Adverse Pregnancy Conditions Among Privately Insured Women With and Without Congenital Heart Defects
What Is Known
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Hemodynamic changes during pregnancy may lead to increased risk of adverse pregnancy conditions for women with severe and nonsevere congenital heart defects (CHD).
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American Heart Association and American College of Gynecology guidelines recommend that women with CHD consult with both obstetricians and cardiologists during pregnancy, receive comprehensive echocardiograms during pregnancy or postpartum, and review benefits and risks of medication use during pregnancy with a clinician.
What the Study Adds
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Women with CHD, compared with those without CHD, and severe CHD, compared with nonsevere CHD, had increased prevalence of obstetric, cardiac, and other adverse conditions and outcomes during pregnancy and postpartum.
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Women with nonsevere CHD also had increased prevalence of adverse conditions and outcomes during pregnancy and postpartum compared with women without CHD.
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Approximately 4% of women with CHD used potentially teratogenic medications, and only 56% of women with CHD received a comprehensive echocardiogram to evaluate cardiac health during pregnancy.
Introduction
Due to improvements in survival, ≈1.4 million US adults are living with congenital heart defects (CHD).1,2 With more US women with CHD reaching reproductive age, their delivery hospitalizations increased by 35% from 1997 to 2007.3,4 However, pregnancy intensifies the physiological demands on the heart. In women with CHD, increases in blood volume, edema, increased heart rate, and respiratory changes during pregnancy may increase the risk of adverse experiences,5,6 including heart failure, cerebrovascular events, and preterm delivery, compared with women without CHD.5,7–10 Therefore, the American Heart Association (AHA), American College of Cardiology (ACC), and American College of Obstetrics and Gynecology recommend providers assess cardiac health of pregnant women with CHD, including performing a comprehensive echocardiogram and reviewing benefits and risks of cardiac-related medications.11,12
Several hospital-based studies described incidence of adverse pregnancy conditions among women with heart disease, but findings combine congenital and acquired heart disease, lack a comparison group without CHD, are not stratified by CHD severity, and may not be generalizable outside those center(s) specializing in cardiac care.13–16 A few studies using national inpatient data have compared women with CHD to those without but only describe adverse conditions recorded at delivery hospitalization, likely missing information on conditions occurring before or after delivery.7–10,17 Therefore, using healthcare claims data from a large, convenience sample of privately insured individuals, we compared the prevalence of adverse conditions, pregnancy outcomes, receipt of cardiac care, and potentially teratogenic or fetotoxic (Food and Drug Administration pregnancy category D or X) cardiac-related prescriptions filled among pregnant women with CHD compared with those without CHD.
Methods
The IBM Marketscan Commercial Database provides individual-level healthcare claims data including enrollment, inpatient and outpatient medical, pharmaceutical, and limited sociodemographic (age, sex, US Census region of residence) data on a large, convenience sample of about 50 million individuals with employer-sponsored insurance and their dependents per year. Using 2007 to 2014 data from the IBM MarketScan Commercial Database, we identified privately insured women aged 15 to 44 years with and without CHD who had ≥1 pregnancy lasting >20 weeks gestation and had prescription drug coverage. Women could contribute >1 pregnancy to the sample. Pregnancies were excluded if the woman was not continuously enrolled (ie, missing >30 days of enrollment from the last menstrual period to 90 days postpartum). The authors cannot make data and study materials available to other investigators for purposes of reproducing the results because of licensing restrictions. Interested parties, however, could obtain and license the data by contacting Truven Health Analytics, Inc.
