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A study of the fetal mortality in patients with organic heart disease
TEEL:
FETAL 'MORTALITY IN PATIE~TS WITH ORGAKIC' HEART DISEASE
5!)
REFERENCES
(1) DeLf'c, Joseph B.: The Prindples anl. f. Gynak. 52: liHO, 1H:2H. (li) JTofbaucr, .T.: Zentralhl. f. Gynak. 42: 74:1, Hilll. (7) Jlofbn,,., .T.: A'r. .J. OnNT'. & Gn·a:c. 26: :n1, l!lil:1. (S) Lfnsflmino, Karl JuU11s, Jloffmann, Friedrich, an,z 11ennuly, TV alter P.: Edinhurgh Med ..T. 39: 376, 19:l3. (9) Cmrner, 1V111.: J. Pharmaeol. & Expel'. 'Therap. 7: 63, 1915. (10) Sofis-Cohen, Solmnon, antl Gifhtns, Thoma.~ Stotcsbury: Pharmacotherapeutics, New York, 1928, D. Appleton anstigation 11: JOOR, 19a2. (13) Lashmet, F. H.: J. Mirh. State l\fe.l. Ro<'. 32: 317, 1!133. (H) Plass, E. D.: Bull. Johns Hopkins Hosp. 35: 84:), 1924. (lG) Ihid.: Referring to Zangt•m~~~ .
A STUDY OP THE FETAL MORTAIJl'J'Y IN PATIENTS WITH ORGANIC HEART DISEASE
IL\IWW :\L
'l'EEL,
l\LD.,
BoHTON, l\fAs~.
(Frorn the Depart-ment of Obstet1·ics, Har,vard Mt>dical School)
medical management of the cardiac patient during pregnaney PROPER involves great sacrifiee of her time, curtailment of her activity, and a considerable expense, over and above that incident to pregnancy in the normal subject. 'I'he risk of pregnancy to her life iH not negligible, even under optimum conditions. In the past, medical and obstetrie discussion of the question whether or not a cardiae patient should undertake pregnancy has concerned itself almost wholly with the maternal risk, without clue consideration of the baby. It would seem that the probability of obtaining a live lwby should be an important factor in sueh a decision. An unusual opportunitr for study of the fetal mortality associated with this complication i" afforded by the large number of patients with heart diseaRc who have heen treatrd at thr Boston IJ:vingin Hospital. 1. MATERIAL A special heart clinic has been in oprration for fift('rn y(~ars at this institution under the clireetion of Dr. B. B. Hamilton. 1 • 2 • 3 During routine prenatal examinations all patients who present signs or symptoms which might be r(•femble 1o heart disease arc direeted to this clinic for cardiac diagnosis. Those fonnd to have organic heart disease are followed by the cardiologist throughout pregnaney, deliver~', and puerperium. In addition to the patients from our own prenatal clinies, a large number of cardiae patients arc referrrd to the heart clinic by the general hospitals of the community, by practitioners who do their own
relatively normal obstet ric·s. and by oth1•r obstdrir im;t itutions in which c·ontrw~cp1 iv1' ndvh·c·. tl11'tn pcntic· aborti011. and sterilization.
religious principles prohibit
he pt·c•sc·nted in 1lii~ paJi'''' lias ht·(·ll ohtainv1l from the e;JI''1'\ f•.n l'unt x-n1r plat(•, fluoroscopP, nnr1 th(' Pll'etrnt•nwlioQTam. _\11 fin;~]
2.
GHO:-::-: JET.\!. ~\IOitT.\LJT\
1'(11{ TTIJ: \\'T!Of.E 1ill01T
During: the ten-~·r:1r pniod oi' thi,., ~tnd)-, fins p:i1 i1·nt,.; \Yith mwmH· lwnrt disPnse havn hel'll tl'1·atv1l m11l t'ld iYPl'l'll in tlJL· 1tnsp1tn 1. Of this group, 514 wrre
GRoss FETAL MOR'rALITY
POl~
/u,r, CARDIAC P.\'PlJo'l\TS
Total pregnant earrliacs in the series Total babieR Died undeHvere
in('hH1('~
nh0rtiot1s nnrl
~
fJnir~
J:\ Till~
liRII!'P
II
Iii
j.,q
1!i ~11.li1~;,,
'7.gS?f ot·
tvdn~.
The gross fetal loss (20.18 per cent) is E-nlig-htening, and at first thought rather d.iscomaging, although .it shmlld h0 pointed ont that more than half of the bahit·P lost were ft·mn spontaneous and t.herapeuti<~ abortions. Abm1iom; are nnt ordinarii.'· inclndcd in computing fetal mortality. Ncvcrth0h•ss, tlds gTo:-s fignrc· is of some importance, for it shows that without sl'lL'<'tion. (•nn1i;Je rmtients have only an 80 TH'l' cent chance of haying a hnhr t hni sm·vi n's. Howevr~r, if one pxc•ludt>s tlw relatively small gnmp of cardiae pnt.ient::; with such Sl'W·re damage that the risk of prcgnanc~T to their own lives is excessive, it will be shown
TEEL:
FETAL MORTALITY IN PATIEXTS "WITH ORGANIC HEAR'r J)JSEASE
55
later that the prospect d obtah1ing a living baby is excellent. On the basis of history and physical examination, it is possible before the onset of pregnancy to recognize a large majority of these patients with heart lesions which are too severe to allow them to earry the strain of pregnancy. This point has been emphasized h,r Hamilton. Such patients whose cardiac condition clearly contraindicated pregnancy made up the great majority in the gt·oup upon whom thera11eutic abortions were performed, and a considerable proportion of those ·whose pregnancies wero terminated because of fuilnre while the baby ·was still premature.
3.
