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812: Does pregnancy affect cardiac function in women with congenital heart disease?
Fetus Diabetes, etc
www.AJOG.org 811 Women with congenital heart disease (CHD): how does CARPREG perform in this population and can it be improved? Vanita Dharan1, Gary Webb2, Mary Sammel3, Nazanin Moghbeli4, Michal Elovitz5, Sindhu Srinivas1, Emmanuelle Pare1 1
University of Pennsylvania, Maternal and Child Health Research Program; Dept OBGYN, Philadelphia, Pennsylvania, 2University of Pennsylvania, Philadelphia Adult Congenital Heart Center; Medicine, Philadelphia, Pennsylvania, 3University of Pennsylvania, Maternal and Child Health Research Program; Biostatistics and Epidemiology, Philadelphia, Pennsylvania, 4University of Pennsylvania, Medicine, Philadelphia, Pennsylvania, 5University of Pennsylvania, Maternal and Child Health Research Program; Dept OBGYN; CRRWH, Philadelphia, Pennsylvania
OBJECTIVE: The CARPREG score (Siu, 2001) is a useful tool to predict adverse cardiac events during pregnancy in women with cardiac disease. We sought to test the performance of CARPREG in women with CHD and assess if CARPREG can be improved in this population. STUDY DESIGN: Retrospective cohort study of pregnant women with CHD who delivered ⱖ20 wks at one institution from Jan 1998-Apr 2009. Subjects were identified by ICD-9 code (648.0-9); mitral valve prolapse only, non-CHD cardiac disease and single ventricle physiology were excluded. The primary outcome (CARDCOMP) was: congestive heart failure, arrhythmia requiring treatment, stroke, cardiac arrest, cardiac death. Actual rates of CARDCOMP were compared to expected (by CARPREG score) using chi-square goodness-of-fit tests. We tested if other factors were predictive of CARDCOMP: tobacco use, pulmonary regurg/subpulm ventricular dysfunction (Khairy), systemic right ventricle (syst RV). Chi-square/Fisher’s exact tests were used for bivariate analyses, MVLR for adjusted analyses. We explored if CARPREG score was improved by incorporating new factors; cstatistic was used to asses the discriminative ability of CARPREG/ revised CARPREG. RESULTS: 117 pregnancies in 95 women met the inclusion criteria. The distribution of CARPREG scores was: 71 pregnancies had 0, 39 had 1, 7 had 2. CARDCOMP occurred in 15 pregnancies: 2 (2.8%) with 0 score, 11 (28.2%) with 1 and 3 (42.9%) with 2. This distribution of actual CARDCOMP was not different than expected (p⫽0.57). In bivariate analyses, only CARPREG score and syst RV were associated with CARDCOMP. In multivariate analysis, only CARPREG score remained a significant predictor of CARDCOMP. Incorporating syst RV into revised CARPREG score improved its discriminative ability, but this was not significant (c-statistic: 0.7977 [0.6841-0.9113] vs 0.7869 [0.6794-0.8944]; p⫽0.56). CONCLUSION: The CARPREG score performed well in predicting cardiac morbidity during pregnancy in our CHD population. Including additional predictive factors specific to this population such as syst RV may improve CARPREG. 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.828
812 Does pregnancy affect cardiac function in women with congenital heart disease? Vanita Dharan1, Michal Elovitz2, Sindhu Srinivas2, Gary Webb3, Emmanuelle Pare4 1
University of Pennsylvania, OBGYN, Philadelphia, Pennsylvania, University of Pennsylvania, Maternal and Child Health Research Program; Dept OBGYN; CRRWH, Philadelphia, Pennsylvania, 3University of Pennsylvania, Philadelphia Adult Congenital Heart Center; Medicine, Philadelphia, Pennsylvania, 4University of Pennsylvania, Maternal and Child Health Research Program; Dept OBGYN, Philadelphia, Pennsylvania 2
OBJECTIVE: Data on the long-term impact of pregnancy on cardiac function in healthy women is limited; even less data exists in women with congenital heart disease (CHD). Our objective was to assess how pregnancy impacts the systemic ventricular function of women with CHD. STUDY DESIGN: Secondary analysis of retrospective cohort study of pregnancies complicated by maternal CHD. Women with CHD cared for at one institution from Jan 1998-Apr 2009 were identified by ICD-9 code (648.0-9). Women with isolated mitral valve prolapse,
