Direct current cardioversion in pregnancy: a multicentre study.

OBJECTIVE: Direct current cardioversion (DCCV) in pregnancy is rarely required and typically only documented in single case reports or case series. A recent UK confidential enquiry reported on several maternal deaths where appropriate DCCV appeared to have been withheld. DESIGN: Retrospective cohort study. SETTING: Seventeen UK and Ireland specialist maternity centres. SAMPLE: Twenty-seven pregnant women requiring DCCV in pregnancy. MAIN OUTCOME MEASURES: Maternal and fetal outcomes following DCCV. RESULTS: Twenty-seven women had a total of 29 DCCVs in pregnancy. Of these, 19 (70%) initial presentations were to Emergency Departments and eight (30%) to maternity settings. There were no maternal deaths. Seventeen of the women (63%) had a prior history of heart disease. Median gestation at DCCV was 28 weeks, median gestation at delivery was 35 weeks, with a live birth in all cases. The abnormal heart rhythms documented at the first cardioversion were atrial fibrillation in 12/27 (44%) cases, atrial flutter in 8/27 (30%), supraventricular tachycardia in 5/27 (19%) and atrial tachycardia in 2/27 (7%). Fetal monitoring was undertaken following DCCV on 14/29 (48%) occasions (10 of 19 (53%) at ≥26 weeks) and on 2/29 (7%) occasions, urgent delivery was required post DCCV. CONCLUSIONS: Direct current cardioversion in pregnancy is rarely required but should be undertaken when clinically indicated according to standard algorithms to optimise maternal wellbeing. Once the woman is stable post DCCV, gestation-relevant fetal monitoring should be undertaken. Maternity units should develop multidisciplinary processes to ensure pregnant women receive the same standard of care as their non-pregnant counterparts.

Screening for late-onset gestational diabetes: Are there any clinical benefits?

OBJECTIVE: To determine whether screening for gestational diabetes mellitus (GDM) in the third trimester and managing those who are screen positive on a diabetes pathway affects obstetric and neonatal outcomes. DESIGN: Retrospective study of prospectively collected data. SETTING: London Teaching Hospital. POPULATION OR SAMPLE: A total of 14 366 women delivering between 1 January 2018 and 31 December 2020. METHODS: Retrospective chart analysis. MAIN OUTCOME MEASURES: Diagnosis of late-onset GDM, obstetric and neonatal outcomes. RESULTS: Five hundred and thirty-one women were tested by home glucose monitoring for late-onset GDM from 33 weeks of gestation. In all, 244 were diagnosed as having GDM (group 1) and managed accordingly, and 287 (group 2) were returned to normal care. A total of 1415 women had GDM diagnosed by oral glucose tolerance test before 33 weeks of gestation (group 3). Of the women in group 2, 49.5% had a spontaneous onset of labour compared with only 25.8% and 27% in groups 1 and 3. However, women in group 2 were significantly more likely to have a macrosomic baby (≥4000 g, 25.4%) than groups 1 (16.0%) or 3 (7.2%), and their babies were more likely to be admitted to special care (5.2% versus 2% in group 1). Macrosomic babies were associated with significantly higher rates of shoulder dystocia, third- and fourth-degree tears and postpartum haemorrhage. CONCLUSIONS: Apparent late-onset GDM affects a significant proportion of women, and targeted intervention was associated with better obstetric and neonatal outcomes. These results suggest that all pregnancies with risk factors for late-onset GDM might benefit from active GDM management irrespective of specific glucose thresholds. TWEETABLE ABSTRACT: Women with risk factors for GDM in the third trimester, and their babies, would probably benefit from active management of their blood sugars irrespective of threshold values.

Maternal and fetal outcomes in women with cerebrovascular malformations in pregnancy: A multicentre retrospective cohort study.

OBJECTIVE: To determine maternal, obstetric and neonatal outcomes in a cohort of women with cerebrovascular malformations (CVMs) that include arterial venous malformations (AVMs) and cavernomas. DESIGN: Retrospective cohort study. SETTING: Six specialist centres managing pregnant women with neurological disorders. POPULATION: Sixty-three women with CVMs in 83 pregnancies of ≥20 completed weeks' gestation. METHODS: Retrospective case notes review. MAIN OUTCOME MEASURES: Neurological outcomes including rates of acute cerebral bleeding in pregnancy and reported seizures during pregnancy. Maternal outcomes included number of women with a livebirth and the proportion of women being delivered by caesarean section. RESULTS: Most women had a good pregnancy outcome with high rates of vaginal delivery (73%) at term. There were no maternal deaths. Six women had an acute cerebral bleed, all of whom were delivered by planned caesarean section. In total, ten women had seizures in pregnancy (of whom four also had a bleed). Six (7%) babies were admitted to a neonatal unit. There was no significant difference in outcomes between women with AVMs and those with cavernomas. CONCLUSION: In the majority of cases, pregnancy outcomes were favourable, with most women having a vaginal delivery. All cases of cerebral bleeds that occurred were at a remove from the peripartum period. TWEETABLE ABSTRACT: Women with cerebrovascular malformations have high rates of vaginal delivery.

