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Timing of Cardiac Surgery During Pregnancy
Quick Takes
- Fetal mortality is high when urgent/emergent maternal cardiac surgery is needed during pregnancy, regardless of the trimester of pregnancy.
- In this study of urgent/emergent cardiac surgery during pregnancy, there were no statistically significant differences in maternal mortality by trimester of pregnancy.
Study Questions:
How does the timing of cardiac surgery during pregnancy impact maternal and fetal outcomes?
Methods:
This was a meta-analysis of studies that included individual patient data related to cardiac surgery during pregnancy. Patients who underwent cesarean delivery prior to cardiac surgery were compared with patients who had cardiac surgery while still pregnant. The trimester of pregnancy, maternal and fetal mortality, and predictors of adverse outcomes were analyzed using multivariable logistic regression.
Results:
Of 179 included studies, 386 patients were identified (120 had cesarean delivery prior to cardiac surgery). The overall maternal mortality was 7.3%, without significant differences based on trimester of pregnancy nor whether cardiac surgery was performed while still pregnant versus postpartum. The overall fetal mortality was 26.5%. Fetal mortality (6.7%) was lowest when cesarean delivery of the fetus occurred prior to the mother undergoing cardiac surgery.
Conclusions:
Cardiac surgery during pregnancy was associated with an overall maternal mortality rate of 7%, and this did not differ significantly by the trimester of pregnancy nor whether delayed until after cesarean. Due to high rates of fetal mortality (26% overall), the authors suggest considering delivery by cesarean prior to cardiac surgery if feasible.
Perspective:
Cardiac surgery is avoided during pregnancy due to maternal and fetal risks. When necessary, expert guidelines have recommended surgery be performed during the second trimester (between 13 and 28 weeks of gestation). This study showed no significant difference for fetal or maternal mortality by the trimester of pregnancy. Fetal survival was highest when cesarean delivery could occur prior to cardiac surgery; however, waiting for fetal viability may not be feasible in many situations and caution is needed. Importantly, 95% of the patients in this study had an urgent or emergent indication for surgery. Fetal mortality during pregnancy may be related to the maternal condition (e.g., severe valve disease, endocarditis, aortic dissection) rather than the effects of cardiac surgery. Delaying urgent cardiac surgery can also lead to maternal and fetal deaths that would not have been measured in this study. Multidisciplinary maternal care teams are necessary, and ideally, patients with known cardiovascular disease will undergo preconception counseling and risk assessment.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement
Keywords: Cardiac Surgical Procedures, Cesarean Section, Fetal Death, Fetal Mortality, Fetal Viability, Fetus, Maternal Mortality, Mothers, Outcome Assessment, Health Care, Postpartum Period, Pregnancy, Pregnancy Complications, Pregnancy Trimesters, Risk Assessment, Secondary Prevention, Women
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