CHD Algorithm
Women with CHD were ascertained using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), diagnosis codes from inpatient admission and outpatient service claims. Similarly to other studies, CHD was defined as ≥2 outpatient CHD ICD-9-CM diagnosis codes separated by >30 days or ≥1 inpatient CHD ICD-9-CM diagnosis code documented anytime between January 1, 2007, and December 31, 2014.18–22 The positive predictive value of singular outpatient CHD coding in administrative data can be as low as 50%, so women with only 1 outpatient CHD were excluded.23 CHD was categorized as severe or nonsevere based on a published algorithm integrating hemodynamic severity and basic anatomy.24 Because CHD is present at birth and is a lifelong condition, women were classified as having CHD regardless of whether the diagnoses were coded before, during, or after pregnancy; however, to prevent misclassification of fetal CHD as maternal CHD,23 we required that CHD ICD-9-CM codes be documented before the 15th week of pregnancy or after 90 days postpartum. Our comparison group had no CHD codes between January 1, 2007, and December 31, 2014. Because Down syndrome is associated with CHD and women with CHD and Down syndrome have greater risk of adverse pregnancy outcomes than those without, we excluded women with ≥1 Down syndrome diagnosis code at any time between January 1, 2007, and December 31, 2014.25
Pregnancy Algorithm
We implemented a published algorithm that uses pregnancy-related procedure and diagnostic codes indicating end of a pregnancy to assign birth outcome, estimate gestational age at the end of pregnancy, and used estimated gestational age to calculate the date of the last menstrual period.26 Multiple births were included, but, due to the limitations of claims data, we could not distinguish a multiple birth from a singleton birth unless the birth outcomes differed between the multiples (eg, combination of live birth[s] and stillbirth[s]). Pregnancies occurring between January 1, 2008, and December 31, 2013, including pregnancies conceived in 2007 and ending in 2008 or conceived in 2013 and ending in 2014, were included in the analytic sample.
Obstetric, Cardiac, and Other Conditions
We compiled a list of severe obstetric, cardiac, and other conditions, which may be related to or result from CHD and can contribute to significant morbidity during pregnancy (Table I in the Data Supplement). We included 12 obstetric conditions such as gestational diabetes mellitus, hemorrhage, obstetric shock, and placental abruption; 7 cardiac conditions (defined as conditions that specifically relate to heart function or heart rhythm) such as atrial fibrillation, cardiomyopathy, heart failure, and myocardial infarction; and 12 other conditions such as acute renal failure, deep vein thrombosis, pulmonary edema, and stroke. These conditions were identified for inclusion based on previous literature and clinician input (M.G. and N.K.T.). Conditions were identified by ICD-9-CM diagnostic codes and ICD-9-CM or Current Procedural Terminology procedure or Healthcare Common Procedure Coding System codes from the last menstrual period to 90 days postpartum per pregnancy; we did not assess whether the condition was first diagnosed during pregnancy. Similar to another study, for deep vein thrombosis and pulmonary embolism, we required ≥1 inpatient diagnosis code or ≥1 anticoagulation outpatient prescription claim documented within 90 days of an outpatient diagnosis code.27 All other conditions, except CHD, were identified by ≥1 procedure or inpatient diagnosis code or ≥2 outpatient diagnosis codes separated by ≥1 day. Women with a diabetes mellitus diagnosis from 2007 to 2014 before a gestational diabetes mellitus code were not classified as having gestational diabetes mellitus; otherwise, the same algorithm applied despite other diabetes mellitus diagnoses.
Analyses
Descriptive and χ2 statistics were assessed for characteristics at delivery including maternal age group (15–19, 20–24, 25–29, 30–34, 35–39, or 40–44 years), US Census region of residence (Northeast, North Central, South, West, or missing), and year of delivery (2008–2009, 2010–2011, or 2012–2014); obstetric, cardiac, and other adverse conditions, individually, as well as cumulative number (0, 1, or ≥2); birth outcomes (live birth or stillbirth; multiple births identified as live birth and stillbirth contributed to both categories); and among live births, delivery by cesarean section (identified by ICD-9-CM diagnosis codes of 669.7X or ICD-9-CM procedure codes 74.0–74.2, 74.4, 74.99 or Current Procedural Terminology codes 59514, 59620 within 14 days of estimated delivery date) and estimated gestational age at birth (preterm or full term; <37 and ≥37 weeks based on diagnosis and procedure codes, respectively26). We assessed whether there was a documented comprehensive echocardiogram during pregnancy (Current Procedural Terminology codes 93303, 93304, 93306, 93307, and 93308). We additionally assessed whether women filled an outpatient prescription from the last menstrual period to end of pregnancy or date of delivery for potentially teratogenic or fetotoxic cardiac medications (defined as Food and Drug Administration pregnancy category D or X; listed in Table II in the Data Supplement).
