Maternal and neonatal outcomes in women with history of coronary artery disease

Matthew Cauldwell1*, Philip J Steer1, Kate von Klemperer2, Fiona Walker2Mandeep Kaler3, Sarah Grixti3 Joanna

Hale4 Josie Evans5, David Warriner6, Stephanie Curtis7, Aarthi R Mohan8, Samuel Dockree9, Lucy Mackillop10,

Cathy Head11, Monique Sterrenburg12, Suzanne Wallace13, Gemma Partridge14, Leisa Freeman15, Jelle

Bateman16, Fionnuala McAuliffe16, Margaret Simpson17, Niki Walker17, Joanna Girling18, Farrah Siddiqui19, Aidan

Bolger20, Foteini Bredkai21, Mark R Johnson2, Anna Roberts23

1. Academic Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, 369 Fulham Road, London,

SW10 9NH, United Kingdom

2. Department of ACHD, Bart’s Health Centre London, United Kingdom

3. Department of Obstetrics, Bart’s Health, London, United Kingdom

4. Department of Obstetrics, Princess Anne Hospital, Southampton.

5. Department of Obstetrics, Queen’s Hospital, Romford,

6. Department of Cardiology, Leeds Teaching Hospitals

7. Adult Congenital Heart Disease Service, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom

8. Department of Obstetrics, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom

9. Women’s Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom

10. Department of Adult Congenital Heart Disease, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom

11. Department of Adult Congenital Heart Disease, St Thomas’ Hospital London, United Kingdom

12. Department of Obstetrics, Sheffield Teaching Hospitals, United Kingdom

13. Maternity Department, University Hospitals NHS Trust, Nottingham, United Kingdom

14. Department of Obstetrics, Norfolk and Norwich Hospital, United Kingdom

15. Department of Adult Congenital Heart Disease, Norfolk and Norwich Hospital, United Kingdom

16. Department of Obstetrics

17. Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, United Kingdom

18. Department of Obstetrics, West Middlesex University Hospital, London

19. Department of Obstetrics, Royal Leicester Infirmary, Leicester, United Kingdom

20. Department of Adult Congenital Heart Disease, Glenfield Hospital, Leicester, United Kingdom

21. Department of Obstetrics, University College Hospital, London, United Kingdom

22. Department of Adult Congenital Heart Disease, Bart’s Heart Centre, London, United Kingdom

23. Department of Obstetrics, St Mary’s Hospital, Manchester, United Kingdom

Keywords: pregnancy, ischaemic heart disease

Conflict of Interest: None

Word count:

*Corresponding author

Acknowledgements: None

Funding: Nil

Conflict of Interest: None declared

Keywords: pregnancy, coronary artery disease.

Abstract

Objective

Pregnancy outcomes in women with pre-existing coronary artery disease are poorly

described. There is therefore a paucity of data therefore on which to base clinical

management and to counsel women with regard to both maternal and neonatal outcomes.

Methods

We conducted a retrospective multicentre study from 16 UK centre specialised cardiac

obstetric clinics of women with an established diagnosis of coronary artery disease. We

included only pregnancies from of 24 weeks gestation or more delivered between January

1998 to October 2018. Data wereas collected on adverse maternal cardiovascular, obstetric

and neonatal events. The study period was January 1998 to October 2018.

Results

A total of 79 women who had 92 pregnancies (94 babies including two sets of twins) were

identified. 35.9% were obese and 24.3% were current smokers. 18/79 (22.8%) had a history

of diabetes, 27/79 (34.2%) had dyslipidaemia and 21/79 (26.2%) had hypertension. CAD was

due to atherosclerosis in 52/79 (65.8%), of women had atherosclerotic disease,

spontaneous coronary artery dissection (SCAD) in 11/17(13.9) had prior spontaneous

coronary artery dissection(SCAD), 11/79 (13.9%) had prior coronary spasm in 11/79 (13.9%)

and 9/79 (11.4%) had prior coronary thrombus in 9/79 (11.4%). 74/79 (93.7%) of women

had previous coronary angiography with 43/79 (56.6%) having coronary stenting performed.