Poster Session V
non-CHD cardiac disease or without pre and post pregnancy echocardiograms were excluded. Pre-pregnancy echo (PRE) qualified if echo was in the 2 years prior to preconception or ⬍20 wks’ gestation. Post-pregnancy echo (POST) qualified if echo was 6 wks-1 yr after delivery. Systemic ventricular function was classified as normal (ⱖ55%), borderline (40-55%) or abnormal (⬍40%). The primary outcome was ⱖ10% decrease in ejection fraction (EF) from PRE to POST. PRE and POST EF were compared using paired t-test. Fisher’s exact test was used to compare categorical variables. RESULTS: 45 pregnancies in 40 women met the inclusion criteria. EF values were available for 36 pregnancies: mean PRE EF was 63% and mean POST EF was 61% (p⫽0.068). A decrease in EF of 10% was noted after 9 pregnancies (25%;95%CI: 10-40). Decrease in EF 10% was not associated with CARPREG score (p⫽0.47), but was seen after half the pregnancies complicated by adverse cardiac events vs after 22% of pregnancies without cardiac events (p⫽0.26). PRE echo: 36 women had normal ventricular function, 8 borderline & 1 abnormal. POST echo: 32 normal, 11 borderline & 2 abnormal. By this classification, 8 women had deterioration and 3 women had improvement in ventricular function after pregnancy. CONCLUSION: In women with CHD, pregnancy appears to negatively impact the ventricular function in a non-negligible proportion of women. Future research should validate our findings in a larger population and assess how these changes in EF after pregnancy affect clinical function and outcomes. 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.829
813 Treatment of cancer in pregnancy: the use of stem cell mobilizers Farhana Irfan1, Rebecca Dougherty2, Elyce Cardonick3 1 Cooper Hospital of South New Jersey, Maternal and fetal Medicine, Collingswood, New Jersey, 2Lankenau, Internal Medicine, Wynnewood, Pennsylvania, 3Robert Wood Johnson, Obstetrics-Gynecology, Maternal-fetal Medicine, Camden, New Jersey
OBJECTIVE: Little is known about the effects of Stem cell mobilizers
(SCM) like pegfilgrastim during pregnancy. Neutropenia could expose the patient to infections which can be harmful to the developing fetus. STUDY DESIGN: Oncologists were asked if SCM were prescribed for pregnant women when necessary, were not necessary, or were held due to pregnancy. Neonatal outcomes were requested. A retrospective chart analysis and Fisher’s Exact test comparing patient outcome was performed. RESULTS: 156 received chemotherapy while pregnant. Twenty six women received pegfilgrastim (9) or filgrastim (17). Reasons for not receiving SCM included 32 “not necessary”, 4 “withheld due to pregnancy” and 72 provided no explanation. Chemotherapy began at a mean gestational age of 20.5 (SD6.1) weeks. Mean gestational age at delivery was 35.9 (2.8) weeks in the unexposed compared with 35.5 (2.76) in exposed, p⫽0.465. Mean birthweight in unexposed was 2694 (750.1) grams, and 2490 (460.1) grams in the exposed, p⫽0.182. Congenital malformations included spina bifida and hydrocephalus in the exposed, and talipes, pyloric stenosis, plagiocephaly, hemihypertrophy and pulmonary artery fistula in the unexposed, p⫽0.33. None of the newborns/children in either group were treated for infections. Of the 26 neonates exposed to SCM, 19 had a CBC performed within 48 hours after birth. Mean WBC in exposed neonates was 12.7 (4.6) compared to 14.5 (7.6) in the unexposed, p⫽0.366. Pediatric follow up was obtained in 137 neonates up to a mean age of 42.9 (SD32) months. Complications reported in exposed newborns included hypoglycemia, and grunting, and in unexposed RDS, neutropenia, jaundice, apnea, GE reflux, one child with eye squint, abnormal hearing test and hemangioma; and a child with a systemic autoimmune disorder. The incidence of complications in each group was not significantly different, 19.2% vs. 15.4%, p⫽0.571.
