Pregnancy-Induced Functional Class Modifications in Patients with Congenital Heart Disease

Research Article

J Cardiovasc Disord. 2017; 4(1): 1032.

Pregnancy-Induced Functional Class Modifications in Patients with Congenital Heart Disease

Daliento L*, Pomiato E, Mazzotti E, Bauce B, Spadotto V and Rizzoli G

Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Italy

*Corresponding author: Daliento L, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova Medical School, Via Giustiniani, 2, 35121- Padova (PD), Italy

Received: April 10, 2017; Accepted:May 23, 2017; Published: May 31, 2017


Background: Pregnancy represents a raising issue in women with Congenital Heart Disease (CHD), but its effect on functional status is not well established. The aim of our study was to assess the probability of modification of functional status due to pregnancy in CHD, thus improving preconceptional counselling.

Methods: Data on maternal NYHA functional class and Ability Index before, during and after pregnancy in 127 pregnancies in 95 women (mean age 31±5 years) with CHD, collected between 2008 and 2013 at Padua University Hospital Clinic were recorded (total visits 498), together with echocardiographic parameters.

Results: Before pregnancy, 93 patients were in NYHA Class I and 9 in NYHA class II; during pregnancy 83 were in class I and 14 in class II; during puerperium, 81 were in class I and 15 in class II; at 6-month follow-up, 82 were in class I and 19 in class II. Worsening of NYHA class from baseline to 6-months after pregnancy was significantly associated to baseline NYHA class >1 (OR 127 p<0.0001), number of pregnancies (OR 1.014, p=0.03), history of palliative operation prior to correction (OR 2.4, p<0.0001), corrective surgery (OR 3.47, p<0.0001) and complex CHD (OR 5.3, p<0.0001). At multivariate analysis, baseline NYHA, and complex CHD remained independent predictors of NYHA class deterioration. Cardiac ultrasound parameters showed the same trend as NYHA.

Conclusions: In-women with CHD the probability of functional class worsening during and after pregnancy adjusted for concomitant risk factors is significantly related to baseline NYHA class and complexity of CHD.

Keywords: GUCH, pregnancy, congenital heart, NYHA, echocardiography


ASD: Atrial Septal Defect; CHD: Congenital Heart Disease; CL: Confidence Limit; FAC: Fractional Area Change; GUCH: Grown-Up Congenital Heart; LMP: Last Menstrual Period; LVEF: Left/Systemic Ventricle Ejection Fraction; PDA: Patent Ductus Arteriosus; PFO: Patent Foramen Ovale With Positive Bubbles Test (PFO); RV: Right Ventricle; Rvdil: Right Ventricle Dilatation; RVEDA: Right Ventricle End-Diastolic Area; Rvfunct: Right Ventricle Function; SPAP: Systolic Pulmonary Artery Pressure; TAPSE: Tricuspid Annular Plane Systolic Excursion; TGA: Transposition Of Great Arteries; TOF: Tetralogy Of Fallot; VSD: Ventricular Septal Defect.


Progress in prenatal screening, surgical techniques and neonatal management of Congenital Heart Disease (CHD) led to an increasing number of Grown up Congenital Heart (GUCH) patients. Therefore, new psychological and clinical issues are raising [1], among them an increasing number of women with CHD want to become pregnant [2].

Fertility in women with CHD is generally preserved [3], but other factors can influence pregnancy outcome and maternal and foetal well-being [4-6].

Many studies have tried to develop maternal and foetal risk scores in this setting [7,8], but simpler predictors are needed to provide an effective counselling. The aim of this study was to evaluate the degree of maternal functional worsening and the foetal outcome in large number of pregnancies among CHD women.

Material and Methods

Study design

The study retrospectively analysed 127 consecutive pregnancies occurred in GUCH women between 2008 and 2013, followed by the Department of Cardiac, Thoracic, and Vascular Sciences and/or the Department of Maternal and Pediatric Health of the Padua University Hospital. Women were divided into two categories: patients with simple CHD (native or surgically repaired) included Atrial Septal Defect (ASD), patent foramen ovale with Positive Bubbles Test (PFO), Ventricular Septal Defect (VSD), patent ductus arteriosus, cor triatriatum, coronary fistula, bicuspid aortic valve, aortic coarctation, pulmonary stenosis, partial anomalous pulmonary venous return and congenital atrioventricular block. Patients with complex CHD (native or surgically corrected) encompassed Tetralogy of Fallot (TOF), atrioventricular septal defect, Transposition of Great Arteries (TGA), double-outlet left ventricle, double-outlet right ventricle, Ebstein’s anomaly and Marfan syndrome.

NYHA functional class and Ability Index [9] were found in medical records. We evaluated them in all pregnancies: before gestation, during it, 1 and 6 months after delivery; thereafter, we continued data collection up to 16 years after delivery, but some patients drop-out.

We collected echocardiographic exams performed before, during and after pregnancy and evaluated them following the most recent echocardiographic guidelines [10].

We also evaluated pregnancy outcome, obstetric complications, time and mode of delivery, offspring outcome, Apgar score [11] and recurrence of CHD.

Statistical analysis

Continuous data were summarised with means (standard deviation) when normally or medians (interquartile range) when non-normally distributed. Relationship between predictors and events was assessed with univariate and multivariate analysis. The hazard of miscarriage and abortion was empirically calculated and parametrically modelled according to Royston Flexible parametric survival models [12].

NYHA class during pregnancy, puerperium and post-puerperium was analysed with a multilevel longitudinal and structural mixed model with an ordered logit link (Stata Meologit procedure) to exclude confounding effects due to random variability among patients and among consecutive pregnancies in a single patient.

Time related echocardiographic changes were analyzed with a non-parametric test for trend across ordered group (Stata Nptrend procedure).

A value of p<0.05 was considered significant. Statistics were analyzed with STATA version 12 (Stata Corp 4906 Texas USA).

Ethical approval

The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki and was approved a priori by our local Ethical Committee (Comitato Etico Provinciale Padova). As statistical analysis was performed on de-identified historical data, the institutional review board waived the need for written informed consent from the participants.



The study analysed 127 consecutive pregnancies occurred between 2008 and 2013 among 95 women with CHD. 63 pregnancies (50%) occurred in women with simple CHD (25 in corrected CHD, 38 in native CHD) and 64 (50%) in women with complex CHD (61 in corrected CHD, 3 in native CHD). The median maternal age at the time of conception was 31 years (min 26, max-33 yrs). Multiple pregnancies were treated as independent events.

Pregnancy outcome and risk of adverse events

125 pregnancies (98%) had natural conception, while two (2%) required medically assisted procreation techniques. In 25 cases (20%) pregnancies did not end in delivery, as there were 15 miscarriages and 10 voluntary abortions (Table 1). Miscarriages occurred in 8 out 63 pregnancies of simple CHD patients (13%) and in 7 out 64 pregnancies in complex CHD patients (11%), (p=0.78). The incidence of miscarriages was higher (15%) among women <30 years old compared to those =30 years old (3%; p=0.02) (Figure 1).