During pregnancy tThere were 6 cardiac events, including one NSTEMI at 23 weeks of’

gestation , and one SCAD recurrence at 9 weeks postpartum, . Oone symptomatic

deterioration in woman with severely impaired LV function developed symptomatic

deterioration and three women with established history ofworsening angina had ongoing

episodes of angina. Preterm birth complicated over a quarter of pregnancies and 14% of

women developed pre-eclampsia, 25% delivered preterm and 25% of. Furthermore, over a

quarter of babies were born small for gestational age.

Conclusion

Women with established CAD have relatively low rates of serious cardiac events in

pregnancy. Nevertheless, but rates of adverse obstetric and neonatal events are much

greater, highlighting the importance of receiving care within from a specialised

multidisciplinary teams.

Keywords:

Introduction

The number of pregnancies complicated by coronary artery (CAD) is increasing in developed

countries. The increase is probably related to greater rates of coronary atheroma, caused by

the increase prevalence of medical co-morbidities, most strikingly diabetes and

hypertension, in the pregnant population. These in turn are increased due to the tendency

to delay pregnancy until later life and the higher rates of obesity (1, 2). Despite this, there

are very few studies on the subject of CAD and pregnancy (2, 3); those that exist suggest

that CAD is associated with a higher risk of an adverse maternal outcome (4); although a

more recent series reported a more favourable maternal outcome (5). Neonatal outcomes

also appear to be adversely affected by maternal CAD, with the Registry on Pregnancy and

Cardiac Disease (ROPAC) reporting that the babies of women with CAD (n=25) had the

lowest birthweight and highest mortality when compared to babies of women with other

forms of heart disease (2). Similarly, our group has reported that women with CAD had

babies with lower birthweights than healthy controls (6). These poor outcomes may be due

to the higher incidence of obstetric complications including gestational diabetes,

hypertension and pre-eclampsia (PET). TCertainly, the risk of CAD doubles after one

pregnancy complicated by PET (7), but it remains unclear whether women with CAD have an

increased risk of developing PET. Women with underlying heart disease are also more likely

to take cardiac medications during pregnancy (8), which may exert negative effects on

birthweight for example, in the case of beta-blockers (9) Further, while there are data

suggesting that the use of many cardiac medications is safe during pregnancy, the impact of

some of the newer agents used in the management of CAD, such as antiplatelet agents, is

unknown (10).

In order to address these questions and to provide more data on the outcome of

pregnancy, we conducted a retrospective multicentre study examining maternal and fetal

outcomes in pregnancies in women with known CAD.

Methods

UK centres that provide joint specialist clinics for pregnant women with heart disease were

invited by email in June 2018 to participate in a joint study. Participating centres identified

pregnancies in women with an established diagnosis of CAD or acute coronary syndrome

including myocardial infarction prior to pregnancy. Pregnancies ending before 24 weeks of

gestation were excluded. Cases were identified from January 1st 1998 until September 30th

2018 and data were collected from detailed review of the medical and obstetric notes.

Pseudo-anonymised data (all personal identifiers omitted) were amalgamated into a single

dataset. The study protocol was approved by the local research governance team at

Imperial College Healthcare.

Demographic data collected included maternal age, race/ethnicity, New York Heart

Association class (NYHA), height, pre-pregnancy weight and body mass index. Data were

obtained on the interval between the diagnosis of CAD and pregnancy, and the incidence of

known cardiovascular risk factors such as smoking, diabetes, hypertension, inherited

thrombophilias and family history of cardiovascular disease. We also recorded whether

cardiac catherization had occurred prior to pregnancy and whether coronary stents were in

situ. Left ventricular (LV) function ejection fraction (EF) (normal LVEF >55%, mild LVEF

impairment 45-55%; moderate LVEF impairment 30-44%; severe impairment <30%) was

assessed prior to pregnancy. Data were also collected on medications used during

pregnancy and whether there was documented evidence of pre-conception counselling.

