Outcome of Pregnancy in Patients With Structural or Ischaemic Heart Disease

Results of a Registry of The European Society of Cardiology

Jolien W. Roos-Hesselink; Titia P.E. Ruys; Jörg I. Stein; Ulf Thilén; Gary D. Webb; Koichiro Niwa; Harald Kaemmerer; Helmut Baumgartner; Werner Budts; Aldo P. Maggioni; Luigi Tavazzi; Nasser Taha; Mark R. Johnson; Roger Hall


Eur Heart J. 2013;34(9):657-665. 

In This Article

Abstract and Introduction


Aims To describe the outcome of pregnancy in patients with structural or ischaemic heart disease.

Methods and results In 2007, the European Registry on Pregnancy and Heart disease was initiated by the European Society of Cardiology. Consecutive patients with valvular heart disease, congenital heart disease, ischaemic heart disease (IHD), or cardiomyopathy (CMP) presenting with pregnancy were enrolled. Data for the normal population were derived from the literature. Sixty hospitals in 28 countries enrolled 1321 pregnant women between 2007 and 2011. Median maternal age was 30 years (range 16–53). Most patients were in NYHA class I (72%). Congenital heart disease (66%) was most prevalent, followed by valvular heart disease 25%, CMP 7%, and IHD in 2%. Maternal death occurred in 1%, compared with 0.007% in the normal population. Highest maternal mortality was found in patients with CMP. During pregnancy, 338 patients (26%) were hospitalized, 133 for heart failure. Caesarean section was performed in 41%. Foetal mortality occurred in 1.7% and neonatal mortality in 0.6%, both higher than in the normal population. Median duration of pregnancy was 38 weeks (range 24–42) and median birth weight 3010 g (range 300–4850). In centres of developing countries, maternal and foetal mortality was higher than in centres of developed countries (3.9 vs. 0.6%, P < 0.001 and 6.5 vs. 0.9% P < 0.001)

Conclusion The vast majority of patients can go safely through pregnancy and delivery as long as adequate pre-pregnancy evaluation and specialized high-quality care during pregnancy and delivery are available. Pregnancy outcomes were markedly worse in patients with CMP and in developing countries.


In women with heart disease, maternal mortality is reported to be much higher than average and the risk appears to be increasing such that in western countries heart disease is the major cause of maternal death.[1–3] However, we do not fully understand what the impact of pregnancy is on the progression of heart disease or how heart disease affects the outcome of pregnancy. The full spectrum of structural heart disease including congenital heart disease (CHD), valvular heart disease (VHD), and cardiomyopathy (CMP), and also ischaemic heart disease (IHD) may be encountered in pregnant women. In developing countries that still struggle with a high prevalence of rheumatic fever, acquired VHD dominates, whereas in developed countries, CHD is the main diagnostic group.[4–8] In addition, over the last few years, the incidence of an acute coronary event during pregnancy has increased, due to older child-bearing age, and changes in lifestyle with more hypertension, smoking, and obesity in women.[9–15] CMP is uncommon during pregnancy, but it is difficult to manage a pregnancy in the context of left ventricular dysfunction or peripartum cardiomyopathy (PPCM) with a high risk of an adverse outcome for both the mother and the baby.[16,17]

In developed countries, optimal care and preconception counselling are available in all centres, although quite often not accessed by the women concerned. In developing countries, only a minority of women with heart disease are assessed and appropriately counselled prior to conception. Not surprisingly, this may have a major adverse influence on pregnancy outcome.

Our understanding of the consequences of heart disease on pregnancy outcome is limited and prevents us from designing relevant randomized controlled trials. To improve our understanding of this complex subject, a registry has been established with the aim of determining patterns of outcome and correlating these with management strategies to determine the areas of danger for both mother and baby and to identify the best forms of treatment. To have any use, such a registry has to be large to include sufficient patients with a wide range of diagnoses. Consequently, the European Registry on Pregnancy and Structural Heart Disease was initiated by the European Society of Cardiology (ESC).