital heart disease (ACHD) in pregnancy. Comprehensive multidisciplinary pre-pregnancy and early pregnancy counseling and risk stratification (CARPREG, CARPREG II, ZAHARA, mWHO) was evaluated on Maternal cardiovascular, obstetric, and fetal adverse events. Pre-pregnancy counseling in women with congenital heart disease must extend beyond traditional cardiac risk scores (CARPREG, ZAHARA, mWHO) to incorporate non-cardiac, obstetric, and fetal risks.

synapsesocial.com/papers/6a7c6e719a607e4564eadc8f https://doi.org/10.15420/usc.2022.16

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Pregnancy and Congenital Heart Disease: Moving Beyond the Current Risk Stratification Tools

Figures

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Pregnancy and Congenital Heart Disease: Moving Beyond the Current Risk Stratification Tools

Figures

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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