FETAL MORTALITY FOR BABIF.i'i DELIVERED AFTER VIABILITY
There were a total of 514 patients in whom pregnancy terminated aftrr the twenty-eighth week. In the cases of fifty-three it was necessary to deliver the patient prematurely because of the condition of the heart (usually because of the occurrence of congestiYe failure). In the otherR, either labor was spontaneous or electi\'C cesarean ~ection was done at term. The fetal mortality for these viable babies is presented with some detail in 'l'able II. TABLE
II.
FETAL 1IORTALITY FOR ALL VIABLE BABIES-IRREBPEC'e!VE OF METHOD 0!' DELIVERY OR CARDIAC CO:
..-=--.' ----
=~==_:..=.----.--=c._-_--_
DPR"\TION OF PREGNANCY II\ WEEKS A'l' DELIVERY ~£) 'l .t),}
Total babies delivered Discharged living Stillborn Neonatal deaths Gross :fetal mortality
THROUGH WEEKS
~,..
.;.),)
APTER, WEEKS
3() li 2
486 467 13
17
()
:i2.77%
TOTAL FOR GROUP
522 -184
15
3.111 '/r
-~-'"-,~---
-
~3
7.28%
The mortality among the babies delivered after the thirty-fifth week (3.91 per eent) compares favorably with the gt>nera1 ft.'tal mortalit~' for the hospital (excluding prematures). Although t hr pn·maturt>s made up less than 7 per cent of the whole gToup, they ac·eom1ted for half of the loss of babies. As >vin be shown in the followi11g Rc:etion, th(' mortality in the p1·emature groul1 is unusually high.
4.
FETAL MORTALITY IN THE PREMATURE GHOUP
'rho total mortality among the premature babies of this group of c.ardiae mothers is considerably higher thn-n that for prematures in general. Of the 36 viable babies dellv<:>red before the thirty-sixth week of gestation, only 17 surviwd. Of those lost, only ~ were Rtillborn, and 17 died subsequent to delivery. Thns, of 34 "Premature babies born alive, 50 per cent subsequently died. What are the factors which have contributed to this high neonatal death rate? It is not to be explained upon an undue proportion of very premature babies (at least so far as weight is concerned), for of the 17 babies who died, 12 weighed over 4 pounds,
-! betwet•n ;~ and
+ pmnHls,
nnd only 1 wt>i~od~t·d lvss than :3 pounds. :'\early all of tlw fatalities 'Jl'('Ul'l'l'd within the fi1·st forty-eight hont·s. Death was usually JHT<'l'th·~l h,,. <·ya.nosis awl labon·d l'el'lpiration. At autops,v littlP \VHs foll!Hl t'X('(•pt fo1· a1t•IP\·lasis. t";id!'JWI' of tht· aspit'Htion of amniofi<' fluid, Hlhl1 he S!''!lH'laP of asphyxia. Tbe ly!Jt~ of deliwry St'"lll:-> 1o han' lit'Pil one impo1'1all1 fa!•tor. In Tahir [IJ is J!I'(•St'll1f'd tiw fetal mortality fol' :ill hahit•s whos\' hirth weig-hts \V(•n• kHs than fin· pmlJH!s, J'!'lnted to tlw nwthwl of th•liwn·. TMll.J·:
III.
< 'o>IPAIUSO:\ "~" TH;: FETAL :\!ownuTY 1:\ B.IHIFK l':\DJ•:n ~'1n: }lELTVF:Rf.Jl 1'HIW1'(lH THR Pn.l'f;-; A"D BY f'f.S,\R;:.\::-- 1'l:i'TI
l'
'l'Y!'l:
Dabirs
...,
1
II
i'F;;.:.\J(f:.\S
+
11
II
7::Uil'/r
Of the fif'h•m JH'(•ma.lmt• babies delin•red through thP pdvis, tlw mortalitr 1vns only 1:3.3a pet· r·(•nt, whel'('HH of a likt• num}wr 1klivPrerl hy <'csarean sL•etion, 73.33 per eent died. ThPse findi11g~'> for ptcmnturP bahicH of cardiae mothc·rs r·ullfirm tho,;t• of ( 'lifford. 1 In his stwlies of prematm·r iJJfant mol'tality he has slJOwn tha1 tlw tH'Itllatal dPath rat!' is much higher aft1T et's;n·ean than aftn· anr type of pelvic dc]i.yery, except for bteeeh extraetion. In his serii!S of prt•matures of cardia1• mothers, the neonatal moriality was 7fi Jll't' ('ent for those dcliwred hy ecsarean, and 30 pf'l' ('t'Jlt for n·r(('X pt·esentation:-; fh•liYt'lWl normally o1· by low forceps.