Efficacy of transvaginal cervical cerclage in women at risk of preterm birth following previous emergency cesarean section.

INTRODUCTION: Emergency cesarean sections (EMCS) are associated with subsequent preterm birth, particularly at full dilation (FDCS), which is a cause of both second trimester miscarriages and early, recurrent spontaneous preterm birth (sPTB). The optimal management for these women in subsequent pregnancies is currently unknown. This study aims to assess efficacy of transvaginal cervical cerclage (TVC) in prevention of preterm birth among women who have had an EMCS followed by a subsequent late miscarriage or sPTB. MATERIAL AND METHODS: A historical cohort study was performed assessing outcomes of women attending the Preterm Surveillance Clinic at St Thomas' Hospital, London, who received TVC, with a history of EMCS (pregnancy A) followed by a sPTB/late miscarriage (pregnancy B) and a subsequent pregnancy (pregnancy C). A historical reference group managed in the same clinic was identified comprising women with any risk factor for sPTB, who required TVC. Incidence of delivery >24 to <30 weeks' gestation was compared with relative risk and 95% confidence intervals (CI). Subgroup analysis was carried out assessing women who had a previous FDCS. RESULTS: 209 women with a previous EMCS during labor (50 with FDCS), followed by sPTB/late miscarriage were identified. 178 progressed beyond 24 weeks; of these, 56 received TVC and formed the study group. 905 high-risk women were identified; of these, 154 received TVC and formed the reference group. Despite TVC treatment, 17/56 (30%) of the study group delivered <30 weeks' gestation compared with 5/154 (3%) of the reference group (RR 9.4, 95% CI 3.6-24.2, P < .001). In the subset of 17 women in the study group with a previous FDCS, followed by sPTB/late miscarriage, 6/17 (35%) delivered <30 weeks' gestation, significantly higher than the reference group (P < .001) but similar to EMCS at less than full dilation (35% vs 28%, P = .596). Overall, 33/72 (46%) women receiving cerclage with prior EMCS had either a mid-trimester loss or delivery <30 weeks. CONCLUSIONS: Transvaginal cervical cerclage appears less effective in preventing preterm birth among pregnant women who have had an EMCS followed by a sPTB/late miscarriage compared with other high-risk women. The lack of efficacy in the subgroup with an FDCS was similar.

Managing subfertility in patients with heart disease: What are the choices?

More women with heart disease are reaching reproductive age and will want to embark upon pregnancy. Furthermore, many of these women are delaying pregnancy until later in life when they may be exposed to a greater number of complications from their heart disease. A relatively high proportion of these women will pursue fertility treatment to achieve a pregnancy; consequently, the management of subfertile couples where the woman (or man) has heart disease is of growing importance. In this review, we discuss how fertility investigations and treatment can impact a women with heart disease and how some of the potential complications can be minimized or avoided. We also consider surrogacy, which is an important option when pregnancy is contraindicated.

Learning about maternal death and grief in the profession: a pilot qualitative study.

INTRODUCTION: The aim of this study was to explore the impact of maternal death on maternity professionals, and their related professional and personal needs. MATERIAL AND METHODS: A qualitative study comprising semi-structured interviews in a UK inner-city academic maternity unit with over 5000 deliveries annually. Purposive sampling was utilized and semi-structured face-to-face interviews were performed with 14 healthcare professionals: four midwives, five doctors in training grades (trainees) and five consultant obstetricians. Identification of key themes was derived by textual analysis. RESULTS: Five main themes were identified: professional culture, organizational culture and external expectation; personal blame and debriefing; professional training; shaping the training; support and counseling. Maternal death has a major impact on professionals' feelings of grief, guilt and shame, which they are reluctant to talk about. Maternity professionals expressed a desire for training to prepare themselves to respond effectively in the event of maternal death. There was ambiguity about "debriefing" within a changing institutional culture. CONCLUSIONS: Maternal death is a devastating consequence of pregnancy. If these findings are replicated by interviewing a greater number and breadth of maternity professionals, then healthcare institutions need to develop appropriate training to prepare and help staff, which should improve the support they can give to the bereaved and to each other.

Best practice recommendations for medically assisted reproduction in patients with known cardiovascular disease or at high risk of cardiovascular disease.

Increasing numbers of people are seeking assisted conception. In people with known cardiac disease or risk factors for cardiac disease, assisted conception may carry increased risks during treatment and any subsequent pregnancy. These risks should be assessed, considered and minimized prior to treatment.

Pre-eclampsia and Cardiovascular Disease: From Pregnancy to Postpartum.