The primary maternal cardiac outcome was the occurrence of cardiac arrest, cardiac death,

need for percutaneous intervention (PCI) or cardiac surgery, ventricular arrhythmia, heart

failure, new onset/worsening angina, acute coronary syndrome (ACS) or myocardial

infarction (MI) in pregnancy or up to 6 months postpartum. Obstetric outcomes included

gestational hypertension (GH; ≥140 mm Hg systolic or ≥90 mm Hg diastolic after 20 weeks’

gestation), PET (GH with proteinuria ≥0.3 g/24 hours), preterm delivery (delivery at <37

completed weeks of gestation) and post-partum haemorrhage (PPH, blood loss ≥500 mL at

vaginal delivery and ≥1000mL at caesarean). Neonatal outcomes were small for gestational

age (SGA, defined as birth weight (BW) <10th centile for sex and gestational age by the

Aberdeen centiles), stillbirth (fetal demise ≥24 weeks’ gestation) and neonatal unit

admission.

Statistics

Data were analysed using SPSS V.23/25 for Windows. Categorical data are presented as

frequencies (numbers) and percentages. Data are presented as medians with inter-quartile

range. Correlations were calculated using Pearson’s product moment if variables were

continuous and Spearman’s rank-order correlation if either of the variables was ordinal.

Differences between continuous variables were assessed with the Mann Whitney U test if

they were not normally distributed. All tests were two tailed and p<0.05 was considered

statistically significant.

Results

Sixteen centres provided data on a total of 79 women who had 92 pregnancies (94 babies

including two sets of twins). 66 (85.3%) were white European and 12 (15.2%) were South

Asian and one (1.3%) black African. Table One shows the demographic detailss of the study

population at in their first pregnancy post diagnosis. 28/78 (35.9%) were obese (BMI not

available in one case). 18/74 women (24.3%) were current smokers, 26/74 (35.1%) were ex-

smokers and 30/74 (40.5%) had never smoked (smoking status was not recorded for 5

women). The majority of the women (57/79, 72.2%) in the study were parous at the time of

the first post event pregnancy post event (para 0, 24 (30.4%), para 1, 32 (40.5%), para 2 or

greater 23 (29.1%). The underlying CAD aetiology was atherosclerosistic in 52/79 (65.8%),

coronary artery dissection in 11/79 (13.9%), coronary spasm in 11/79 (13.9%) and coronary

thrombus in 9/79 (11.4%). 74/79 (93.7%) had had previous coronary angiography with

43/79 (56.6%) having had a coronary stent inserting performed. One woman had had

previous coronary artery bypass surgery prior to pregnancy. 18/79 (22.8%) had a history of

diabetes, 27/79 (34.2%) of dyslipidaemia and 21/79 (26.2%) hypertension. 18/79 (22.8%)

women had impaired ventricular function (left ventricular systolic dysfunction, LVSD) with

10/18 (55.6%) having mild, 7/18 (38.9%) moderate and 1/18 (5.6%) severe impairment. In

the first pregnancy post event, 67/79 (84.8%) were NYHA class 1 and 12/79 (15.2%) NYHA

class 2, cf 12/13. (92.3%) vs 1/13 (7.7%) in the second pregnancy. Only 22/79 (27.8%)

women in their first pregnancy post event had received preconception counselling.

Cardiac outcomes

In total there were 6 recorded cardiac events (Table 2). Whilst there were no cardiac deaths,

there was one case of nNon-ST-elevation myocardial infarction (NSTEMI) at 23 weeks of’

gestation managed medically. One woman had recurrence of spontaneous coronary artery

dissection (SCAD) at 9 weeks postpartum. One womaen, with previous severely impaired LV

function, developed symptomatic deterioration and three women with established history

of angina had ongoing episodesworsening symptoms of angina. NThere were no cases of

symptomatic or sustained ventricular arrhythmia were identified. No women required

cardiac surgery during pregnancy or postpartum. Cardiac events exclusively occurred

exclusively in parous women (6/67 pregnancies in parous women cf 0/25 in nulliparous

womena). Cardiac events were more common in women with atherosclerotic disease,

occurring in 6/61 pregnancies in women with this diagnosis vs 1/31 in all the other

diagnostic groups combined, but this was not statistically significant (p=0.333). Cardiac

events appeared to be more common in women with atherosclerotic disease occurring in