'Tlw prN·isr rrnsmts wh,\· th(•se pn·malllt't•s cklin•rt>d hy l'PSal'(•;m section have do11e sn poor1y nre not t•ntirPI~c (•km·. HuwvH'l'. seVE'l'Hl fartors whirh would 'n·rn to lwat· some t'!'latim' should h;· mt•ntion!'d. Fil'st. as noted abon·, autopsies in the fat ;.d ,;,•n m'. l\lm1y of the"c ('t':>:al'<'11ll S!'etions W(•n· dma' nndPt' loc·al mwstlll'sia. :1 JH'OI'('dm·(' which lll'l'essitates gentlP and somewhat Hlow<>r OJWl'atin~ than wmal. The slight dela~· in tlw extraetion of thPse habies from tlw ull'J'Us ma~· haw a(lded in some degre~;
TEEL:
FETAL MORTAUTY IN PATIENTS WITH ORGANH' HEAR'f DISEASE
57
to a preexisting intrauterine asphyxia. A number. have required resuscitation. MoiTJhia is no longer userl in the preparation of thc~e patients for cesarean section. Indeed, it is preferred to gin: no medi<'ation whatever in preparing th(: mother of a premature baby for delivery by eesaI'E'an section. The operation 1s now done either under lo<'al anesthesia o1· with a minimum of drop ether. Of the group of prematurcs delivered through the pelvis, only two mothers wer·e in mild decompensation, and morphia was given in only one case. These facts undoubt(·dly lwlp to explain the much lower fetal mortality in this group. There is one other sugg('stion which may have some significance in the explanation of the very high neonatal death rate among the prematm·es delivered by cesarean section. :Most of the babies in this group have been very well nourished. The mothers of the premature cesarean babies have usually been in bed for weeks or months before delivery, a circumstance which might tend to produce well-nourished infants. Possibly many of these babies have btun more premature in weeks of gestation than the birth weights would indicate. One certainly sees th(' ovposite condition fairly commonly in the thin premature ha by of the toxrmie patient, which, on the basis of weig·ht alone. should lw more prematnrf' than one would expect from the duration of pregnancy. Clifford states 1hat these prematures of the toxemic patients, onee they are born alive, han~ as good a chaneo for survjva.l as any J.1I'emature. His cha1t a('tually shows that the mortality among the prematures born alive of toxemic mothers is slightly less than that of similar babies born of presumabl;' normal mothers, ilnd. much Jess than for those of any other group. Very likely this may be explained by the rclativrl;· greater maturity of the thin toxernie baby )n actual weeks' duration of pregnaney, in compat·ison with its birth weight. In Table III the conventional five pounds was used as the criterion of prematurity. Because it was susp('cted that the prt'mature babies of cardiac patients (the activities of whom have been greatly restri(·ted during pregnancy) might be somewhat h('avier than other prematures on a basis of weeks' duration of pregnancy, the fetal mortality of aU babies born of cardiac patienhi, regardlt·ss of the type of ddivery, has been tabulated according to estimated W('eks' dmation of th(' pregnancy at the time of delivrry. Th<> rrsult is seen in Table IV. The result of the tabulation in Tn ble IV is surprisingly consistent. For comparison, the .~11me data al'e presented for the mortality of these babies on a basis of bit·th weight. ThiR may bt' seen in. Table V. Comparing the two tables, it would appear that estimated weeks' duration of pregnancy is a more reliable index of the dwnce of SUITival than t lw actual birth weight. The former should be considerably more reliable than an estimate of thr size of the bahy in utero by palpation. For this reason it would appear that, at least when the duration of the
TABLE
lV.
2\Eo'>AT.\r, DE.\TH HATE FOtt
Ar.r,
R\I;LFtJ
RKL.\TED •ro ERTf~L\TJm Dmt\TWN OP PRr:G:\AKt:Y
Bote--;
,\u\·t:
.\'P TorE m•
1·::-n:tMATEn \\'~:f·J\."'' Dl~RA'flO:\
m•
\'.\t{i>L\<'
OF l 1 ltEG~.\~C'Y A'r
llU:L!YEIW ')0
i TtJ
• J ....
Liw
VVK •
..
~;:)~~3-t
::.'5-aG
:{7 -~·iH
:)\l-4u
s
:;o
7:~
:;
:)7~
.j
l'i
li
lj
t .~
li?
:Ol<>'t!II·:J{s
lli<:U\'El!'\'
:~-<
II
N!WK.\T.\J, Dt~A'rH lt.l.H: roH ALL YL\HLE BArnER or <'.\J{!HAl1 Mo'l'HKRR
1lJ.:LNrrn To Bm•rn \VEHnt'P lllR'l'll WEIGHT lK POUKDS LEC'f; TITAN
n
Livc
1!11 I
..
R-+
4-:3
:;
l:!
l·U
8 .J\l
·>
Died PPI'
3
:'H\ :~,
:2 .i ~ ,-~ /I
(~
plus
4os :.>
11.-lc!l
pregnancy by dates lw:-> been con;.;istent with obstetric examination, the likelihood of survival mn~· lw mm~P aeenrately prognosticated on the basis of weeks' duration of pregnaney than by estimated weight of the baby. ·whethel' the nwthc<1 of mea;-;uting the oeeipitofrontal diameter of the fetal head in utero h~· x-ruy" will be of gl'eater prognostie value remains to be SC'('l1. On tlw hn::ds or ilte te:,ultH shown in ~'ahle IV one may infer that the <•hanee of snniYnl is ioo small he-fore Uw thirty-fifth week if tlre baby is to be :owr·icmsl;· Nmsidert•d; the ebanee is reasonably good in the thirty-flfth ;md thirty-:-dxth weeks; und nft<'l' the thirt~·-sixth week tlw ehnnee of survival is excellent. :l.
'!'fiE Hl~J,ATIO:-:
(H'
'l'Yl'E OJ·' l>ELl\'lcHY TO Tl·m FE'L\f. :XJOR'l'ALI'PY OF :\;lA'lTRE R\l31E:-'
'l'here ·wet\' 462 patients ddivn·l'd t•ithPt' nfter 1ht• spontmwous onst't of labor, or h.v dl'eti\'1' <'('SHTUtll se<·iion Hl term. 'l'he Yarious types of dPlivel'y and 1ltP fda! mortality of e;wh an.· shown in Table VI.
l'YPE
OF m:LlVJmY
1
Normal Forceps (24 midton:t.•p;;l Breech cxtr::wtion. veri' ion Cesarean at term ---
-
TO'J',\L
j)J :-;~
ru.uu:c<
t'IL\Hil!(D
Tll•: u n:1a:n
·wEI.!,
2!0 :.:.~
J tiN :!OX 21
:i7
:-~o
iltl
:-;'J'lLL BUHS
!I
nn:n •>
-
•)
1*
0
II
PER l'EKT :.tuR'L\Ll'l'Y
li.lJ O.P.'i
1:.:.;-;o 1.i5
----------
*This Rtillborn babY v;af; knnwn to be dead befort· the OPt-'r<--ttion \vhich was done for abruptio placentae. Thu'. th<· f'nrt'<'<·t<>•l f,,taJ mortality for ('esarean Aeetion at tern1 foe this series \V:J.s. nil.
