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Clinical features and peripartum outcomes in pregnant women with cardiac disease: a nationwide retrospective cohort study in Japan

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Abstract

Although the number of pregnancies in women with cardiac disease is increasing worldwide, there are few data concerning their clinical characteristics and peripartum outcomes. Using the Diagnosis Procedure Combination database between 2008 and 2014 in Japan, we retrospectively identified pregnant women who underwent high-risk delivery due to obstetric or non-obstetric comorbidities. We classified eligible women into those with pre-existing cardiac disease (cardiac disease group) and those with non-cardiac comorbidities (non-cardiac disease group) and compared their characteristics and peripartum outcomes. Of 94,364 women undergoing high-risk delivery at 556 hospitals, 857 (0.91%) had pre-existing cardiac disease (302, congenital heart disease; 190, arrhythmia; 176, valvular heart disease; 120, ischemic heart disease; 65, cardiomyopathy; 4, pericardial disease). Women in the cardiac disease group were more likely to be treated at university hospitals (51.1 versus 28.6%; p < 0.001) and in intensive care units (33.5 versus 18.8%; p < 0.001) than those in the non-cardiac disease group. The proportion of cesarean deliveries was 69.4% (emergency, 28.4%; elective, 41.1%) in the cardiac disease group and 73.4% (emergency, 38.4%; elective, 35.0%) in the non-cardiac disease group. Epidural analgesia during vaginal delivery was used significantly more frequently in the cardiac disease than non-cardiac disease group (15.6 versus 2.3%; p < 0.001). Heart failure occurred more frequently in the cardiac disease than the non-cardiac disease group (10.2 versus 0.3%; p < 0.001). In cardiac subgroup comparisons, heart failure occurred more frequently in women with congenital heart disease (12.3%), valvular heart disease (12.5%), or cardiomyopathy (12.3%) than in women with arrhythmia (6.3%) or ischemic heart disease (5.8%). Multivariable logistic regression analysis showed a significant positive association between pre-existing cardiac disease and risk of heart failure (adjusted odds ratio, 24.7; 95% confidence interval, 17.6–34.6; p < 0.001). No woman in the cardiac disease group died, whereas 18 women (0.02%) in the non-cardiac disease group did (p = 1.000). These findings suggest that pregnant women with pre-existing cardiac disease are at a higher risk of heart failure during the peripartum period than those with non-cardiac comorbidities.

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Funding

This work was supported by Grants from the Ministry of Health, Labour and Welfare, Japan (Grant Numbers: H29-Policy-Designated-009 and H29-ICT-General-004); the Ministry of Education, Culture, Sports, Science and Technology, Japan (Grant Number: 17H04141); and the Japan Agency for Medical Research and Development (AMED). The funders had no role in the execution of this study or the interpretation of the results.

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Authors and Affiliations

  1. Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan

    Toshiaki Isogai, Hiroki Matsui & Hideo Yasunaga

  2. Department of Cardiology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan

    Toshiaki Isogai & Hiroyuki Tanaka

  3. Department of Obstetrics and Gynecology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan

    Akira Kohyama

  4. Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan

    Kiyohide Fushimi

Authors
  1. Toshiaki Isogai
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  2. Hiroki Matsui
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  3. Hiroyuki Tanaka
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  4. Akira Kohyama
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  5. Kiyohide Fushimi
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  6. Hideo Yasunaga
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Corresponding author

Correspondence to Toshiaki Isogai.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was approved by The Institutional Review Board at The University of Tokyo.

Informed consent

The requirement for informed consent was waived because all data in the DPC database are anonymized.

Appendix

Appendix

The following International Classification of Diseases, 10th Revision code (ICD-10) codes were used to identify diseases. Use of both a Japanese-text diagnosis and an ICD-10 code to identify a disease is designated by placing “with Japanese-text” after the ICD-10 code.

Cardiac disease Congenital heart disease (Q20.x–Q24.x); ventricular septal defect (Q21.0); atrial septal defect (Q21.1 with Japanese-text); atrioventricular septal defect (Q21.2); tetralogy of Fallot (Q21.3); double outlet right ventricle (Q20.1); complete transposition of great arteries (Q20.3 with Japanese-text); corrected transposition of great arteries (Q20.5 with Japanese-text); Ebstein anomaly (Q22.5); unspecified congenital malformation of heart (Q24.9); second degree atrioventricular block (I44.1); third degree atrioventricular block (I44.2); Wolff–Parkinson–White syndrome (I45.6 with Japanese-text); supraventricular tachycardia (I47.1); atrial fibrillation/flutter (I48.0); sick sinus syndrome (I49.5); post-implantation of cardiac implantable electronic device (Z95.0, Z95.8 with Japanese-text); long QT syndrome (I49.0 with Japanese-text); Brugada syndrome (I49.0 with Japanese-text); valvular heart disease (I34.x–I37.x); non-rheumatic valve disease (I34.x–I36.x); mitral valve prolapse or regurgitation (I34.0, I34.1); aortic stenosis (I35.0); aortic regurgitation (I35.1); aortic stenosis with regurgitation (I35.2); rheumatic valve disease (I05.x–I09.x); mitral stenosis (I05.0); mitral stenosis with regurgitation (I05.2); tricuspid regurgitation (I07.1); tricuspid stenosis with regurgitation (I07.2); pulmonary valve disease (I37.x); pulmonary heart disease (I27.x, I28.x); Marfan syndrome (Q87.4); angina pectoris (I20.0); chronic ischemic heart disease (I25.x); coronary artery disease of Kawasaki disease (coronary artery aneurysm or ischemic heart disease, M303 with Japanese-text); cardiomyopathy (I42.x, I43.x); dilated cardiomyopathy (I42.0 with Japanese-text); obstructive hypertrophic cardiomyopathy (I42.1); non-obstructive hypertrophic cardiomyopathy (I42.2); endocardial fibroelastosis (I42.4); arrhythmogenic right ventricular cardiomyopathy (I42.8 with Japanese-text); pericardial disease (I31.x, I32.x); post-cardiac surgery (Z95.1–Z95.5 with Japanese-text).

Comorbidity Gestational hypertension (O13.x); pre-eclampsia or eclampsia (O11.x, O14.x, O15.x); chronic hypertension (I10.x, I15.x, O10.x); diabetes mellitus (E10–14.x, O24.x); anemia (D46.x, D50.x, D51.x, D52.x, D53.x, D55.x, D56.x, D58.x, D59.x, D60.x, D62, D63.x, D64.x, O99.0); history of uterine surgery including cesarean section (O34.2); multiple gestation (O30.x); fetal malpresentation (O32.x); cephalopelvic disproportion (O33.x); premature rupture of membranes (O42.x); threatened premature labor (O47.0 with Japanese text); intrauterine fetal growth restriction (O36.5); fetal distress (O68.x); placental disorders (O43.x); obstructed labor (O64.x–O66.x); placenta previa (O44.x); placental abruption (O45.x).

Outcome Heart failure (I11.0, I13.0, I13.2, I50.x); ventricular fibrillation (I49.0 with Japanese text); acute myocardial infarction (I21.x with Japanese text); pulmonary embolism (I26.x); cerebral infarction (I63.x); intracerebral hemorrhage (I61.x).

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Isogai, T., Matsui, H., Tanaka, H. et al. Clinical features and peripartum outcomes in pregnant women with cardiac disease: a nationwide retrospective cohort study in Japan. Heart Vessels 33, 918–930 (2018). https://doi.org/10.1007/s00380-018-1137-1

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