Maternal right ventricular function, uteroplacental circulation in first trimester and pregnancy outcome in women with congenital heart disease

Abstract

Objective Pregnant women with congenital heart disease (CHD) have an increased risk of abnormal uteroplacental flow, measured from the second trimester onwards, which is associated with pregnancy complications affecting the mother and the fetus. Maternal right ventricular (RV) dysfunction has been suggested as a predisposing factor for impaired uteroplacental flow in these women. The aim of this study was to investigate the association of first-trimester uteroplacental flow measurements with prepregnancy maternal cardiac function and pregnancy complications in women with CHD, with particular focus on the potential role of RV (dys)function. Methods This study included 138 pregnant women with CHD from the prospective ZAHARA III study (Zwangerschap bij Aangeboren HARtAfwijkingen; Pregnancy and CHD). Prepregnancy clinical and echocardiographic data were collected. Clinical evaluation, echocardiography (focused on RV function, as assessed by tricuspid annular plane systolic excursion (TAPSE)) and uterine artery (UtA) pulsatility index (PI) measurements were performed at 12, 20 and 32 weeks of gestation. Univariable and multivariable regression analyses were performed to assess the association between prepregnancy variables and UtA-PI during pregnancy. The association between UtA-PI at 12 weeks and cardiovascular, obstetric and neonatal complications was also assessed.

Reduced right ventricular function on cardiovascular magnetic resonance imaging is associated with uteroplacental impairment in tetralogy of Fallot

“…These findings suggest that impaired RV function might be a predisposing factor for poor placental function, which is known to be associated with adverse maternal and neonatal outcome. The current study combining CMR with PI confirms our previous findings that pre-existing reduced RV function is associated with impaired uteroplacental circulation [1,[12][13][14]. In our previous echocardiographic studies, we were limited in the assessment of RV function and CO measurements due to the specific modality.…”

“…In the ZAHARA II and III study 66 repaired ToF women were included. For the present study, women were excluded because of miscarriage (n = 3), no CMR evaluation available because of a pacemaker (n = 3) or no CMR evaluation available within 2 years before pregnancy (n = 29), resulting in a total study population of 31 repaired ToF women (median time between the CMR evaluation and date of conception was 8 [3][4][5][6][7][8][9][10][11][12][13][14] months).…”

“…Median time between pre-pregnancy CMR evaluation and uteroplacental flow measurements at 20 weeks and 32 weeks gestation were 12 [7][8][9][10][11][12][13][14][15][16][17][18][19] Tables 3 and 4. Reduced RVEF, higher indexed LV end diastolic volume (EDV) and LV end systolic volume (ESV) were associated with impaired uterine artery PI at 20 weeks with univariable analyses (P = 0.037, P = 0.001 and P = 0.003, respectively).…”

“…Therefore, similar hemodynamic interactions between the heart and the placenta may be present. Our previous studies in pregnant women with congenital heart diseases showed a consistent association between impaired right ventricular (RV) parameters and impaired uteroplacental Doppler parameters [ 1 , 12 – 14 ]. However, these studies only focused on echocardiography parameters, which has known limitations, particularly in the assessment of RV function.…”

Severe pulmonary hypertension and reduced right ventricle systolic function associated with maternal mortality in pregnant uncorrected congenital heart diseases

“…12 RV dysfunction and failure are also associated with worsened outcome for pregnant women with CHD-PH. 13 Reduced TAPSE (mean TAPSE < 19 mm) was observed in nonsurvivors, which indicated the reduced RV systolic function during current pregnancy. The LV function was still normal (mean LVEF 66.8%) in nonsurvivors; however, RV dysfunction might affect LV function, which contributed to reduced cardiac output.…”