H 'vill lw sef'n from Tahk VI ihat the gl'osx f\'lal mortalit.v followinf( wmnal ddivPl'.\' is on·1· six tinws that following forceps. 'l'his dol's not pri'Sl\ni 1fH· ('liSe for nornwl d,·li\'1'1',\' quitP fail']~·. sincP there wel'P Hmong the 11ine stillhit·t h:.; d<"lh·<·l'l'!l normally fivo monsters and one
macerated fetus. However, the fetal mortality after forceps delivery of 0.95 per cent speaks ;,:trougly in fann· of this method as a routine in all cases in whieh spontanrous deliwry lloes not occur vvithin a few minutes after full dilatation i:> 1.·eached. Tlwrr i~-1 much to be said for lo\v forceps delivery from the f>tandpoint of the cardiac mother. The hulk of the strenuous physical exertion of lahor is expended in the expulsiw~ stage, after full dilatation lws been reached. It would seem then that the use of lmv forceps to eliminate the exertion incident to the sreoml stage of lalwr is a ,·er.'' rea<~onahl<' prceantion in patients ,,-ith heart dif;eaS('. Forreps oeliYC'lJ' s(\rves the beRt interests of both mother and baby.
In view of the high fetal rnOl'!allty among premature bahieN deliverC'd by cesarean section, it is somewhat TC'assuring to find that among 57 cesarean sections performed on cardiac patients at or near term, there was but one baby lost. This baby \vas known to hPcntixe crsaTean ~<'rtions at term without a fetal death. fi. THE INFLllE:'\CE OF DECOJ\il'E)Ji'-t\TIO::\ AT THE 'l'L:vn: OF DELIVERY TTPOX FE'l'\L siORTALTTY
It has been found by Clifford that tlw highest mortality among IH'Cmature babks is in that group df'liven:d of \lt•romp<'nsatcd cardiaes by l:esarean section. He found that the mortality rate in a small series of such babies was about 80 per cent. In this stud~', a patient was not ('011Sidered to }W dCCf;l1lpC'BSHh'd Ull!PRS she had at least persistent rales at the lung bases. The fetal mortality according to type of delivery and 11uration o:E pregnaney at tlH' time of delivery is ginn for thl:' faihm' rmd nonfailure groups in Table VII. 'rABLE VII.
THE I?\FLl:E:"CE OF :t'AJI,J1RE I?\ CARDL\i'S Nl' Till~ TI:I!J<: m' DFLI\'ERY 0" ~'HE :f'.vn; OF THE BABY DELIVERED AFT'ER WEEKS )10 >'AlLURE
F·AILURE
Pelvio Deliveries: Babies ,]iseharges stillborn Total Fetal
II I)
ll
11
~1
355
:~
1 3
0 R
~5
~63
:l LG 31<;i
16%
a
:JO
(l.t
"
7
7
II
0
0 0
s
10
:JO
R7 . .G9~
~.20%
{l(;f,,
4
70 S.57){.
The mortality of 1:'.7.:) per et•n1 in thiN st•riPs for fll'<'lllllts in sen•n· failnrr; W\'t'\'
Study of the f1•tal mort a! i 1~- of 1his gmup of J>atieuts has brought uut a numhrr of points whic·h ]lllntlld those already g-lPant·d from inw·stigntions of thr mal<• rna! risk in <'ill'd!;w patients. The ~'l'eatt•st fetal loss oc•rurs in that ratlwr t»Hlall g'toup of pat it•Hts with S<'Yere !waTt ll'sions, most of whom. had the~· :;onght t·ompd1'nt nwdieal attention. ••tmld lum· he•·n addst>d that their !wart !'PS\'l'\'c' wns too low to withstand iht> stnli11 of pt•cg1unu·~·. "\u mwxpPdedl~· lal'IJ.'t' liUmht>r of t!WS\' <~arast histories n·vcal 110 f;!ilut'(' aml 110 gross loss of 1'\'Set·n•. who will fail for the first timP in lht· mi1ldk of Jln·gBane~·. Tlwir babies arp extr('mely important, for most of t IH·m will 11\'YPI' snhsPqlwntl.'· lw in as good conditioH to withstaml 1lw sti':Jin ul' pr<'g!Htll\',\'. Thesi:' patiPn1s usually fail soml' tim1• nftt•r the 1\\'l'llii<'th \H'I'k. \\'ith ;1 ral'<' I'X~'I'Ption. they improV(' to a \'at·ying ~·:deltt lltHli•J' he•Hd ;1 lwtl- .:qJ('rtt•d dtltt· of ;•ontinemcnt is ]mown with reasonJll'm·e~;
'rEEL:
FETAI" MORTALITY TX PATJEX'ff' \YITH ORGANIC IIF.ART TlJSEASE
61
able certainty, it would appear that waiting until the thirty-sixth week, and if possible, the thirty-seventh, offers a more certain prognosii'l than estimation of the size of the baby. In these eases in which the mother is on the edge of failure, hut not in severe or gross failure, there would appear to be little likelihood that the baby ~will succumb to asphyxia in utero. Of fifty-five patients delivered while in congestive failur(\ then• were only five stillborn babies. The mothers of these babies \vcre in severe failure. The choice of method of delivery is equally troublesome. As far as the baby alone is eoneernC>d, pelvic delivery which implies induction of labor is the method of clwirt•. One hesitatC>::; to attempt tlw induction of labm· on sueh a patient. Inducrd labors so far from term are often long m1d tiring and cardiac patients should not he suhjC>etl·d to sneh an ordeal. RuptnrP of the membranes is uot infrrqucntly in<'ffertual, and even bagging may fail. 'rht'l'<' an• l'(•ports in the literature of artificial ruptme of the nwmlmmes having lwen immediately followed by acute and fatal congestive failure in cardiac patients. On the othrr hand, in our past rxperit'IH'C at 1rast. et'sat·ean sPction offers the poorrst ehance for the premature baby of tlw eardiac mother. Newrtheless, rertainly for primiparas, and probahJ~, ahw for multiparas whosP eonditiou doe~'\ 110t p(•rrnit of awaiting tnm delivery, res;wean SP('tioll will doubtless rrmain the method of ehoiel'. It would appPar that pn•maturc hahies do not tolerate well the moderah• degree. of asph~·xia i11(•idcnt to the combination of impaired matrrnal (•irculution and cesarean dt>livery. The prognosis for babies born after the thirty-fifth wPek of pregnancy when the mothe1· is on the Nlge of. ot· in. mild eon).rPstin• failur·c· is vPr~~ much brighter. The hig·h fptal mortality whic·h has hPen Pxperienecd in the past in this premature group c·an prohahl;' bt• n•ration of the liahy into oe bpyond the thirty-Rixth \vrrk. Qniek removal of the baby under \()('<11 anestlwsht or after a minimum peri()(l of inhalation mwsthPsia >vithout prC>limimll'y medication, eiipPeialJ~· without morphia, may also aid h1 1wlueing tlwse premature draths.