We used the generalized estimating equation approach to log-linear regression with exchangeable correlation structure to account for clustering of multiple pregnancies per woman. We calculated adjusted prevalence ratios (aPRs) and 95% CIs for all outcomes comparing pregnancies among (1) women with CHD (severe or nonsevere) to those without CHD, (2) women with nonsevere CHD to those without CHD, and (3) women with severe CHD to nonsevere CHD. Estimates were adjusted for age, region, and year of delivery. Frequencies were provided for cells with >5 observations.
To account for cumulative effects of multiple pregnancies, we performed a sensitivity analysis limiting results to the woman’s first pregnancy in the study period. We also performed a sensitivity analysis excluding women whose only CHD claims were ostium secundum type atrial septal defects (ICD-9-CM 745.5)—a diagnosis code with low specificity.28,29
All analyses were performed using SAS 9.4. Data are deidentified, administrative data and not considered human subjects research by the Centers for Disease Control and Prevention.
Results
Between 2007 and 2014, there were 18 969 pregnant women with ≥1 inpatient or ≥2 outpatient CHD claims separated by >30 days and 3 099 451 pregnant women without CHD claims. After implementing inclusion and exclusion criteria, there were 2056 women with CHD claims contributing 2334 pregnancies and 1 374 982 women without CHD claims contributing 1 524 077 pregnancies (Figure 1). About 12.6% of women with CHD and 10.2% of women without CHD contributed >1 pregnancy to the analysis.
Figure 1. Exclusion criteria and final sample of pregnant women with and without congenital heart defects (CHD), IBM Watson Health MarketScan Commercial Database, 2007 to 2014. *Pregnancies occurring between January 1, 2008, and December 31, 2013, including pregnancies conceived in 2007 and ending in 2008 or conceived in 2013 and ending in 2014. †One inpatient or ≥2 outpatient CHD diagnosis claims ≥30 d apart. ‡Fifteen-week gestation through 90 d postpartum. §Missing >30 d. ‖Includes 552 that were live birth and still birth.
Distributions of age, region, and year at delivery were similar among women with and without CHD (Table 1). Only 1.2% of women included in the analysis were missing region of residence at delivery. Overall, 55.9% of women with CHD had a comprehensive echocardiogram during pregnancy, with a higher prevalence among pregnancies in women with severe (73.0%) compared with nonsevere (52.9%) CHD (Figure 2). Overall, 4.0% of women with CHD filled a prescription for ≥1 potentially teratogenic or fetotoxic cardiac medication during pregnancy.
| No CHD (n=1 524 077) | CHD | |||||||
|---|---|---|---|---|---|---|---|---|
| Any (n=2334) | Severe (n=352) | Nonsevere (n=1982) | ||||||
| n | % | n | % | n | % | n | % | |
| Age at delivery, y† | ||||||||
| 15–19 | 53 682 | 3.5 | 116 | 5.0 | 14 | 4.0 | 102 | 5.2 |
| 20–24 | 178 490 | 11.7 | 293 | 12.6 | 62 | 17.6 | 231 | 11.7 |
| 25–29 | 433 806 | 28.5 | 603 | 25.8 | 106 | 30.1 | 497 | 25.1 |
| 30–34 | 533 012 | 35.0 | 800 | 34.2 | 115 | 32.7 | 685 | 34.6 |
| 35–39 | 267 000 | 17.5 | 412 | 17.7 | 47 | 13.4 | 365 | 18.4 |
| 40–44 | 58 087 | 3.8 | 110 | 4.7 | 8 | 2.3 | 102 | 5.2 |
| Region of residence at delivery‡ | ||||||||
| Northeast | 207 706 | 13.6 | 357 | 15.3 | 68 | 19.3 | 289 | 14.6 |
| North Central | 379 289 | 24.9 | 605 | 25.9 | 78 | 22.2 | 527 | 26.6 |
| South | 610 221 | 40.0 | 775 | 33.2 | 120 | 34.1 | 655 | 33.1 |
| West | 308 254 | 20.2 | 574 | 24.6 | 82 | 23.3 | 492 | 24.8 |
| Year of delivery | ||||||||
| 2008–2009 | 396 929 | 26.0 | 526 | 22.5 | 71 | 20.2 | 455 | 23.0 |
| 2010–2011 | 458 653 | 30.1 | 783 | 33.6 | 116 | 33.0 | 667 | 33.7 |
| 2012–2014 | 668 495 | 43.9 | 1025 | 43.9 | 165 | 46.9 | 860 | 43.4 |
Figure 2. Prevalence of echocardiograms and cardiac-related prescriptions filled during pregnancies* of privately insured women aged 15 to 44 y with and without congenital heart defects (CHDs), 2007 to 2014.*Pregnancies lasting > 20 gestational weeks. †Any:no CHD χ2 P<0.05. ‡Severe:nonsevere χ2 P<0.05. §Included medications are listed in Table II in the Data Supplement.