Hypertensive disorders of pregnancy (HDP) complicate approximately 10% of pregnancies. In addition to multiorgan manifestations related to endothelial dysfunction, HDP confers an increased risk of cardiovascular disease during delivery hospitalisation, such as heart failure, pulmonary oedema, acute MI and cerebrovascular events. However, the cardiovascular legacy of HDP extends beyond birth since these women are significantly more likely to develop cardiovascular risk factors in the immediate postnatal period and major cardiovascular disease in the long term. The main mediator of cardiovascular disease in women with a history of HDP is chronic hypertension, followed by obesity, hypercholesterolaemia and diabetes. Therefore, optimising blood pressure levels from the immediate postpartum period until the first months postnatally could have beneficial effects on the development of hypertension and improve long-term cardiovascular health. Peripartum screening based on maternal demographic, and clinical and echocardiographic data could help clinicians identify women with HDP at highest risk of developing postpartum hypertension who would benefit from targeted primary cardiovascular prevention.

Pregnancy following personalised aortic root support in Marfan syndrome.

Marfan syndrome (MFS) is linked with adverse pregnancy events, one of the most significant being aortic dissection. We present a case of a woman with MFS with prior aortic root dilatation who opted for a Personalised External Aortic Root Support (PEARS). To date, she is only the fifth woman to have had this valve-sparing procedure prior to pregnancy. We outline her care in a tertiary centre with multidisciplinary expertise, from preconception through to the postpartum period.

Encouraging brisk walking with the free Active10 app in postnatal women who had a hypertensive pregnancy: "Just Walk It" feasibility study.

OBJECTIVE: To explore the feasibility of a future trial to investigate whether encouraging use of the free NHS smartphone app Active10 increases brisk walking and reduces blood pressure (BP) in postnatal mothers who had hypertensive disorders of pregnancy (HDP). DESIGN: 3-month feasibility study. SETTING: London maternity unit. POPULATION: 21 women with HDP. METHODS: At recruitment we recorded initial (booking) clinic BP and asked participants to complete a questionnaire. Two months after delivery all participants were sent (by post/email/WhatsApp) a "Just Walk It" leaflet encouraging them to download the Active10 app and walk briskly for at least 10 minutes/day. This was backed by a telephone call after 2-weeks. Assessments were repeated 3-months later, and included telephone interviews about the acceptability and use of Active10. MAIN OUTCOME MEASURES: Were recruitment rate, follow-up rate and acceptability/use of Active10. RESULTS: Of 28 women approached, 21 (75%, 95% CI 55.1-89.3%) agreed to participate. Age range was 21-46 years and five (24%) self-identified as black ethnicity. One woman dropped out of the study, and one became ill. The remaining participants (90%, 19/21, 95% CI 69.6-98.8%) were followed up after 3-months. Ninety-five percent (18/19) downloaded the Active10 app and 74% (14/19) continued using it at 3-months, averaging 27-minutes brisk walking/day according to Active10 weekly screenshots. Comments included: "Brilliant app", "Really motivates me". Mean BP was 130/81mmHg at booking and 124/80mmHg at 3-months follow-up. CONCLUSIONS: The Active10 app was acceptable to postnatal women after HDP and may have increased minutes of brisk walking. A future trial could explore whether this simple, low-cost intervention could reduce long-term BP in this vulnerable group.

Reproductive health after thoracic transplantation: An ISHLT expert consensus statement.

Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.

Prevalence of pre-eclampsia and adverse pregnancy outcomes in women with pre-existing cardiomyopathy: a multi-centre retrospective cohort study.

Pre-eclampsia is associated with postnatal cardiac dysfunction; however, the nature of this relationship remains uncertain. This multicentre retrospective cohort study aimed to determine the prevalence of pre-eclampsia in women with pre-existing cardiac dysfunction (left ventricular ejection fraction < 55%) and explore the relationship between pregnancy outcome and pre-pregnancy cardiac phenotype. In this cohort of 282 pregnancies, pre-eclampsia prevalence was not significantly increased (4.6% [95% C.I 2.2-7.0%] vs. population prevalence of 4.6% [95% C.I. 2.7-8.2], p = 0.99); 12/13 women had concurrent obstetric/medical risk factors for pre-eclampsia. The prevalence of preterm pre-eclampsia (< 37 weeks) and fetal growth restriction (FGR) was increased (1.8% vs. 0.7%, p = 0.03; 15.2% vs. 5.5%, p < 0.001, respectively). Neither systolic nor diastolic function correlated with pregnancy outcome. Antenatal ß blockers (n = 116) were associated with lower birthweight Z score (adjusted difference - 0.31 [95% C.I. - 0.61 to - 0.01], p = 0.04). To conclude, this study demonstrated a modest increase in preterm pre-eclampsia and significant increase in FGR in women with pre-existing cardiac dysfunction. Our results do not necessarily support a causal relationship between cardiac dysfunction and pre-eclampsia, especially given the population's background risk status. The mechanism underpinning the relationship between cardiac dysfunction and FGR merits further research but could be influenced by concomitant ß blocker use.