Supplement to DECEMBER 2009 American Journal of Obstetrics & Gynecology
S291
www.AJOG.org 811 Women with congenital heart disease (CHD): how does CARPREG perform in this population and can it be improved? Vanita Dharan1, Gary Webb2, Mary Sammel3, Nazanin Moghbeli4, Michal Elovitz5, Sindhu Srinivas1, Emmanuelle Pare1 1
University of Pennsylvania, Maternal and Child Health Research Program; Dept OBGYN, Philadelphia, Pennsylvania, 2University of Pennsylvania, Philadelphia Adult Congenital Heart Center; Medicine, Philadelphia, Pennsylvania, 3University of Pennsylvania, Maternal and Child Health Research Program; Biostatistics and Epidemiology, Philadelphia, Pennsylvania, 4University of Pennsylvania, Medicine, Philadelphia, Pennsylvania, 5University of Pennsylvania, Maternal and Child Health Research Program; Dept OBGYN; CRRWH, Philadelphia, Pennsylvania
OBJECTIVE: The CARPREG score (Siu, 2001) is a useful tool to predict adverse cardiac events during pregnancy in women with cardiac disease. We sought to test the performance of CARPREG in women with CHD and assess if CARPREG can be improved in this population. STUDY DESIGN: Retrospective cohort study of pregnant women with CHD who delivered ⱖ20 wks at one institution from Jan 1998-Apr 2009. Subjects were identified by ICD-9 code (648.0-9); mitral valve prolapse only, non-CHD cardiac disease and single ventricle physiology were excluded. The primary outcome (CARDCOMP) was: congestive heart failure, arrhythmia requiring treatment, stroke, cardiac arrest, cardiac death. Actual rates of CARDCOMP were compared to expected (by CARPREG score) using chi-square goodness-of-fit tests. We tested if other factors were predictive of CARDCOMP: tobacco use, pulmonary regurg/subpulm ventricular dysfunction (Khairy), systemic right ventricle (syst RV). Chi-square/Fisher’s exact tests were used for bivariate analyses, MVLR for adjusted analyses. We explored if CARPREG score was improved by incorporating new factors; cstatistic was used to asses the discriminative ability of CARPREG/ revised CARPREG. RESULTS: 117 pregnancies in 95 women met the inclusion criteria. The distribution of CARPREG scores was: 71 pregnancies had 0, 39 had 1, 7 had 2. CARDCOMP occurred in 15 pregnancies: 2 (2.8%) with 0 score, 11 (28.2%) with 1 and 3 (42.9%) with 2. This distribution of actual CARDCOMP was not different than expected (p⫽0.57). In bivariate analyses, only CARPREG score and syst RV were associated with CARDCOMP. In multivariate analysis, only CARPREG score remained a significant predictor of CARDCOMP. Incorporating syst RV into revised CARPREG score improved its discriminative ability, but this was not significant (c-statistic: 0.7977 [0.6841-0.9113] vs 0.7869 [0.6794-0.8944]; p⫽0.56). CONCLUSION: The CARPREG score performed well in predicting cardiac morbidity during pregnancy in our CHD population. Including additional predictive factors specific to this population such as syst RV may improve CARPREG. 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.828
812 Does pregnancy affect cardiac function in women with congenital heart disease? Vanita Dharan1, Michal Elovitz2, Sindhu Srinivas2, Gary Webb3, Emmanuelle Pare4 1
University of Pennsylvania, OBGYN, Philadelphia, Pennsylvania, University of Pennsylvania, Maternal and Child Health Research Program; Dept OBGYN; CRRWH, Philadelphia, Pennsylvania, 3University of Pennsylvania, Philadelphia Adult Congenital Heart Center; Medicine, Philadelphia, Pennsylvania, 4University of Pennsylvania, Maternal and Child Health Research Program; Dept OBGYN, Philadelphia, Pennsylvania 2
OBJECTIVE: Data on the long-term impact of pregnancy on cardiac function in healthy women is limited; even less data exists in women with congenital heart disease (CHD). Our objective was to assess how pregnancy impacts the systemic ventricular function of women with CHD. STUDY DESIGN: Secondary analysis of retrospective cohort study of pregnancies complicated by maternal CHD. Women with CHD cared for at one institution from Jan 1998-Apr 2009 were identified by ICD-9 code (648.0-9). Women with isolated mitral valve prolapse,