The prevalence of any, obstetric, cardiac, and other conditions in women with CHD was 60%, 45%, 19%, and 20%, respectively (Figure 3). aPRs comparing women with CHD to those without were elevated for any (aPR, 1.9 [95% CI, 1.7–2.1]), obstetric (aPR, 1.3 [95% CI, 1.2–1.4]), cardiac (aPR, 10.2 [95% CI, 9.1–11.4]), and other conditions (aPR, 2.2 [95% CI, 2.0–2.4]). Overall, 60% of women with CHD had ≥1 adverse conditions compared with 45% of women without, and of those, more than twice as many women with CHD experienced ≥2 conditions compared with those without CHD (30.3% versus 15.1%).
Figure 3. Prevalence and adjusted prevalence ratios (aPRs) for adverse conditions in pregnancies of privately insured women aged 15 to 44 y with and without congenital heart defects (CHD), 2007 to 2014.A: Prevalence and aPRs of having any (obstetric, cardiac, or other) conditions in pregnancy comparing women with CHD to women without CHD and women with severe CHD to women with nonsevere CHD. B: Prevalence and aPRs of having any obstetric conditions in pregnancy comparing women with CHD to women without CHD and women with severe CHD to women with nonsevere CHD. C: Prevalence and aPRs of having any cardiac conditions in pregnancy comparing women with CHD to women without CHD and women with severe CHD to women with nonsevere CHD. D: Prevalence and aPRs of having any other conditions in pregnancy comparing women with CHD to women without CHD and women with severe CHD to women with nonsevere CHD. aPR: prevalence ratio for ≥1 complication vs none adjusted for age, region of residence, and year at delivery. *Pregnancies lasting >20 gestational weeks. †Obstetric conditions include gestational diabetes mellitus; gestational hypertension, eclampsia, or preeclampsia; hemorrhage; hysterectomy; infections including chorioamnionitis, endocarditis, endometritis, endomyometritis, metritis, pyelonephritis, and sepsis; maternal death; obstetric shock; placental abruption; placenta previa; premature rupture of membranes; preterm labor or preterm birth; and transfusion. ‡Cardiac conditions include atrial fibrillation, atrial flutter, or supraventricular tachycardia; cardiomyopathy; conduction disorders; coronary dissection; heart failure; incident ventricular tachycardia, ventricular fibrillation, or sudden cardiac arrest; and myocardial infarction or ischemia. §Other conditions include acute renal failure, acute respiratory distress syndrome, anemia, deep vein thrombosis, disseminated intravascular coagulation, mechanical ventilation, pulmonary disease, pulmonary edema, pulmonary embolism, pulmonary hypertension, seizure disorders, stroke or cerebrovascular disorders, and thrombocytopenia.
Pregnancies in women with severe CHD, compared with nonsevere CHD, had elevated aPRs for any (aPR, 1.5 [95% CI, 1.2–1.9]) and cardiac conditions (aPR, 2.7 [95% CI, 2.1–3.5]; Figure 3). Among those who experienced ≥1 adverse conditions, more women with severe CHD experienced ≥2 conditions in pregnancy (any, obstetric only, cardiac only, or other) than women with nonsevere CHD. Women with nonsevere CHD had 1.8× (95% CI, 1.6–2.0) the prevalence of any conditions compared with women without CHD.