Ro far as the tC>rm babies of the eompenS11ted (•ardiacs are e~oncP~l'lle mot her. REPEREXCES
(1) Hamilton, B. E.: Boston M. &i R..J. 1S8: !lf\7, Hl~3. (~) Hamilton, B. JL and Kellogg, F. 8.: A~r. .T. 0Bf.l'I'. & GY:\El'. 13: ;-;:\;). l!l~7. 0:) JTamilton, B. E., and 1\.f'llo.r;g, F. 8.: Bo8ton M. & R. .T. 91: 194:.!, Hl~R. (4) Gliffori!., S. H.: .T. Per1iat. 5: 139, 1!134. (.'i) Cliffon!, S. H.: J. A.M. A. 103: 1117, 1934.
FETAL 'MORTALITY IN PATIE~TS WITH ORGAKIC' HEART DISEASE
5!)
REFERENCES
(1) DeLf'c, Joseph B.: The Prindples an
A STUDY OP THE FETAL MORTAIJl'J'Y IN PATIENTS WITH ORGANIC HEART DISEASE
IL\IWW :\L
'l'EEL,
l\LD.,
BoHTON, l\fAs~.
(Frorn the Depart-ment of Obstet1·ics, Har,vard Mt>dical School)
medical management of the cardiac patient during pregnaney PROPER involves great sacrifiee of her time, curtailment of her activity, and a considerable expense, over and above that incident to pregnancy in the normal subject. 'I'he risk of pregnancy to her life iH not negligible, even under optimum conditions. In the past, medical and obstetrie discussion of the question whether or not a cardiae patient should undertake pregnancy has concerned itself almost wholly with the maternal risk, without clue consideration of the baby. It would seem that the probability of obtaining a live lwby should be an important factor in sueh a decision. An unusual opportunitr for study of the fetal mortality associated with this complication i" afforded by the large number of patients with heart diseaRc who have heen treatrd at thr Boston IJ:vingin Hospital. 1. MATERIAL A special heart clinic has been in oprration for fift('rn y(~ars at this institution under the clireetion of Dr. B. B. Hamilton. 1 • 2 • 3 During routine prenatal examinations all patients who present signs or symptoms which might be r(•femble 1o heart disease arc direeted to this clinic for cardiac diagnosis. Those fonnd to have organic heart disease are followed by the cardiologist throughout pregnaney, deliver~', and puerperium. In addition to the patients from our own prenatal clinies, a large number of cardiae patients arc referrrd to the heart clinic by the general hospitals of the community, by practitioners who do their own
relatively normal obstet ric·s. and by oth1•r obstdrir im;t itutions in which c·ontrw~cp1 iv1' ndvh·c·. tl11'tn pcntic· aborti011. and sterilization.
religious principles prohibit
he pt·c•sc·nted in 1lii~ paJi'''' lias ht·(·ll ohtainv1l from the e;JI'
2.
GHO:-::-: JET.\!. ~\IOitT.\LJT\
1'(11{ TTIJ: \\'T!Of.E 1ill01T
During: the ten-~·r:1r pniod oi' thi,., ~tnd)-, fins p:i1 i1·nt,.; \Yith mwmH· lwnrt disPnse havn hel'll tl'1·atv1l m11l t'ld iYPl'l'll in tlJL· 1tnsp1tn 1. Of this group, 514 wrre
GRoss FETAL MOR'rALITY
POl~
/u,r, CARDIAC P.\'PlJo'l\TS
Total pregnant earrliacs in the series Total babieR Died undeHvere
in('hH1('~
nh0rtiot1s nnrl
~
fJnir~
J:\ Till~
liRII!'P
II
Iii
j.,q
1!i ~11.li1~;,,
'7.gS?f ot·
tvdn~.
The gross fetal loss (20.18 per cent) is E-nlig-htening, and at first thought rather d.iscomaging, although .it shmlld h0 pointed ont that more than half of the bahit·P lost were ft·mn spontaneous and t.herapeuti<~ abortions. Abm1iom; are nnt ordinarii.'· inclndcd in computing fetal mortality. Ncvcrth0h•ss, tlds gTo:-s fignrc· is of some importance, for it shows that without sl'lL'<'tion. (•nn1i;Je rmtients have only an 80 TH'l' cent chance of haying a hnhr t hni sm·vi n's. Howevr~r, if one pxc•ludt>s tlw relatively small gnmp of cardiae pnt.ient::; with such Sl'W·re damage that the risk of prcgnanc~T to their own lives is excessive, it will be shown
TEEL:
FETAL MORTALITY IN PATIEXTS "WITH ORGANIC HEAR'r J)JSEASE
55
later that the prospect d obtah1ing a living baby is excellent. On the basis of history and physical examination, it is possible before the onset of pregnancy to recognize a large majority of these patients with heart lesions which are too severe to allow them to earry the strain of pregnancy. This point has been emphasized h,r Hamilton. Such patients whose cardiac condition clearly contraindicated pregnancy made up the great majority in the gt·oup upon whom thera11eutic abortions were performed, and a considerable proportion of those ·whose pregnancies wero terminated because of fuilnre while the baby ·was still premature.