5/46 women vs 1/26 in all other diagnostic groups for all other groups but this was not

statistically significant (Fishers exact p=0.65)

Obstetric and Neonatal variables

The main obstetric and neonatal variables are shown in Table 3. Excluding twin pregnancies

and pregnancies with birthweights <500g, preterm birth was common, with 20/75 (26.7%)

babies being born preterm in the first pregnancy post event, and 2/11 (18.2%) in the second

pregnancy post event. Pre-eclampsia occurred in 11/75 (14.7%) of first pregnancies after the

cardiac event cf none of 11 second pregnancies. Pre-eclampsia was significantly associated

with earlier delivery - 7/11 (63.6%) preterm with pre-eclampsia cf 13/64 (20.3%) without

(p=0.006 Fisher’s exact test). Only two of the women developing PET were nulliparous.

Three of 11 (27.2%) of women developing PET had a history of coronary thrombosis

compared with 8 of 68 (11.8%) with no such history, although this was not statistically

significant (p=0.177 Fisher’s exact test). GH occurred in four women, all in their first

pregnancy post event, two of whom were already on a beta-blocker. 15 of 23 women (65%)

with known hypertension at the beginning of pregnancy were taking a beta-blocker at

booking visit; beta-blockade was used in 42 of the 92 pregnancies (45.6%).

Excluding twin pregnancies, stillbirths, and babies weighing <500g, in first pregnancies post

event 19/74 babies (25.7%) were born weighing less than the tenth centile for gestational

age (5/11 (45.5%) in the second pregnancy post event). Univariate analysis revealed that the

cardiac diagnosis did not impact birthweight, but left ventricular systolic function did, with

all grades of dysfunction being associated with lower birthweight (statistically significant in

relation to mild dysfunction; figure 1). Smoking (figure 2) and PET (figure 3) were both

associated with mothers having babies of lower birthweights, but this was only statistically

significant for PET. 21.6% of babies (19/88 livebirths) were admitted to the neonatal unit,

largely as a result of preterm delivery. There were three stillbirths, all with growth-restricted

babies. No women agreed for a post-mortem to be carried out. The two neonatal deaths

were both associated with extreme prematurity, both infants were born at 24 weeks

gestation.

In first pregnancies post event, 37/79 (46.8%) were vaginal births, 14/79 (17.7%) were

emergency caesarean sections during labour, and 28/79 (35.4%) deliveries were by elective

caesarean section before labour. The corresponding figures in the second pregnancy post

event were 4/13 (30.8%), 2/13 (15.4%) and 7/13 (53.8%), which are not significantly

different from the first pregnancy post event (p=0.209 by MannWhitney U).

The overall rate of postpartum haemorrhage defined as an estimated bloodd loss of 500ml

or more was 50/92 (54.3%) and correlated strongly with mode of delivery – 10/41 (24.4%)

vaginal deliveries, 11/16 (68.8%) emergency caesarean sections and 29/35 (82.9%) of

elective caesarean sections (p<0.001 Kruskal-Wallis test).

Cardiac Medications

Table 2 lists the cardiac medications used before and during pregnancy; at least one of these

was used in 88/92 (95.6%) of pregnancies. 84/92 (91.3%) took aspirin, (71/79 (89.8%) in

first pregnancies post event and; 13/13 (100%) in second. As well as having an antiplatelet

effect Aspirin reduces the incidence of PET (11) and is advocated by many groups for women

at high risk of developing PET (12). The rate of PET in first pregnancies after the event was

9/71 (12.7%) in women taking aspirin and 3/8 (37.5%) in women not taking aspirin (p=0.098

by Fisher’s exact test).