Among women with CHD, the most common conditions were preterm labor/preterm birth; preeclampsia, eclampsia, or gestational hypertension; gestational diabetes mellitus; hemorrhage; and infections. Prevalence of preterm labor/preterm birth differed by both CHD presence (any or nonsevere CHD versus none) and severity (severe versus nonsevere CHD). Prevalence of hemorrhage and infections differed only by CHD presence (Figure 4).
Figure 4. Top 5 most prevalent obstetric conditions in pregnancies* of privately insured women aged 15 to 44 y with and without congenital heart defects (CHD), 2007 to 2014. *Among pregnancies lasting >20 gestational weeks. †Any:no CHD χ2P<0.05. ‡Nonsevere:no CHD χ2P<0.05. §Severe:nonsevere χ2P<0.05. ‖Chorioamnionitis, endocarditis, endometritis, endomyometritis, metritis, pyelonephritis, or sepsis.
Comparing women with CHD to those without, aPRs were elevated for 7 of 12 obstetric conditions and were the highest for obstetric shock and transfusion (Table 2). Results were similar comparing women with nonsevere CHD to women without CHD. Comparing women with severe CHD to nonsevere CHD, aPRs were elevated for placental abruption and preterm labor/preterm birth.
| Type of Condition | No CHD (n=1 524 077) | CHD | Ratio of Any CHD to No CHD | Ratio of Nonsevere CHD to No CHD | Ratio of Severe CHD to Nonsevere CHD | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Any (n=2334) | Severe (n=352) | Nonsevere (n=1982) | ||||||||
| n (%) | n (%) | n (%) | n (%) | aPR | 95% CI | aPR | 95% CI | aPR | 95% CI | |
| Obstetric conditions† | ||||||||||
| Obstetric shock | 778 (0.1) | 5 (0.2) | NR | NR | 4.3 | 1.8–10.3 | 4.0 | 1.5–10.7 | …‡ | |
| Transfusion | 8709 (0.6) | 30 (1.3) | 5 (1.4) | 25 (1.3) | 2.2 | 1.5–3.2 | 2.2 | 1.5–3.3 | … | |
| Placental abruption | 16 106 (1.1) | 40 (1.7) | 14 (4.0) | 26 (1.3) | 1.6 | 1.2–2.2 | 1.2 | 0.8–1.8 | 3.0 | 1.5–6.0 |
| Preterm labor/preterm birth | 240 736 (15.8) | 497 (21.3) | 96 (27.3) | 401 (20.2) | 1.4 | 1.3–1.6 | 1.3 | 1.2–1.5 | 1.5 | 1.1–1.9 |
| Infections | 63 954 (4.2) | 130 (5.6) | 17 (4.8) | 113 (5.7) | 1.3 | 1.1–1.6 | 1.4 | 1.1–1.6 | 0.8 | 0.4–1.3 |
| Placenta previa | 37 730 (2.5) | 74 (3.2) | 12 (3.4) | 62 (3.1) | 1.3 | 1.0–1.6 | 1.3 | 1.0–1.6 | … | |
| Hemorrhage | 84 100 (5.5) | 168 (7.2) | 35 (9.9) | 133 (6.7) | 1.3 | 1.1–1.5 | 1.2 | 1.0–1.4 | 1.5 | 1.0–2.3 |
| Cardiac conditions§ | ||||||||||
| Conduction disorders | 1094 (0.1) | 101 (4.3) | 47 (13.4) | 54 (2.7) | 63.0 | 50.8–78.2 | 39.2 | 29.5–52.2 | 5.5 | 3.6–8.4 |
| VT, VF, or SCA | 555 (0.0) | 28 (1.2) | 7 (2.0) | 21 (1.1) | 34.4 | 23.4–50.5 | 30.1 | 19.4–46.9 | … | |
| Heart failure | 2330 (0.2) | 47 (2.0) | 16 (4.6) | 31 (1.6) | 14.0 | 10.4–18.9 | 10.7 | 7.5–15.4 | 3.0 | 1.5–5.8 |
