Outcomes of pregnancy in women after Fontan palliation Marielle Gouton, Magalie Ladouceur, Jacky...

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