outcomes of pregnancy in women after fontan palliation marielle gouton, magalie ladouceur, jacky...
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Outcomes of pregnancy in women after Fontan
palliation
Marielle Gouton, Magalie Ladouceur, Jacky Nizard, Marc Dommergues
Centre Chirurgical Marie Lannelongue – Le Plessis-RobinsonHôpital Européen Georges Pompidou – Paris
Groupement Hospitalier La Pitié-Salpêtrière – ParisFrance
The 3rd International Congress on Cardiac Problems in Pregnancy – Venice 2014
Design
Outcomes of all pregnancies in women with Fontan palliation in France
Methods : Retrospective study French M3C centers
Outcomes of pregnancy in women after Fontan palliation – 3rd International Congress on CPP – Venice 2014
2001-2013 All known pregnancies Cardiac, obstetrical
and neonatal complicationsPre-partum, peri-partum, post-partum, follow-up
Population
27 women, 41 pregnancies (1 twin-pregnancy)
4 / 27 (15 %) had previous infertility
9 had 2 pregnancies or more
Age at first pregnancy : 20 – 41 y (mean 27± 5)
Outcomes of pregnancy in women after Fontan palliation – 3rd International Congress on CPP – Venice 2014
Women n (%)
Cardiac malformation Tricuspid atresia DILV DORV Single Ventricle (undefined) Large VSD – straddling valves
(n=27)13 (48%) 2 (7.5%) 2 (7.5%) 9 (33%) 1 (4%)
Type of Fontan palliation Fontan Kreutzer Extracardiac TCPC Intracardiac TCPC Unknown
326115
Mean age at Fontan palliation, ±SD 15±6 y
Conversion Fontan or Kreutzer in to TCPC 5
CV complications before pregnancy SV tachycardia Heart failure Thromboembolism
6 (23%)314
Outcomes of pregnancy in women after Fontan palliation – 3rd International Congress on CPP – Venice 2014
Population
Results : 41 pregnancies
Outcomes of pregnancy in women after Fontan palliation – 3rd International Congress on CPP – Venice 2014
Type of palliatio
n
Abortion
Miscarriage
Fetal death
Live births Total
Fontan / Kreutzer 0 2 1 4 7
TCPC 2 10 0 17 29
? 1 1 0 3 5
Total 3 13 1 24 41
58 %
33 %
Maternal complications10 / 41 (25 %)
Outcomes of pregnancy in women after Fontan palliation – 3rd International Congress on CPP – Venice 2014
Type n
Supra Ventricular Tachycardia 2
Thromboembolism 2
Hypoxemia 1
Others Dizziness Renal insufficiency Anemia (requiring transfusion) Hepatic cytolysis (x3) Hypoalbuminemia
11111
Maternal death 0
Obstetrical complications 25 / 41 (61 %)
Type n
Miscarriage 13
SGA 2
Fetal death 1
Utero placentar anomaly 1
Amniotic anomaly 4
Abruptio 2
Premature rupture of membranes 5
Preterm labor 5
Delivery bleeding 1
Outcomes of pregnancy in women after Fontan palliation – 3rd International Congress on CPP – Venice 2014
Anticoagulation ?
Type n Live births (%)
Maternal complicatio
n / thrombotic
No anticoagulation 2 2 (100) 1 / 0
Aspirin 5 2 (40) 2 / 1
Vitamin K inhibitor 6 2 (33) -
Heparin (preventive) 10 8 (80) 4 / 0
Heparin (curative) 8 6 (75) 3 /1
? 9 3 (33) -Outcomes of pregnancy in women after Fontan palliation – 3rd International Congress on CPP –
Venice 2014
Post-natal follow-up
Outcomes of pregnancy in women after Fontan palliation – 3rd International Congress on CPP – Venice 2014
Mode of delivery : Vaginal : 12 Cesarean section : 12
Mean gestational age : 34 (±3) w Mean birth weight :
2024 (±690) g (10th percentile) Prematurity : 17 / 24 (70 %)
33-36+6 w : 11 28-32+6 w : 5 22-27+6 w : 1
Neonatal death : 1 (birth at 25 w) Twins : birth by cesarean section at 32 w Recurrence of congenital heart disease :
1 left superior vena cava (fetal death : tricuspid atresia)
Maternal follow-up
Post-partum complications Parietal hematoma :1 Fontan failure: 1 ↗NYHA: 1
21 / 27 women (75%) have ≥ 1 newborn 0 newborn : 6 1 newborn : 18 (1 neonatal death) 2 newborns : 3
Late follow-up : 43 months (1 – 144) Fontan failure : 2 No maternal death
Le switch a 30 ans ! Atelier-débat - CCML 6 et 7 février 2014
Fontan and pregnancy: Is it possible ?
Outcomes of pregnancy in women after Fontan palliation – 3rd International Congress on CPP – Venice 2014
Yes, but only if : Pre-conception visit
Cardiac function Ventricular function (echo, MRI) TCPC function AV valve insufficiency
Counseling High risk of maternal complications
Arrhythmia Thromboembolism
Therefore: anticoagulation High risk of miscarriage (33%) High risk of prematurity (70%) Risk of recurrence
Multidisciplinary follow-up (tertiary hospital) Adult cardiac congenitalist Obstetrician Anesthesiologist Neonatologist
Vaginal delivery if obstetrician agrees
Fontan and twin pregnancy ?Yes, they can
Outcomes of pregnancy in women after Fontan palliation – 3rd International Congress on CPP – Venice 2014