| Cardiomyopathy | 1908 (0.1) | 36 (1.5) | 7 (2.0) | 29 (1.5) | 13.1 | 9.4–18.4 | 12.6 | 8.5–17.8 | … | |
| Myocardial infarction | 264 (0.0) | 5 (0.2) | NR | NR | 12.5 | 5.1–30.2 | 14.3 | 5.9–34.7 | … | |
| AF, AFL, or SVT | 32 091 (2.1) | 355 (15.2) | 97 (27.6) | 258 (13.0) | 8.5 | 7.6–9.5 | 7.1 | 6.2–8.1 | 2.5 | 1.9–3.2 |
| Other conditions‖ | ||||||||||
| Pulmonary hypertension | 544 (0.0) | 45 (1.9) | 12 (3.4) | 33 (1.7) | 57.2 | 41.6–78.8 | 48.6 | 33.4–70.6 | 2.3 | 1.1–4.6 |
| Stroke or cerebrovascular disorders | 2380 (0.2) | 85 (3.6) | 10 (2.8) | 75 (3.8) | 24.5 | 19.5–30.7 | 25.4 | 20.0–32.3 | 0.7 | 0.4–1.5 |
| Pulmonary edema | 794 (0.1) | 8 (0.3) | NR | NR | 6.9 | 3.4–13.8 | 7.0 | 3.3–14.8 | … | |
| Pulmonary embolism | 2092 (0.1) | 19 (0.8) | 7 (2.0) | 12 (0.6) | 5.9 | 3.7–9.4 | 4.3 | 2.4–7.8 | 3.5 | 1.3–8.9 |
| Acute respiratory distress syndrome | 2051 (0.1) | 17 (0.7) | 6 (1.7) | 11 (0.6) | 5.6 | 3.5–9.0 | 4.2 | 2.3–7.6 | 3.0 | 1.1–8.3 |
| Deep vein thrombosis | 5084 (0.3) | 36 (1.5) | NR | NR | 4.8 | 3.4–6.6 | 4.9 | 3.4–7.0 | … | |
| Disseminated intravascular coagulation | 4728 (0.3) | 24 (1.0) | NR | NR | 3.4 | 2.2–5.1 | 3.8 | 2.5–5.8 | … | |
| Acute renal failure | 1365 (0.1) | 6 (0.3) | NR | NR | 2.9 | 1.3–6.4 | 2.6 | 0.8–6.1 | … | |
| Mechanical ventilation | 2513 (0.2) | 9 (0.4) | NR | NR | 2.4 | 1.2–4.6 | 1.5 | 0.6–3.7 | … | |
| Pulmonary disease | 45 692 (3.0) | 137 (5.9) | 26 (7.4) | 111 (5.6) | 2.0 | 1.7–2.4 | 1.9 | 1.6–2.3 | 1.3 | 0.8–2.1 |
| Thrombocytopenia | 18 783 (1.2) | 45 (1.9) | 10 (2.8) | 35 (1.8) | 1.6 | 1.2–2.2 | 1.4 | 1.0–2.0 | 1.8 | 0.9–3.8 |
| Anemia | 84 648 (5.6) | 160 (6.9) | 22 (6.3) | 138 (7.0) | 1.2 | 1.0–1.4 | 1.2 | 1.0–1.5 | 0.8 | 0.5–1.4 |
The prevalence of individual cardiac conditions during pregnancy was 9 to 63× higher among women with CHD compared with those without (Table 2) and 7 to 39× higher among women with nonsevere CHD compared with those without. Conduction disorders and ventricular tachycardia, ventricular fibrillation, or sudden cardiac arrest had the largest aPRs. Comparing women with severe CHD to those with nonsevere CHD, aPRs for conduction disorders, heart failure, and atrial flutter were elevated.
Comparing women with CHD to those without, aPRs were elevated for 12 of 13 other conditions and were the highest for pulmonary hypertension and stroke or cerebrovascular disorders (Table 2). Women with nonsevere CHD also had elevated aPRs for 8 of 13 other conditions compared with those without. Comparing women with severe CHD to nonsevere CHD, aPRs were elevated for pulmonary hypertension, pulmonary embolism, and acute respiratory distress syndrome.