Beta blocker use was also very common; 42/92 (45.7%) overall, 38/79 (48.1% in first and

4/13 (30.8%) in second pregnancies after the event, as was the use of low molecular weight

heparin, 17/79 (21.5%) in first pregnancies and 5/13 (38.5%) in second pregnancies after the

event. Only 7/92 (7.6%) used GTN, the same proportion in first and second pregnancies post

event. Clopidogrel was also rarely used; 8/79 (8.7%) in first pregnancies only. Excluding

twins and birthweights <500g, there was no significant correlation of drug usage with

birthweight or birthweight centile, except with low molecular weight heparin (p=0.03 for

birthweight and 0.009 for birthweight centile, Mann-Whitney U) (see figures 4 & 5). None of

the drugs used had any significant correlation with blood loss at delivery.

Discussion

The primary findings from this study suggest that maternal cardiac outcomes for women

with CAD are relatively favourable compared to outcomes for women with other forms of

acquired heart disease (13, 14). In contrast, the rate of obstetric and neonatal complications

is relatively high compared to healthy women. Of particular note, there were no maternal

deaths in this series and only one woman had a serious cardiac event during pregnancy

(NSTEMI), but even she went on to have a livebirth near term (35 weeks). These data

suggest that a pre-existing diagnosis of CAD is not associated with a marked increase in

cardiac events during a subsequent pregnancy. However, whether pregnancy has a negative

effect in the long term on the prognosis of women with CAD this cohort will have a worse

long term prognosis compared to women with a diagnosis of CAD who did not have a

pregnancy was not examined in this study. andHowever, older women embarking on

pregnancy have been shown to experience a higher rate of later cardiovascular events (15),

suggesting that pregnancy may have an adverse cardiovascular impact.

The absence of maternal deaths in our study contrasts to findings from the UK Confidential

Enquiry (MBBRACE UK) which consistently reports thating cardiac disease is the single

biggest cause of indirect maternal death and that CAD is one of the most important causes

(16). In their 2016 review, over a five year period they reported 153 cardiac maternal deaths

with over a fifth of cases being attributable to ischaemic heart disease (16). Equally, In their

review Burchill et al only reported a single maternal death in a group of women with known

CAD (3). We surmise that the relatively good outcomes observed in both our study and the

study of Burchill et al ;is we hypothesise, as they do, that because women had anwith

known CAD have often identified diagnosis and because most women had undergone

coronary revascularisation and wewere also taking appropriate medical therapy then

maternal mortality remains very low.

Women in our study that experienced cardiovascular events were more likely to have

underlying atherosclerotic disease rather than any other aetiology. This is likelymay be

because this was the most common aetiology encountered. Interestingly two of the women

who experienced worsening angina had a prior diagnosis of dyslipidaemia (all 3 women had

>1 risk factor for cardiac disease) with one stopping her statin during pregnancy. Studies

have shown that during pregnancy LDL particles may become more atherogenic as they

appear to be denser in size (17). However, there is a paucity of data to recommendwhether

the safety of statins are safe in pregnancy is not clear ;(18), but in selected cases women

may benefit from their use as there is no clear link with increased risk of teratogenicity (19)

and women may benefit from their use in selected cases.

The majority of women in our study, as with the MBBRACE UK report, had more than one

risk factor for CAD, with over half of women continuing to smoke or having a past history of

cigarette use and a third of women being obese. Moreover, the median age of women in

pregnancy was 35 years demonstrating that advanced maternal age is a clear risk factor for

CAD. These risk factors-smoking, obesity and age, are the same as those in the general

population; in England a 2015 report from the UK Health and Social Care Information

Centre, showed that in the general population, 20% of mothers were 35 or older, 21% of

women were obese and 13% of women continued to smoke in pregnancy. Whether

screening for these factors in the antenatal population and then performing exercise testing

on screen positive women would impact rates of ACS and CAD-related death during

pregnancy remains unclear, but at an individual level this approach has the potential to

identify women at high risk of future coronary events. Nevertheless, at present the costs for

undertaking such screening are likely to remain prohibitive.

