Research
HJOG 2025, 24 (1), 17-21| doi: 10.33574/hjog.0580
Stavroula Papadea, Kyriaki Mitta, Ioannis Tsakiridis, Apostolos Mamopoulos, Ioannis Kalogiannidis, Themistoklis Dagklis, Apostolos Athanasiadis
Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
Correspondence: Ioannis Tsakiridis, Konstantinoupoleos 49, 54642, Thessaloniki, Tel: +30 2313312120 and Fax: +30 2310 992950, e-mail: iotsakir@gmail.com
Abstract
Introduction: The management of women with cardiac disease may be a dilemma for the obstetricians, especially regarding the mode of delivery. The aim of this study was to present the clinical practice regarding the mode of delivery among women with cardiac disease in Northern Greece.
Material and methods: This was a retrospective study which included pregnant woman with cardiac disease that was already known or diagnosed during pregnancy. Data were collected (2011-2023) from three university departments of Obstetrics and Gynecology in Thessaloniki, Greece. Demographics, mode of delivery and its indications were all thoroughly reported and analyzed. The indications were categorized as either obstetric or cardiac.
Results: Out of a total sample of 63 pregnant women with heart disease, 36.5% underwent vaginal, while 63.5% cesarean delivery. Among those who delivered via cesarean, 55% had the cardiac disease as the indication, while 45% had an obstetric indication. Excluding women with obstetric indications for cesarean section, the remaining sample of 45 women resulted in a vaginal delivery rate of 51%, with 49% undergoing cesarean section. Moreover, focusing only on pregnant women who had cesarean sections due to cardiac disease, after excluding those with obstetric indications, 18% were in agreement with national and European guidelines, while 82% could have attempted vaginal delivery according to these recommendations.
Conclusion: The findings of the present study suggest that there is a tendency towards cesarean delivery in women with cardiac disease, without being necessitated by the guidelines.
Keywords: Pregnancy, mode of delivery, cardiac disease, heart
Introduction
The prevalence of maternal cardiac disease is estimated to be 5.8% and up to 20.5% of all maternal deaths are attributed to cardiovascular disease (CVD); CVD is a leading cause of non-obstetric mortality during pregnancy [1]. During pregnancy, significant physiological adjustments occur to ensure adequate blood flow to the uterus, supporting fetal development [2, 3]. In the first trimester, there is an increase in the Renin-Angiotensin-Aldosterone System, leading to sodium and water retention [2, 4]. Simultaneously, hormonal stimulation enhances protein synthesis and hematopoiesis by the liver and bone marrow, respectively [3]. Consequently, red cell mass elevates by nearly 50% of its pre-pregnancy level by the end of the second trimester. Additionally, plasma volume expands by 30-50% before 30 weeks of gestation [3].
Maternal heart rate experiences a significant and rapid increase during pregnancy; increased preload and reduced afterload contribute to elevated cardiac output [5, 6]. There is also an increased risk of thromboembolic events due to hypercoagulability. These hemodynamic changes typically revert to pre-pregnancy baseline values within 2-4 weeks following vaginal delivery and 4-6 weeks after cesarean section [7]. Recent data revealed enhanced cardiac performance and progressive left ventricular remodeling throughout pregnancy, including the progressive development of eccentric hypertrophy, which typically resolves postpartum [8].
CVD during pregnancy is complex, as women may present with either pre- or postpartum, stemming from pre-existing conditions i.e. congenital heart disease (operated or unoperated), valvular heart disease, or idiopathic dilated cardiomyopathy; symptoms and signs of heart failure are often observed [7]. Managing women with CVD during pregnancy requires close collaboration among cardiologists, obstetricians and intensivists. However, prospective studies and establishing prevalence rates remain scarce, with hospital-based registries often providing only incidence data. Hence, the aim of this study was to present the clinical practice regarding the mode of delivery among women with cardiac disease in Northern Greece.
Material and methods
This was a retrospective study (2011 – 2023) which included pregnant woman with a history of heart disease that was already known or diagnosed during pregnancy. Data were collected from three university departments of Obstetrics and Gynecology in Thessaloniki, Greece. Demographic characteristics, mode of delivery and its indication were all reported and analyzed thoroughly. The indications were categorized as either obstetric or cardiological. All cardiac diseases were categorized according to the World Health Organization (WHO).
