Timing of delivery is individualized based upon cardiac status, gestational age, Bishop score, and other factors.
"Many of you probably start to lose your nerve a bit at the end and say, ‘Pregnancy is bad for heart disease; we should just deliver.’ But generally speaking, if your patients are doing well in the third trimester, there’s really no reason to induce prematurity," Dr. Economy asserted.
She cited a large multicenter study that has turned heads in the world of maternal-fetal medicine. The study showed significantly increased rates of NICU admission, newborn sepsis, and respiratory complications requiring prolonged intubation with delivery at 37-38 weeks’ gestation, compared with 39 weeks’, in a broad population of pregnant women (N. Engl. J. Med. 2009;360:111-20).
"If your patients are doing well, let them stay pregnant," the ob.gyn. urged.
Cesarean section is really popular in patients with congenital heart disease. The joint guidelines state, "Fetal delivery via cesarean section is reasonable for patients with significant aortic enlargement, dissection, or severe aortic valve regurgitation" (Circulation 2010;121:1544-79). But Dr. Economy pointed out that this recommendation is rated class II, level of evidence C, meaning that it is based solely on expert opinion. And these joint guidelines were drawn up and approved by numerous cardiovascular and imaging societies without the endorsement of any obstetric organizations.
"I would put to you that every time you think about a cesarean section, you stop and remember that cesarean section is worse for women. For all women. C-section is worse for them, okay? It increases the risk of significant blood loss, increases infection risk, and increases the risk of venous thromboembolism," she said.
"My personal opinion is cesarean section should be reserved for obstetric indications – things like failure to progress, breech presentation, or nonreassuring fetal status in labor. The vast majority of patients will be better served by vaginal delivery. Plan on an interdisciplinary effort between obstetrics, cardiology, anesthesiology, and nursing," Dr. Economy advised.
Dr. Economy and her associates reported that they had no relevant financial disclosures.