3.
FETAL MORTALITY FOR BABIF.i'i DELIVERED AFTER VIABILITY
There were a total of 514 patients in whom pregnancy terminated aftrr the twenty-eighth week. In the cases of fifty-three it was necessary to deliver the patient prematurely because of the condition of the heart (usually because of the occurrence of congestiYe failure). In the otherR, either labor was spontaneous or electi\'C cesarean ~ection was done at term. The fetal mortality for these viable babies is presented with some detail in 'l'able II. TABLE
II.
FETAL 1IORTALITY FOR ALL VIABLE BABIES-IRREBPEC'e!VE OF METHOD 0!' DELIVERY OR CARDIAC CO:
..-=--.' ----
=~==_:..=.----.--=c._-_--_
DPR"\TION OF PREGNANCY II\ WEEKS A'l' DELIVERY ~£) 'l .t),}
Total babies delivered Discharged living Stillborn Neonatal deaths Gross :fetal mortality
THROUGH WEEKS
~,..
.;.),)
APTER, WEEKS
3() li 2
486 467 13
17
()
:i2.77%
TOTAL FOR GROUP
522 -184
15
3.111 '/r
-~-'"-,~---
-
~3
7.28%
The mortality among the babies delivered after the thirty-fifth week (3.91 per eent) compares favorably with the gt>nera1 ft.'tal mortalit~' for the hospital (excluding prematures). Although t hr pn·maturt>s made up less than 7 per cent of the whole gToup, they ac·eom1ted for half of the loss of babies. As >vin be shown in the followi11g Rc:etion, th(' mortality in the p1·emature groul1 is unusually high.
4.
FETAL MORTALITY IN THE PREMATURE GHOUP
'rho total mortality among the premature babies of this group of c.ardiae mothers is considerably higher thn-n that for prematures in general. Of the 36 viable babies dellv<:>red before the thirty-sixth week of gestation, only 17 surviwd. Of those lost, only ~ were Rtillborn, and 17 died subsequent to delivery. Thns, of 34 "Premature babies born alive, 50 per cent subsequently died. What are the factors which have contributed to this high neonatal death rate? It is not to be explained upon an undue proportion of very premature babies (at least so far as weight is concerned), for of the 17 babies who died, 12 weighed over 4 pounds,
-! betwet•n ;~ and
+ pmnHls,
nnd only 1 wt>i~od~t·d lvss than :3 pounds. :'\early all of tlw fatalities 'Jl'('Ul'l'l'd within the fi1·st forty-eight hont·s. Death was usually JHT<'l'th·~l h,,. <·ya.nosis awl labon·d l'el'lpiration. At autops,v littlP \VHs foll!Hl t'X('(•pt fo1· a1t•IP\·lasis. t";id!'JWI' of tht· aspit'Htion of amniofi<' fluid, Hlhl1 he S!''!lH'laP of asphyxia. Tbe ly!Jt~ of deliwry St'"lll:-> 1o han' lit'Pil one impo1'1all1 fa!•tor. In Tahir [IJ is J!I'(•St'll1f'd tiw fetal mortality fol' :ill hahit•s whos\' hirth weig-hts \V(•n• kHs than fin· pmlJH!s, J'!'lnted to tlw nwthwl of th•liwn·. TMll.J·:
III.
< 'o>IPAIUSO:\ "~" TH;: FETAL :\!ownuTY 1:\ B.IHIFK l':\DJ•:n ~'1n: }lELTVF:Rf.Jl 1'HIW1'(lH THR Pn.l'f;-; A"D BY f'f.S,\R;:.\::-- 1'l:i'TI
l'
'l'Y!'l:
Dabirs
...,
1
II
i'F;;.:.\J(f:.\S
+
11
II
7::Uil'/r
Of the fif'h•m JH'(•ma.lmt• babies delin•red through thP pdvis, tlw mortalitr 1vns only 1:3.3a pet· r·(•nt, whel'('HH of a likt• num}wr 1klivPrerl hy <'csarean sL•etion, 73.33 per eent died. ThPse findi11g~'> for ptcmnturP bahicH of cardiae mothc·rs r·ullfirm tho,;t• of ( 'lifford. 1 In his stwlies of prematm·r iJJfant mol'tality he has slJOwn tha1 tlw tH'Itllatal dPath rat!' is much higher aft1T et's;n·ean than aftn· anr type of pelvic dc]i.yery, except for bteeeh extraetion. In his serii!S of prt•matures of cardia1• mothers, the neonatal moriality was 7fi Jll't' ('ent for those dcliwred hy ecsarean, and 30 pf'l' ('t'Jlt for n·r(('X pt·esentation:-; fh•liYt'lWl normally o1· by low forceps.