Stillbirths were more prevalent in pregnancies among women with CHD and women with nonsevere CHD than those among women without (Table 3). Among pregnancies ending in live birth, preterm births were more prevalent in pregnancies among women with CHD and nonsevere CHD compared with those without and among women with severe compared with nonsevere CHD. Prevalence of cesarean delivery was elevated among women with CHD and nonsevere CHD compared with those without and among women with severe compared with nonsevere CHD. Results did not change appreciably when limiting analyses to the first pregnancy from 2008 to 2013 (excluding 149 373 pregnancies), nor when excluding 336 women with ostium secundum type atrial septal defect only.
| No CHD | CHD | Any:No CHD | Nonsevere:No CHD | Severe:Nonsevere | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Any | Severe | Nonsevere | |||||||||
| n | % | n | % | n | % | n | % | aPR (95% CI) | aPR (95% CI) | aPR (95% CI) | |
| Pregnancy outcome | n=1 524 077 | n=2334 | n=352 | n=1982 | |||||||
| Any live birth† | 1 513 169 | 99.3 | 2306 | 98.8 | 348 | 98.9 | 1958 | 98.8 | Ref | Ref | Ref |
| Any stillbirth† | 11 460 | 0.8 | 28 | 1.2 | 4 | 1.1 | 24 | 1.2 | 1.6 (1.1–2.4) | 1.6 (1.1–2.5) | 1.1 (0.4–3.3) |
| Delivery characteristics (live births only) | n=1 513 169 | n=2306 | n=348 | n=1958 | |||||||
| Cesarean delivery | 533 782 | 35.3 | 924 | 40.1 | 153 | 44.0 | 771 | 39.4 | 1.3 (1.2–1.4) | 1.2 (1.1–1.3) | 1.4 (1.1–1.8) |
| Preterm birth (<37 wk) | 128 912 | 8.5 | 294 | 12.8 | 61 | 17.5 | 233 | 11.9 | 1.6 (1.4–1.8) | 1.5 (1.3–1.7) | 1.6 (1.2–2.3) |
Discussion
Only about 1 in 2 privately insured women with CHD and 3 in 4 with severe CHD received AHA/ACC-recommended comprehensive echocardiograms during pregnancy. Additionally, 4% of pregnant women with CHD filled prescriptions for potentially teratogenic or fetotoxic cardiac-related medications. Women with CHD had higher prevalence of adverse pregnancy outcomes, including stillbirth and preterm birth, elevated prevalence of adverse conditions overall, and 34 to 63× higher prevalence of pulmonary hypertension, conduction disorders, and ventricular tachycardia, ventricular fibrillation, or sudden cardiac arrest compared with women without CHD. Though women with severe CHD were the most affected, pregnancies among women with nonsevere CHD also had higher prevalence of adverse conditions than women without CHD.
Several AHA/ACC and American College of Obstetrics and Gynecology statements for women with CHD recommend that obstetricians and adult CHD cardiologists collaboratively manage pregnancies among women with symptomatic or complex CHD; that pregnant or postpartum women with known or suspected CHD receive echocardiograms; and that clinicians review benefits and risks of medications known to be teratogenic or fetotoxic and make appropriate adjustments, as needed.5,11,12,30 Yet, only slightly more than half of all pregnant women with CHD received comprehensive echocardiograms. Additionally, 4 of 100 women filled prescriptions for potentially teratogenic or fetotoxic cardiac-related medications during pregnancy. Guidelines recommend evaluations of health risks begin before conception, but, in a similar sample of privately insured women with CHD, <1% received all AHA/ACC-recommended preconception assessments in the year before conception.19 However, in that sample, 9% of women filled prescriptions for the same list of potentially teratogenic or fetotoxic cardiac-related medications in the year before the pregnancy began, suggesting women with CHD may decrease their use of these medications during pregnancy. However, it is unknown whether women in our study population discussed their medication use with their provider before making any changes, in accordance with the AHA/ACC and American College of Obstetrics and Gynecology recommendations.
