Mode of delivery and peripartum outcome in women with heart disease according to the ESC guidelines: an Italian multicenter study

Introduction The European Society of Cardiology (ESC) guidelines (GL) provide indications on the mode of delivery in women with heart disease. However available data suggests that the rate of Cesarean Delivery (CD) is high and widely variable among such patients. In this study, we aimed to investigate the degree of adherence to the ESC recommendations among women delivering in four tertiary maternity services in Italy and how this affects the maternal and neonatal outcomes. Material and methods Retrospective multicenter cohort study including pregnant women with heart disease who gave birth between January 2014 and July 2020. Composite adverse maternal outcome (CAM) was defined by the occurrence of one or more of the following: major postpartum hemorrhage, thrombo-embolic or ischemic event, de novo arrhythmia, heart failure, endocarditis, aortic dissection, need for re-surgery, sepsis, maternal death. Composite Adverse Neonatal outcome (CAN) was defined as cord arterial pH <7.00, APGAR <7 at 5 min, admission to the intensive care unit, and neonatal death. We compared the incidence of CAM and CAN between the cases with planned delivery in accordance (group ESC consistent) or in disagreement (group ESC not consistent) with the ESC GL. Results Overall, 175 women and 181 liveborn were included. A higher frequency of CAN was found when delivery was not planned accordingly to the ESC guidelines [(ESC consistent 9/124 (7.2%) vs ESC not consistent 13/57 (22.8%) p = 0.002 OR 3.74 (CI 95% 1.49-9.74) , while the occurrence of CAM was comparable between the two groups. At logistic regression analysis, the gestational age at delivery was the only parameter independently associated with the occurrence of CAN (p = 0.006). Conclusion Among pregnant women with heart disease, deviating from the ESC guidelines scheduling cesarean delivery does not seem to improve maternal outcomes and it is associated with worse perinatal outcomes, mainly due to lower gestational age at birth.

Automated summary

This study aimed to investigate the adherence to the ESC guidelines for mode of delivery in women with heart disease and its effect on maternal and neonatal outcomes in Italy. The results showed that deviating from the guidelines for planned cesarean delivery was associated with higher incidence of adverse neonatal outcomes, while there was no significant difference in adverse maternal outcomes between the two groups. Gestational age at delivery was found to be the only independent factor associated with the occurrence of adverse neonatal outcomes.