The cardiac diseases were recorded and classified as followed; congenital heart diseases (operated or not), abnormalities of heart rate, diseases of mitral valve, diseases of aortic valve, diseases of tricuspid valve, diseases of pulmonary valve, acquired heart disease, coronary artery disease, pulmonary embolism and unknown when there was no information about the disease but in the medical history of the pregnant woman was written the term ‘’cardiac / heart disease ‘’.
Regarding the mode of delivery, vaginal delivery or cesarean section were the two main groups recorded and those that gave birth via cesarean section were divided further in two subgroups, according to the indication; cesarean section due to obstetrical indication and cesarean due to cardiac disease. The differences among the protocols followed for delivering women with cardiac disease were examined and compared with the guidelines by the European Society of Cardiology (ESC) [9].
Results
In total, 63 cases of pregnant women with cardiac disease were recorded during the study period; 35% of them had category I cardiac disease according to WHO, 32% category II, 14% category II-III, 11% category III and 6% category IV. Five women gave birth via cesarean section, in accordance to European guideline; the first one had a history of operated aortic isthmus stenosis, bicuspid aortic valve with mild to moderate insufficiency, mild isthmus stenosis, mild isthmus stenosis after the effusion of left subclavian artery and mild proptosis of mitral valve. The second had a history of two episodes of acute heart attack with borderline right ventricular diastolic function, the third had severe aortic valve stenosis, the fourth had aortic valve stenosis, insufficiency and resistant primary hypertension and the fifth had a history of two acute heart attacks and also placenta previa. The indication of every cesarean was recorded exactly as it was declared on the delivery room registries.
From the total number of pregnant women with heart disease, 36.5% (23 out of 63) underwent vaginal and 63.5% (40 out of 63) caesarean delivery. Within the group of women who underwent cesarean delivery, 55% (22/40) had cardiac disease as the indication, while 45% (18/40) had obstetric indications i.e. previous cesarean section, fetal growth restriction (FGR), twin pregnancies, placenta previa or breech presentation.
Within the subgroup of 22 women with cardiological indications, each case of heart disease was compared with the pathologies that justify cesarean delivery according to European guideline; this comparison revealed that only 4 out of 22 cases were in alignment with the guideline, while in 18 out of 22 cases, “cardiac disease/heart disease” was cited as an indication without corresponding to any of the specified pathologies. Additionally, it was noted that only 7 out of 63 pregnant women with cardiac disease received counseling from the attending cardiologist regarding the mode of delivery or an evaluation of whether the labor posed a high- or low-risk.
After excluding the pregnant women with heart disease who had obstetric indications for cesarean section, the remaining sample consists of 45 women. Statistical analysis showed that 51% (23/45) had a vaginal and 49% (22/45) had a cesarean delivery. Focusing solely on the pregnant women with cardiac disease who underwent cesarean sections due to cardiac disease itself and excluding those with obstetric indications, 18% (4/22) were in agreement with the European guideline, while 82% (18/22) could have attempted vaginal delivery according to these recommendations.
In total, only 11% (7/63) of the women received any consultation from the attending cardiologist regarding the mode of delivery. Excluding the women with obstetric indications for cesarean section, this percentage drops to 9% (4/45). Furthermore, among the subgroup of women who underwent cesarean section solely due to their cardiac disease, 14% (3/22) had a consultation from the attending cardiologist about their delivery. It should be noted that the absence of a recorded cardiologic consultation in the delivery room registries does not necessarily mean that no consultation occurred; it indicates that the decision for vaginal or cesarean delivery was primarily at the discretion of the obstetrician.
Discussion
The main findings of this study were that in women with cardiac disease: 1) 63.5% underwent cesarean section, 2) 55% of those who delivered via cesarean had a cardiac disease as an indication, 3) after focusing solely on the pregnant women with cardiac disease who had cesarean sections due to cardiac disease and after excluding those with obstetric indications, only 18% were in agreement with the European guideline.
According to the guideline of the European Society of Cardiology, vaginal delivery is recommended for the majority of pregnant women with heart disease [9]. This recommendation is based on the lower likelihood of profuse blood loss, inflammation, and thromboembolic disease, with no significant differences in neonatal outcomes. However, the results of the present study indicate that obstetricians opted for cesarean section in the majority of cases.
Regarding the rate of cesarean section in women with cardiac disease, it is mentioned in the literature that the rate of cesarean in women with cardiac disease during an 8-year period in Munich was 46.6% [10]. Another study conducted in United States reported that the rate of cesarean section in women with cardiac disease was 32.2% during a 9-year period [11]. A study, based on the same database, during another 10-year period, mentioned a rate of 40.7%, whereas a study in Netherlands reported a rate of 25% in 5-year period [12]. Considering that the overall cesarean section rate in Greece is about 60.5%, it is expected that the subgroup of Greek pregnant women with heart disease will have a higher cesarean section rate compared to pregnant women with cardiac disease in other countries.