'Tlw prN·isr rrnsmts wh,\· th(•se pn·malllt't•s cklin•rt>d hy l'PSal'(•;m section have do11e sn poor1y nre not t•ntirPI~c (•km·. HuwvH'l'. seVE'l'Hl fartors whirh would 'n·rn to lwat· some t'!'latim' should h;· mt•ntion!'d. Fil'st. as noted abon·, autopsies in the fat ;.d ,;,•n m
TEEL:
FETAL MORTAUTY IN PATIENTS WITH ORGANH' HEAR'f DISEASE
57
to a preexisting intrauterine asphyxia. A number. have required resuscitation. MoiTJhia is no longer userl in the preparation of thc~e patients for cesarean section. Indeed, it is preferred to gin: no medi<'ation whatever in preparing th(: mother of a premature baby for delivery by eesaI'E'an section. The operation 1s now done either under lo<'al anesthesia o1· with a minimum of drop ether. Of the group of prematurcs delivered through the pelvis, only two mothers wer·e in mild decompensation, and morphia was given in only one case. These facts undoubt(·dly lwlp to explain the much lower fetal mortality in this group. There is one other sugg('stion which may have some significance in the explanation of the very high neonatal death rate among the prematm·es delivered by cesarean section. :Most of the babies in this group have been very well nourished. The mothers of the premature cesarean babies have usually been in bed for weeks or months before delivery, a circumstance which might tend to produce well-nourished infants. Possibly many of these babies have btun more premature in weeks of gestation than the birth weights would indicate. One certainly sees th(' ovposite condition fairly commonly in the thin premature ha by of the toxrmie patient, which, on the basis of weig·ht alone. should lw more prematnrf' than one would expect from the duration of pregnancy. Clifford states 1hat these prematures of the toxemic patients, onee they are born alive, han~ as good a chaneo for survjva.l as any J.1I'emature. His cha1t a('tually shows that the mortality among the prematures born alive of toxemic mothers is slightly less than that of similar babies born of presumabl;' normal mothers, ilnd. much Jess than for those of any other group. Very likely this may be explained by the rclativrl;· greater maturity of the thin toxernie baby )n actual weeks' duration of pregnaney, in compat·ison with its birth weight. In Table III the conventional five pounds was used as the criterion of prematurity. Because it was susp('cted that the prt'mature babies of cardiac patients (the activities of whom have been greatly restri(·ted during pregnancy) might be somewhat h('avier than other prematures on a basis of weeks' duration of pregnancy, the fetal mortality of aU babies born of cardiac patienhi, regardlt·ss of the type of ddivery, has been tabulated according to estimated W('eks' dmation of th(' pregnancy at the time of delivrry. Th<> rrsult is seen in Table IV. The result of the tabulation in Tn ble IV is surprisingly consistent. For comparison, the .~11me data al'e presented for the mortality of these babies on a basis of bit·th weight. ThiR may bt' seen in. Table V. Comparing the two tables, it would appear that estimated weeks' duration of pregnancy is a more reliable index of the dwnce of SUITival than t lw actual birth weight. The former should be considerably more reliable than an estimate of thr size of the bahy in utero by palpation. For this reason it would appear that, at least when the duration of the
TABLE
lV.
2\Eo'>AT.\r, DE.\TH HATE FOtt
Ar.r,
R\I;LFtJ
RKL.\TED •ro ERTf~L\TJm Dmt\TWN OP PRr:G:\AKt:Y
Bote--;
,\u\·t:
.\'P TorE m•
1·::-n:tMATEn \\'~:f·J\."'' Dl~RA'flO:\
m•
\'.\t{i>L\<'
OF l 1 ltEG~.\~C'Y A'r
llU:L!YEIW ')0
i TtJ
• J ....
Liw
VVK •
..
~;:)~~3-t
::.'5-aG
:{7 -~·iH
:)\l-4u
s
:;o
7:~
:;
:)7~
.j
l'i
li
lj
t .~
li?
:Ol<>'t!II·:J{s
lli<:U\'El!'\'
:~-<
II
N!WK.\T.\J, Dt~A'rH lt.l.H: roH ALL YL\HLE BArnER or <'.\J{!HAl1 Mo'l'HKRR
1lJ.:LNrrn To Bm•rn \VEHnt'P lllR'l'll WEIGHT lK POUKDS LEC'f; TITAN
n
Livc
1!11 I
..
R-+
4-:3
:;
l:!
l·U
8 .J\l
·>
Died PPI'
3
:'H\ :~,
:2 .i ~ ,-~ /I
(~
plus
4os :.>
11.-lc!l
pregnancy by dates lw:-> been con;.;istent with obstetric examination, the likelihood of survival mn~· lw mm~P aeenrately prognosticated on the basis of weeks' duration of pregnaney than by estimated weight of the baby. ·whethel' the nwthc<1 of mea;-;uting the oeeipitofrontal diameter of the fetal head in utero h~· x-ruy" will be of gl'eater prognostie value remains to be SC'('l1. On tlw hn::ds or ilte te:,ultH shown in ~'ahle IV one may infer that the <•hanee of snniYnl is ioo small he-fore Uw thirty-fifth week if tlre baby is to be :owr·icmsl;· Nmsidert•d; the ebanee is reasonably good in the thirty-flfth ;md thirty-:-dxth weeks; und nft<'l' the thirt~·-sixth week tlw ehnnee of survival is excellent. :l.
'!'fiE Hl~J,ATIO:-:
(H'
'l'Yl'E OJ·' l>ELl\'lcHY TO Tl·m FE'L\f. :XJOR'l'ALI'PY OF :\;lA'lTRE R\l31E:-'
'l'here ·wet\' 462 patients ddivn·l'd t•ithPt' nfter 1ht• spontmwous onst't of labor, or h.v dl'eti\'1' <'('SHTUtll se<·iion Hl term. 'l'he Yarious types of dPlivel'y and 1ltP fda! mortality of e;wh an.· shown in Table VI.
l'YPE
OF m:LlVJmY
1
Normal Forceps (24 midton:t.•p;;l Breech cxtr::wtion. veri' ion Cesarean at term ---
-
TO'J',\L
j)J :-;~
ru.uu:c<
t'IL\Hil!(D
Tll•: u n:1a:n
·wEI.!,
2!0 :.:.~
J tiN :!OX 21
:i7
:-~o
iltl
:-;'J'lLL BUHS
!I
nn:n •>
-
•)
1*
0
II
PER l'EKT :.tuR'L\Ll'l'Y
li.lJ O.P.'i
1:.:.;-;o 1.i5
----------
*This Rtillborn babY v;af; knnwn to be dead befort· the OPt-'r<--ttion \vhich was done for abruptio placentae. Thu'. th<· f'nrt'<'<·t<>•l f,,taJ mortality for ('esarean Aeetion at tern1 foe this series \V:J.s. nil.