It was notable that ten women developed PET, the majority of whom were parous and

delivered prior to 37 weeks (preterm-PET). This rate of PET is approximately three times

greater than the background rate in western Europe (20). Furthermore, the majority of

women were taking aAspirin during pregnancy, usually 75mg, which from a prior systematic

review has been shown to have a 15% reduction in risk of developing PET (21). A recent

study by Rolnik et al demonstrated a 60% in preterm PET in women who took Aspirin 150mg

compared to placebo (22), given the higher than expected rate of PET observed in this

study, the data from Rolnik et al suggest that women with CAD may benefit from 150mg of

aAspirin, because in terms ofof the reducing the risk of of PET. Identifying relatively high

rates of PET in women with CAD might support the view of Melchiorre et al, that PET occurs

as a consequence of cardiovascular maladaptation to pregnancy (23), however it would also

be consistent with PET being a consequence of a more widespread endothelial dysfunction

or metabolic syndrome. If this is the case, then the recognised relationship between PET and

increased risk of later cardiovascular disease may actually not be causal, but only different

facets features of a common underlying disorder. PET was also associated in our study with

earlier delivery and having a baby born small for gestational age, both of which are known

to have long term consequence for the neonate (24).

Impaired fetal growth was a common feature of our study. Median birthweight in first

recorded pregnancies in our study was 2920g which is approximately 150g lower than that

reported by the ROPAC authors in their study (2). Importantly though, when correcting for

gestation at delivery, fetal sex and parity, we found that 29% of infants were SGA, this is a

similar finding to Gelson et al who examined birthweights in a cohort of women with

congenital heart disease (25). A more recent, larger publication from our group (n=1053)

(6), of women with heart disease, identified 15 women with CAD who had babies with a

lower birthweight centile than normal controls (6). We and other authors have also

reported a significant reduction in birthweight in women with cardiac disease taking beta-

blockers (26, 27), whereas although this was not apparent in the current study. Impaired left

ventricular systolic function may also have significantly impaired on fetal birthweight

growth suggesting these women may havedue to an impaired cardiovascular adaptation to

pregnancy (28).

A high proportion (94%) of women took at least one cardiac medication during pregnancy; t.

This being was almost three times greater than the ROPAC study assddressing cardiac

medication use during pregnancy (8). The reasons for this are multifactorial, but all the

women in our study were managed through specialist clinics having joint care from an

obstetrician and cardiologist. Furthermore, because this cohort had a greater number of

established cardiac risk factors namely hypertension, diabetes and dyslipidaemia, and

wouldthey are likely to have been on cardiac medication for several years. Two women

continued on the antiplatelet drug Ticagrelor without having any adverse fetal or maternal

effect. Importantly, there was no association with maternal haemorrhage (PPH) at delivery

with the use of antiplatelet agents or LMWH during pregnancy, although it was routine

practice to halt Clopidogrel and LWMH (but not aAspirin prior to cases of planned delivery

at 7 days and 12 hours respectively. High. rates of PPH (>50%) may have been higher due to

the use of lower dose of syntocinon and the avoidance ergometrine for the management of

the third stage of labour as t. The combination of ergometrine and syntocinon has been

shown to be more effective than syntocinon alone in the prevention of PPH, but

ergometrine can cause hypertension and myocardial ischaemia (29).

We were not able to identify any risk factors demonstrate with an accuracy which were

more likely to havefor cardiac events during pregnancy, as such events the time course of

the study because they were rare. This was similar to the experience reported by the ROPAC

group, who reported found that out of the 20 women with a prior history of ischemic heart

disease, only one women experienced a new episode of ACS (30). In our study, Out of of the

11 women with SCAD, we saw only one woman hadve a recurrent eventce associated with

pregnancy. This recurrence rate of (9%), which appears lower to be than that reported by

Tweet et al (15%)(31);, although however, we acknowledge their series had included a

larger number of women and our follow up period was shorter. It was noteworthy that just

over a quarter of women received preconception counselling, this maybe explained by lack

of easy access to professionals with the expertise to provide such counselling.

Our data show that women with underlying CAD generally have favourable cardiovascular

outcomes in pregnancy. However, Given there are high rates of adverse obstetric and

neonatal complications events and we would advocateensure that antenatal care for of

these women should be optimised, including encompasses the routine use of aAspirin in

order to reduce early onset pre-eclampsia and . We would also advocate regular fetal

surveillance with of fetal growth, scans given the large proportion of babies born SGA. The

relatively favourable outcome reported in our study may be because the majority of women

continued to take their cardiac medications. Furthermore, we would advocate that the

majority of cardiovascular medications are safe and should be continued in pregnancy and

the continued usage of many of these medications may contribute to more favourable

maternal outcomes.