This difference may be attributed to Greek obstetricians’ limited familiarity with managing the coexistence of heart disease and pregnancy, as well as the stress this may cause in the delivery room. Additionally, these women often do not have regular access to an attending cardiologist and may not be fully aware of their cardiological status. Some cases involve women from low socioeconomic backgrounds, where the diagnosis of heart disease is made during labor. Consequently, obstetricians frequently practice defensive medicine, which influences their decision regarding the mode of delivery for pregnant women with cardiac disease.
In this study, only 11% of the women received counseling from the attending cardiologist regarding the mode and place of delivery, as well as the potential risks of vaginal delivery. For the remaining women, it was unclear whether they had received appropriate cardiac care, as this was not documented in the birth plan. It is an undeniable fact that no obstetrician would choose a cesarean section as the mode of delivery if there was a clear recommendation for vaginal delivery from the attending cardiology team, and if they could rely on the support of an experienced cardiologist and intensive care unit during labor. Furthermore, a crucial factor influencing this decision was the experience of the obstetrician and their team in handling pregnancies of women with heart disease, as well as the workload of the delivery room.
The heart disease of each woman was compared with the five cardiac pathologies that the ESC defines as absolute indications for cesarean section. The results showed that only 18% of the deliveries in our study adhered to the guideline, while in the remaining 82%, the heart disease was listed as an indication for cesarean section in the delivery room registries, even though the specific cardiac disease did not align with any of the indications. Consequently, we can infer that in 82% of cases, there is an insecurity regarding the vaginal mode of delivery, leading obstetricians to indicate cardiac disease as a reason to proceed with a cesarean section.
To conclude, the data on deliveries of pregnant women with heart disease clearly indicate that the European guideline for the mode of delivery in such cases is not widely followed. Therefore, it would be beneficial to establish medical structures staffed by cardiologists and obstetricians experienced in managing pregnancies with heart disease. These specialized teams would oversee the pregnancy and develop a proper birth plan tailored to the needs of each woman.
References
- Prasad D, Prasad RV, Choudhary MK, Kumari K. Cardiovascular disease in pregnancy and its outcome: A prospective study. J Family Med Prim Care. 2023;12:2714-20.
- Metcalfe J, Ueland K. Maternal cardiovascular adjustments to pregnancy. Prog Cardiovasc Dis. 1974;16:363-74.
- Pritchard JA. Changes in the Blood Volume during Pregnancy and Delivery. Anesthesiology. 1965;26:393-9.
- McFaul PB, Dornan JC, Lamki H, Boyle D. Pregnancy complicated by maternal heart disease. A review of 519 women. Br J Obstet Gynaecol. 1988;95:861-7.
- Katz R, Karliner JS, Resnik R. Effects of a natural volume overload state (pregnancy) on left ventricular performance in normal human subjects. Circulation. 1978;58:434-41.
- Robson SC, Hunter S, Moore M, Dunlop W. Haemodynamic changes during the puerperium: a Doppler and M-mode echocardiographic study. Br J Obstet Gynaecol. 1987; 94:1028-39.
- Sahu AK, Harsha MM, Rathoor S. Cardiovascular Diseases in Pregnancy – A Brief Overview. Curr Cardiol Rev. 2022;18:e250821195824.
- Savu O, Jurcut R, Giusca S, et al. Morphological and functional adaptation of the maternal heart during pregnancy. Circ Cardiovasc Imaging. 2012;5:289-97.
- European Society of G, Association for European Paediatric C, German Society for Gender M, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:3147-97.
- Hrycyk J, Kaemmerer H, Nagdyman N, Hamann M, Schneider K, Kuschel B. Mode of Delivery and Pregnancy Outcome in Women with Congenital Heart Disease. PLoS One. 2016;11: e0167820.
- Opotowsky AR, Siddiqi OK, D’Souza B, Webb GD, Fernandes SM, Landzberg MJ. Maternal cardiovascular events during childbirth among women with congenital heart disease. Heart. 2012;98:145-51.
- Thompson JL, Kuklina EV, Bateman BT, Callaghan WM, James AH, Grotegut CA. Medical and Obstetric Outcomes Among Pregnant Women With Congenital Heart Disease. Obstet Gynecol. 2015;126:346-54.