H 'vill lw sef'n from Tahk VI ihat the gl'osx f\'lal mortalit.v followinf( wmnal ddivPl'.\' is on·1· six tinws that following forceps. 'l'his dol's not pri'Sl\ni 1fH· ('liSe for nornwl d,·li\'1'1',\' quitP fail']~·. sincP there wel'P Hmong the 11ine stillhit·t h:.; d<"lh·<·l'l'!l normally fivo monsters and one
macerated fetus. However, the fetal mortality after forceps delivery of 0.95 per cent speaks ;,:trougly in fann· of this method as a routine in all cases in whieh spontanrous deliwry lloes not occur vvithin a few minutes after full dilatation i:> 1.·eached. Tlwrr i~-1 much to be said for lo\v forceps delivery from the f>tandpoint of the cardiac mother. The hulk of the strenuous physical exertion of lahor is expended in the expulsiw~ stage, after full dilatation lws been reached. It would seem then that the use of lmv forceps to eliminate the exertion incident to the sreoml stage of lalwr is a ,·er.'' rea<~onahl<' prceantion in patients ,,-ith heart dif;eaS('. Forreps oeliYC'lJ' s(\rves the beRt interests of both mother and baby.
In view of the high fetal rnOl'!allty among premature bahieN deliverC'd by cesarean section, it is somewhat TC'assuring to find that among 57 cesarean sections performed on cardiac patients at or near term, there was but one baby lost. This baby \vas known to hP
It has been found by Clifford that tlw highest mortality among IH'Cmature babks is in that group df'liven:d of \lt•romp<'nsatcd cardiaes by l:esarean section. He found that the mortality rate in a small series of such babies was about 80 per cent. In this stud~', a patient was not ('011Sidered to }W dCCf;l1lpC'BSHh'd Ull!PRS she had at least persistent rales at the lung bases. The fetal mortality according to type of delivery and 11uration o:E pregnaney at tlH' time of delivery is ginn for thl:' faihm' rmd nonfailure groups in Table VII. 'rABLE VII.
THE I?\FLl:E:"CE OF :t'AJI,J1RE I?\ CARDL\i'S Nl' Till~ TI:I!J<: m' DFLI\'ERY 0" ~'HE :f'.vn; OF THE BABY DELIVERED AFT'ER WEEKS )10 >'AlLURE
F·AILURE
Pelvio Deliveries: Babies ,]iseharge
II I)
ll
11
~1
355
:~
1 3
0 R
~5
~63
:l LG 31<;i
16%
a
:JO
(l.t
"
7
7
II
0
0 0
s
10
:JO
R7 . .G9~
~.20%
{l(;f,,
4
70 S.57){.
The mortality of 1:'.7.:) per et•n1 in thiN st•riPs for fll'<'lll
Study of the f1•tal mort a! i 1~- of 1his gmup of J>atieuts has brought uut a numhrr of points whic·h ]lllntlld those already g-lPant·d from inw·stigntions of thr mal<• rna! risk in <'ill'd!;w patients. The ~'l'eatt•st fetal loss oc•rurs in that ratlwr t»Hlall g'toup of pat it•Hts with S<'Yere !waTt ll'sions, most of whom. had the~· :;onght t·ompd1'nt nwdieal attention. ••tmld lum· he•·n addst>d that their !wart !'PS\'l'\'c' wns too low to withstand iht> stnli11 of pt•cg1unu·~·. "\u mwxpPdedl~· lal'IJ.'t' liUmht>r of t!WS\' <~ar
'rEEL:
FETAI" MORTALITY TX PATJEX'ff' \YITH ORGANIC IIF.ART TlJSEASE
61
able certainty, it would appear that waiting until the thirty-sixth week, and if possible, the thirty-seventh, offers a more certain prognosii'l than estimation of the size of the baby. In these eases in which the mother is on the edge of failure, hut not in severe or gross failure, there would appear to be little likelihood that the baby ~will succumb to asphyxia in utero. Of fifty-five patients delivered while in congestive failur(\ then• were only five stillborn babies. The mothers of these babies \vcre in severe failure. The choice of method of delivery is equally troublesome. As far as the baby alone is eoneernC>d, pelvic delivery which implies induction of labor is the method of clwirt•. One hesitatC>::; to attempt tlw induction of labm· on sueh a patient. Inducrd labors so far from term are often long m1d tiring and cardiac patients should not he suhjC>etl·d to sneh an ordeal. RuptnrP of the membranes is uot infrrqucntly in<'ffertual, and even bagging may fail. 'rht'l'<' an• l'(•ports in the literature of artificial ruptme of the nwmlmmes having lwen immediately followed by acute and fatal congestive failure in cardiac patients. On the othrr hand, in our past rxperit'IH'C at 1rast. et'sat·ean sPction offers the poorrst ehance for the premature baby of tlw eardiac mother. Newrtheless, rertainly for primiparas, and probahJ~, ahw for multiparas whosP eonditiou doe~'\ 110t p(•rrnit of awaiting tnm delivery, res;wean SP('tioll will doubtless rrmain the method of ehoiel'. It would appPar that pn•maturc hahies do not tolerate well the moderah• degree. of asph~·xia i11(•idcnt to the combination of impaired matrrnal (•irculution and cesarean dt>livery. The prognosis for babies born after the thirty-fifth wPek of pregnancy when the mothe1· is on the Nlge of. ot· in. mild eon).rPstin• failur·c· is vPr~~ much brighter. The hig·h fptal mortality whic·h has hPen Pxperienecd in the past in this premature group c·an prohahl;' bt• n•
Ro far as the tC>rm babies of the eompenS11ted (•ardiacs are e~oncP~l'lle
(1) Hamilton, B. E.: Boston M. &i R..J. 1S8: !lf\7, Hl~3. (~) Hamilton, B. JL and Kellogg, F. 8.: A~r. .T. 0Bf.l'I'. & GY:\El'. 13: ;-;:\;). l!l~7. 0:) JTamilton, B. E., and 1\.f'llo.r;g, F. 8.: Bo8ton M. & R. .T. 91: 194:.!, Hl~R. (4) Gliffori!., S. H.: .T. Per1iat. 5: 139, 1!134. (.'i) Cliffon!, S. H.: J. A.M. A. 103: 1117, 1934.