Poster Session V
non-CHD cardiac disease or without pre and post pregnancy echocardiograms were excluded. Pre-pregnancy echo (PRE) qualified if echo was in the 2 years prior to preconception or ⬍20 wks’ gestation. Post-pregnancy echo (POST) qualified if echo was 6 wks-1 yr after delivery. Systemic ventricular function was classified as normal (ⱖ55%), borderline (40-55%) or abnormal (⬍40%). The primary outcome was ⱖ10% decrease in ejection fraction (EF) from PRE to POST. PRE and POST EF were compared using paired t-test. Fisher’s exact test was used to compare categorical variables. RESULTS: 45 pregnancies in 40 women met the inclusion criteria. EF values were available for 36 pregnancies: mean PRE EF was 63% and mean POST EF was 61% (p⫽0.068). A decrease in EF of 10% was noted after 9 pregnancies (25%;95%CI: 10-40). Decrease in EF 10% was not associated with CARPREG score (p⫽0.47), but was seen after half the pregnancies complicated by adverse cardiac events vs after 22% of pregnancies without cardiac events (p⫽0.26). PRE echo: 36 women had normal ventricular function, 8 borderline & 1 abnormal. POST echo: 32 normal, 11 borderline & 2 abnormal. By this classification, 8 women had deterioration and 3 women had improvement in ventricular function after pregnancy. CONCLUSION: In women with CHD, pregnancy appears to negatively impact the ventricular function in a non-negligible proportion of women. Future research should validate our findings in a larger population and assess how these changes in EF after pregnancy affect clinical function and outcomes. 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.829
813 Treatment of cancer in pregnancy: the use of stem cell mobilizers Farhana Irfan1, Rebecca Dougherty2, Elyce Cardonick3 1 Cooper Hospital of South New Jersey, Maternal and fetal Medicine, Collingswood, New Jersey, 2Lankenau, Internal Medicine, Wynnewood, Pennsylvania, 3Robert Wood Johnson, Obstetrics-Gynecology, Maternal-fetal Medicine, Camden, New Jersey
OBJECTIVE: Little is known about the effects of Stem cell mobilizers
(SCM) like pegfilgrastim during pregnancy. Neutropenia could expose the patient to infections which can be harmful to the developing fetus. STUDY DESIGN: Oncologists were asked if SCM were prescribed for pregnant women when necessary, were not necessary, or were held due to pregnancy. Neonatal outcomes were requested. A retrospective chart analysis and Fisher’s Exact test comparing patient outcome was performed. RESULTS: 156 received chemotherapy while pregnant. Twenty six women received pegfilgrastim (9) or filgrastim (17). Reasons for not receiving SCM included 32 “not necessary”, 4 “withheld due to pregnancy” and 72 provided no explanation. Chemotherapy began at a mean gestational age of 20.5 (SD6.1) weeks. Mean gestational age at delivery was 35.9 (2.8) weeks in the unexposed compared with 35.5 (2.76) in exposed, p⫽0.465. Mean birthweight in unexposed was 2694 (750.1) grams, and 2490 (460.1) grams in the exposed, p⫽0.182. Congenital malformations included spina bifida and hydrocephalus in the exposed, and talipes, pyloric stenosis, plagiocephaly, hemihypertrophy and pulmonary artery fistula in the unexposed, p⫽0.33. None of the newborns/children in either group were treated for infections. Of the 26 neonates exposed to SCM, 19 had a CBC performed within 48 hours after birth. Mean WBC in exposed neonates was 12.7 (4.6) compared to 14.5 (7.6) in the unexposed, p⫽0.366. Pediatric follow up was obtained in 137 neonates up to a mean age of 42.9 (SD32) months. Complications reported in exposed newborns included hypoglycemia, and grunting, and in unexposed RDS, neutropenia, jaundice, apnea, GE reflux, one child with eye squint, abnormal hearing test and hemangioma; and a child with a systemic autoimmune disorder. The incidence of complications in each group was not significantly different, 19.2% vs. 15.4%, p⫽0.571.
Supplement to DECEMBER 2009 American Journal of Obstetrics & Gynecology
S291