Two non-US hospital-based studies examined pregnancy outcomes among women with congenital and acquired heart disease combined but did not provide results specific to women with CHD nor to women outside of their cardiac patient population.13,14 Nevertheless, our overall prevalence of 19% for ≥1 cardiac condition among women with CHD was comparable to 16% reported by the CARPREG (Cardiac Disease in Pregnancy Study) II Canadian study of 1938 pregnancies of congenital or acquired heart disease patients at 2 large hospitals.13 Prevalence of cardiac conditions in our analysis was higher than 6.6% in the NORMANDY (Neonatal and Maternal Outcomes of Pregnancy With Maternal Cardiac Disease) French hospital-based study of 197 pregnancies of congenital or acquired heart disease patients. Additionally, >50% with CHD in our sample experienced obstetric events relative to 35% with heart disease in NORMANDY, but NORMANDY included a different, smaller subset of obstetric events.14
Our estimate that 19% of pregnant women with CHD experience cardiac conditions was greater than the 2.3% to 6.6% estimates from 3 National Inpatient Sample analyses on 10 000 to 40 000 pregnancies of women with CHD; however, these studies cannot examine events documented outside of the delivery hospitalization.7–9,14 Similar to our findings, studies using inpatient data reported that women with CHD have increased risk of transfusion, arrhythmias, pulmonary hypertension, cerebrovascular disorders, preterm delivery, and stillbirth.7–10,17 One found women with severe CHD had more heart failure, conduction disorders, and rhythm disorders than women with mild-to-moderate CHD, though adjusted estimates were not provided.10 Another reported elevated prevalence of preterm labor, infections, anemia, heart failure, and atrial and ventricular arrhythmias among women with noncomplex CHD compared with women with no CHD.17
This is the first analysis, to our knowledge, examining receipt of AHA/ACC-recommended cardiac evaluations and filled prescriptions for potentially teratogenic or fetotoxic cardiac-related medications during pregnancy. Our analysis benefited from a large, nationwide sample of pregnancies with severe, nonsevere, and no CHD linked to prescription drug data. We were able to assess rare conditions not included in previous studies, such as hysterectomy and obstetric shock. However, as a convenience sample of women continuously enrolled in private insurance with prescription drug coverage, results are likely not generalizable to all women in the United States. We expect receipt of AHA/ACC-recommended cardiac evaluations to be lower among women covered by Medicaid and those who are not enrolled in health insurance continuously throughout pregnancy. Use of administrative data may result in misclassification of CHD status, pregnancy identification/timing, and adverse conditions. We implemented algorithms to help improve the positive predictive value for both CHD status and conditions (eg, excluding women with CHD documented only during pregnancy possibly reflecting a fetal CHD, requiring ≥2 outpatient visits to define CHD).23 If excluded women are healthier than included cases, we could have overestimated the prevalence of conditions in women with CHD. Alternatively, if women with CHD were incorrectly classified as not having CHD, we may have underestimated the prevalence of conditions among those with CHD. Information on the cardiac functional status or the full history of surgical repair was not available in our datasets, and we were unable to use that information in the classification of CHD severity. Additionally, for some conditions, it was not possible to separate events incident to pregnancy from those chronic or preexisting (eg, deep vein thrombosis, heart failure). We also had no information on the indication for the medications prescribed during pregnancy or on counseling about medication risks and benefits.
Conclusions
We found women with CHD (any, severe only, and nonsevere only) had higher prevalence of adverse pregnancy outcomes and conditions than women without CHD, yet only half received recommended comprehensive echocardiograms during pregnancy or up to 90 days postpartum. AHA/ACC and American College of Obstetrics and Gynecology recommendations to assess cardiac health, including performing echocardiograms and reviewing medications for benefits and risks, in pregnant women with CHD may lead to early identification, prevention, or treatment of adverse conditions and improved pregnancy outcomes.5,11,12,30
Acknowledgments
The findings and conclusion in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. This analysis has been replicated by C.J. Alverson and R.M. Simeone.
Footnotes
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