Adverse Pregnancy Conditions Among Privately Insured Women With and Without Congenital Heart Defects

Abstract

Background In women with congenital heart defects (CHD), changes in blood volume, heart rate, respiration, and edema during pregnancy may lead to increased risk of adverse outcomes and conditions. The American Heart Association recommends providers of pregnant women with CHD assess cardiac health and discuss risks and benefits of cardiac-related medications. We described receipt of American Heart Association-recommended cardiac evaluations, filled potentially teratogenic or fetotoxic (Food and Drug Administration pregnancy category D/X) cardiac-related prescriptions, and adverse conditions among pregnant women with CHD compared with those without CHD. Methods and Results Using 2007 to 2014 US healthcare claims data, we ascertained a retrospective cohort of women with and without CHD aged 15 to 44 years with private insurance covering prescriptions during pregnancy. CHD was defined as ≥1 inpatient code or ≥2 outpatient CHD diagnosis codes >30 days apart documented outside of pregnancy and categorized as severe or nonsevere. Log-linear regression, accounting for multiple pregnancies per woman, generated adjusted prevalence ratios (aPRs) for associations between the presence/severity of CHD and stillbirth, preterm birth, and adverse conditions from the last menstrual period to 90 days postpartum. We identified 2056 women with CHD (2334 pregnancies) and 1 374 982 women without (1 524 077 pregnancies). During the last menstrual period to 90 days postpartum, 56% of women with CHD had comprehensive echocardiograms and, during pregnancy, 4% filled potentially teratogenic or fetotoxic cardiac-related prescriptions. Women with CHD, compared with those without, experienced more adverse conditions overall (aPR, 1.9 [95% CI, 1.7-2.1]) and, specifically, obstetric (aPR, 1.3 [95% CI, 1.2-1.4]) and cardiac conditions (aPR, 10.2 [95% CI, 9.1-11.4]), stillbirth (aPR, 1.6 [95% CI, 1.1-2.4]), and preterm delivery (aPR, 1.6 [95% CI, 1.4-1.8]). More women with severe CHD, compared with nonsevere, experienced adverse conditions overall (aPR, 1.5 [95% CI, 1.2-1.9]). Conclusions Women with CHD have elevated prevalence of adverse cardiac and obstetric conditions during pregnancy; 4 in 100 used potentially teratogenic or fetotoxic medications, and only half received an American Heart Association-recommended comprehensive echocardiogram.

Keywords: adult; cardiology; heart defects, congenital; pregnancy; pregnancy complications; pregnancy outcomes.

Figure 1.. Exclusion criteria and final sample of pregnant women with and without congenital heart defects (CHD), IBM Watson Health MarketScan® Commercial Database, 2007–2014

*Pregnancies occurring between January 1, 2008, and December 31, 2013, including pregnancies conceived in 2007 and ending in 2008 or conceived in 2013 and ending in 2014. ^†1 inpatient or ≥2 outpatient CHD diagnosis claims ≥ 30 days apart. ^‡15 weeks gestation through 90 days postpartum. ^§Missing >30 days. ^||Includes 552 that were live birth and still birth.

Figure 2.. Prevalence of echocardiograms and cardiac-related prescriptions filled during pregnancies* of privately insured women aged 15 to 44 y with and without congenital heart defects (CHDs), 2007 to 2014

*From last menstrual period to 90 days postpartum in pregnancies lasting more than 20 gestational weeks. ^†Any: No CHD χ² p<0.05. ^‡Severe: Non-severe χ² p<0.05. ^§Included medications are listed in Supplemental Table 2.

Figure 3.. Prevalence and adjusted prevalence ratios (aPR) for adverse conditions in pregnancies of privately-insured women aged 15–44 with and without congenital heart defects (CHD) 2007–2014

aPR: Prevalence ratio for ≥1 complication vs. none adjusted for age, region of residence and year at delivery; CI: Confidence interval; *Pregnancies lasting more than 20 gestational weeks. ^†Obstetric conditions include gestational diabetes; gestational hypertension, eclampsia or preeclampsia; hemorrhage; hysterectomy; infections including chorioamnionitis, endocarditis, endometritis, endomyometritis, metritis, pyelonephritis, and sepsis; maternal death; obstetric shock; placental abruption; placenta previa; premature rupture of membranes; preterm labor or preterm birth; and transfusion. ^‡Cardiac conditions include atrial fibrillation, atrial flutter or supraventricular tachycardia; cardiomyopathy; conduction disorders; coronary dissection; heart failure; incident ventricular tachycardia, ventricular fibrillation, or sudden cardiac arrest; and myocardial infarction or ischemia. ^§Other conditions include acute renal failure; acute respiratory distress syndrome; anemia; deep vein thrombosis; disseminated intravascular coagulation; mechanical ventilation; pulmonary disease; pulmonary edema; pulmonary embolism; pulmonary hypertension; seizure disorders; stroke or cerebrovascular disorders; and thrombocytopenia.

Figure 4.. Top five most prevalent obstetric conditions in pregnancies* of privately-insured women aged 15–44 with and without congenital heart defects (CHD), 2007–2014.

*Among pregnancies lasting more than 20 gestational weeks. ^†Any: No CHD χ² p<0.05. ^‡Non-severe: No CHD χ² p<0.05. ^§Severe: Non-severe χ² p<0.05. ^||Chorioamnionitis, endocarditis, endometritis, endomyometritis, metritis, pyelonephritis, or sepsis