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Canadian Journal of Cardiology

Cardiac Risk Score to Predict Small for Gestational Age Infants in Pregnant Women With Heart Disease

  • Jasmine Grewal
    Correspondence
    Corresponding author: Dr Jasmine Grewal, St Paul's Hospital, Rm 478, 1081 Burrard St, Vancouver, British Columbia V6Z 1Y6, Canada. Tel.: +1-604-806-8785; fax: +1-604-806-8137.
    Affiliations
    Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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  • Samuel C. Siu
    Affiliations
    Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada

    Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Program, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

    Division of Cardiology, University of Western Ontario, London, Ontario, Canada
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  • Rohan d'Souza
    Affiliations
    Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Program, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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  • Terry Lee
    Affiliations
    Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
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  • Joel Singer
    Affiliations
    School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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  • Valerie Rychel
    Affiliations
    Department of Obstetrics and Gynecology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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  • Marla Kiess
    Affiliations
    Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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  • Mathew Sermer
    Affiliations
    Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada

    Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Program, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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  • Candice K. Silversides
    Affiliations
    Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, Toronto, Ontario, Canada

    Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Program, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Published:April 07, 2021DOI:https://doi.org/10.1016/j.cjca.2021.03.023

      Abstract

      Background

      One of the most common fetal complications in pregnant women with cardiovascular disease is a small for gestational age (SGA) neonate, which is associated with a higher risk of perinatal morbidity/mortality and poor long-term health outcomes. The objective of this study was to identify cardiac determinants and derive a risk score for clinically relevant SGA < 5th percentile (SGA-5th).

      Methods

      A prospective cohort of 1812 pregnancies in women with heart disease were studied. SGA-5th was the outcome of interest, defined as birth weight < 5th percentile for gestational age and sex. Multivariable logistic regression analysis was used to identify predictors for SGA-5th. Based on the regression coefficients, a weighted risk score was created.

      Results

      SGA-5th complicated 10% of pregnancies, 11 predictors of SGA-5th were identified, and each was assigned a weighted score: maternal cyanosis (8), Fontan palliation (7), smoking (3), moderate or severe valvular regurgitation (3), β-blocker use throughout pregnancy (4) or only in the 2nd and 3rd trimesters (2), high baseline β-blocker dose (4), body mass index < 18.5 kg/m2 (3) or 18.5-24.9 kg/m2 (1), Asian/other ethnicity (2), and significant outflow tract obstruction (1). In the absence of these identified risk factors, the risk of SGA-5th was approximately 4%. Pregnancies with risk scores of 1 had a rate of 5%; 2, 7%; 3, 9%; 4, 12%; 5, 14%; 6, 18%; 7, 23%; 8, 28%; and ≥ 9, 34%.

      Conclusions

      There are a number of cardiac predictors that are associated with increased risk of SGA-5th. This is a prognostically important outcome, and consideration should be given to routinely predicting and modifying the risk whenever possible.

      Résumé

      Contexte

      L'une des complications fœtales les plus courantes chez les femmes enceintes atteintes d'une maladie cardiovasculaire est la naissance d'un nouveau-né de petit poids pour l'âge gestationnel (PAG), qui est associée à un risque plus élevé de morbidité/mortalité périnatale et des effets négatifs à long terme sur la santé. L'objectif de cette étude était d'identifier les déterminants cardiaques et de dériver un score de risque pour un PAG < 5e percentile (PAG-5e) cliniquement pertinent.

      Méthodes

      Une cohorte prospective de 1 812 grossesses chez des femmes souffrant de maladies cardiaques a été étudiée. L'objectif principal était le PAG-5e, défini comme le poids de naissance <5e percentile pour l'âge gestationnel et le sexe. Une analyse de régression logistique multivariable a été utilisée pour identifier les prédicteurs du PAG-5e. Un score de risque pondéré a été créé sur la base des coefficients de régression.

      Résultats

      Le PAG-5e a compliqué 10 % des grossesses, 11 prédicteurs de PAG-5e ont été identifiés, et chacun s'est vu attribuer un score pondéré: cyanose maternelle (8), intervention de Fontan (7), tabagisme (3), régurgitation valvulaire modérée ou sévère (3), utilisation de bêtabloquants tout au long de la grossesse (4) ou seulement au cours des 2e et 3e trimestres (2), dose initiale élevée de bêtabloquants (4), indice de masse corporelle < 18,5 kg/m2 (3) ou compris entre 18,5-24,9 kg/m2 (1), origine ethnique asiatique/autre (2), et obstruction significative des voies d'éjection (1). En l'absence de ces facteurs de risque identifiés, le risque de PAG-5e était d'environ 4 %. Les grossesses avec un score de risque de 1 avaient un taux de 5 % ; 2, 7 %; 3, 9 %; 4, 12 %; 5, 14 %; 6, 18 %; 7, 23%; 8, 28 %; et ≥ 9, 34 %.

      Conclusions

      Il existe un certain nombre de facteurs prédicteurs cardiaques qui sont associés à un risque accru de PAG-5e. Il s'agit d'un résultat important sur le plan pronostique, et il convient d'envisager de prédire et de modifier le risque de manière systématique chaque fois que cela est possible.
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      Linked Article

      • Pregnancies With Maternal Heart Disease: Small Babies, Big Problems?
        Canadian Journal of CardiologyVol. 37Issue 12
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          The care of children with heart diseases has tremendously improved in the past few decades. Most children with heart conditions, even those with the most complex conditions, now grow up and reach adulthood, find jobs, fall in love, and hope to have children of their own. Pregnancy comes with its share of joy along with, inevitably, an increased but necessary hemodynamic burden to sustain the life of two beings instead of one. Despite our best efforts, women with acquired and congenital heart diseases often have residual structural heart lesions or ongoing functional cardiac impairments that will chronically increase the cardiovascular load, which may very well worsen during pregnancy.
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