This study is limited by several factors; it is retrospective in nature and only captures data

from women managed in specialist clinics therefore increasing the chance of referral bias.

Furthermore, we do not have a matched control group so we can compare outcomes.

Whilst this study is relatively small in size we believe it is the largest study to date describing

outcomes for women with known CAD to date.

Conclusion

Women with existing CAD under specialist review tend to have favourable maternal

outcomes during pregnancy and the postpartum period. Women with CAD appear to be

older, parous and have multiple cardiovascular risk factors. Fetal outcomes are less

reassuring with high rates of late fetal loss, preterm delivery and babies born small for

gestational age. Rates of preconception counselling are poor and require improvement

Table 1 Baseline maternal characteristics at first recorded pregnancy

Demographics (n=72) N (%) unless

otherwise stated

Age in years, median (interquartile range) 35 (31-39)

(minimum and maximum) (23-43

Body Mass Index (median and interquartile range) 26 (22-31)

(minimum and maximum) (19-42)

Nulliparous 22(31)

Parous 50(69)

White European 60(83.3)

South Asian 11(15.3)

Black African 1(1.4)

Functional status

NYHA Class 1 64(89)

NYHA Class 2 8(11)

NYHA Class 3 and 4 0

Cardiac Diagnosis

Atherosclerotic Disease 46 (64)

Previous Spontaneous Coronary Artery Dissection 11 (15)

Coronary Thrombus 8 (11)

Coronary Spasm 7 (10)

Underlying cardiovascular risk factors

Current Smoker/ExSmoker 16(22)/23(32)

Hypertension 21(29)

Obesity 24(33)

Diabetes 15(14)

Dyslipidaemia 22(31)

Thrombophilia 6(8)

Family history 23(32)

Prior cardiac catherization 67(93)

Coronary stents in situ 38(53)

LV Systolic Function

Normal 55(76)

Mild Impairment 10(14)

Moderate Impairment 6(8)

Severe Impairment 1(1)

Table 2- Cardiac Medication used prior to and during pregnancy

Pre-Pregnancy

Aspirin

Clopidogrel

Beta blockers

Nitrates

ACE Inhibitor

Angiotensin Receptor Blocker

Statin

Ticagrelor

Medication during Pregnancy

Aspirin 76(90)

Clopidogrel 6 (7)

Low Molecular Weight Heparin 20(24)

Beta Blockers 36(43)

Nitrates

Ticagrelor

Statin

Table 3 Details of cardiac events during pregnancy and postpartum

Age Event Type Cardiac History Timing ManagementPre-pregnancy

Patient A 29 NSTEMI AtheroscleroticPrevious NSTEMI 23weeks Aspirin and Clopidogrel

Patient B 43 Deterioration LV AtheroscleroticFunction Previous STEMI 30 weeks Medical management

Patient C 34 SCAD recurrence Prior SCAD intramural 9 weeks Haematoma RCA* postpartum

Patient D 39 Progressive Atherosclerotic Began Medical managementAngina Previous STEMI second trimester

Patient E 39 Progressive Atherosclerotic Began Medical managementAngina Previous STEMI 31 weeks

Patient F29 Progressive Atherosclerotic Began Medical managementAngina Previous NSTEMI first trimester

*RCA= Right circumflex artery

Table 4 Obstetric and Neonatal Complications

Obstetric Complications (total pregnancies n=84C) N (% to nearest whole number)*

Postpartum Haemorrhage

Pre-eclampsia

Gestational hypertension )

Mode of Delivery

Spontaneous Vaginal

Assisted vaginal

Elective CS

Emergency CS

No record

Neonatal complications (total births n=84 ) (% to nearest whole number)

Intrauterine death

Neonatal death

SGA (<10th Centile) )

Preterm Prelabour Rupture of Membranes

Preterm delivery

Neonatal Unit Admission

References

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