Discussion
Although it is traditionally believed that women with CHD should undergo
surgery before pregnancy, this view is still
controversial7.
In our sociodemographic information, the rate of CHD surgery is higher
in cities than in rural areas, which may be related to economic reasons,
some families in the rural areas couldn’t pay for hospitalization in the
early days, so the surgery was delayed. And the proportion of patients
who underwent surgery had a college education was higher than those who
did not, which may be related to physical fitness, a healthy body was
guaranteed to go to school. Moreover, patients in the non-surgical group
tend to have children after multiple pregnancies for reasons such as
spontaneous or induced abortion.
The incidence of simple CHD such as ASD, VSD is higher than that of
complex CHD. On the one hand, the incidence of simple CHD is higher than
that of complex CHD. On the other hand, some patients with complex CHD
have died before they reach reproductive age or choose not to have
children, including abortion after pregnancy. It should be noted that in
our classification, some cases are combined with malformations, and we
mainly classify them according to the most major malformations. For
example, if one patient has a double outlet right ventricle (DORV)
combined with VSD, the statistics was calculated according to DORV.
In our study, the proportion of non-surgical patients (60.0%) was
higher. On the one hand, because there were more simple CHD, such as
ASD, VSD, etc, and some small defects had no symptoms in the early
stage, pregnancy was generally well-tolerated, and even CHD was known
until during pregnancy physical examination. In addition, some cases,
such as PFO, do not need surgical treatment because of their small
defect and little pathophysiological impact. None of the 20 cases of PFO
were operated in our study. This was in agreement with the study of
Bredy C et al8. On the other hand, some patients with
complicated CHD, such as TOF, should be operated at an early stage, but
there were still 7 cases (10.1%) in our group without surgery, most of
them were due to family economic reasons. A few complex CHD patients did
not have an operation because they didn’t take seriously, which delayed
treatment. And some patients were advised to have surgery, but they
refused treatment.
In our study, the incidences of almost all adverse events in the
non-surgical group were higher than that in the surgical group, and some
events such as pre-term delivery, LBW, HF, CS, PH, and death existed
obvious differences (P<0.05). We believe that surgery can reduce
maternal and fetal risk, which was different from the study of Vikas
Yadav, et al7.
A total of 16 maternal deaths in this study, all of who were related to
PH and HF and other reasons. The two cases dead in the surgical group
were due to too late CHD surgery and had irreversible PH, resulting in
death during childbirth. Therefore, CHD such as VSD, ASD, PDA, which can
result in PH and develop into ES in late-stage, surgical treatment
should be conducted as early as possible to avoid irreversible results.
In this study, there were patients who wanted surgery due to PH and lost
the chance of surgery, or those who were prepared for surgery, but
stopped during the operation due to severe PH, which was in agreement
with the view of Karen Sliwa et al9,10. There were 59
ES patients in this study, and 58 (98.3%) in the non-surgical group,
which further illustrated the necessity of early surgery. Of course,
there were also complicated CHD cases, although the doctors didn’t
recommend giving birth, they didn’t follow the advice and insisted on
giving birth. A few such patients had bad outcome. Of course, there were
positive news, for example, a mother with complicated CHD who had c-TGA,
PA, ASD, VSD, PDA, underwent Glenn surgery for the first time, and then
underwent a total caval pulmonary connection. She became pregnant a few
years later, and gave birth to a child, and both mother and child were
well in the follow-up. which is
consistent with the report of M A Naguib et al11.
The events of maternal PH, HF, death, and neonatal death were also more
in the non-surgical group during our follow-up, further supporting our
view.
It should be pointed out that if CHD needs treatment, try to treat it
before pregnancy, but the operation itself has risks, it is important to
choose an experienced cardiac center for treatment, and a “pregnancy
heart team” is needed12-14. Moreover, the rate of
arrhythmia in the surgical group was higher than that in the surgical
group (14.4 vs 12.1), which suggested that more arrhythmias may occur
after surgery. This was consistent with the reports of Jason W Greenberg
et al15,16.
All in all, CHD with left-to-right shunts, such as ASD, VSD, underwent
surgery before severe PH occurred, and the outcome of pregnancy and
childbirth was good. Some complicated CHD, such as TOF, generally
tolerated pregnancy well after surgical correction. Patients who have
had systemic-pulmonary shunt or palliative procedures, which need to be
evaluated to see the functional status of their shunt. For those with
severe PH and complicated CHD without surgery, the risk of mother and
child during the perinatal period is significantly increased. Through
our research, we believed that early surgery was helpful to reduce the
risk of both mother and child during the perinatal period. For these
patients who still have left-to-right shunts, the attendant risk of
embolization should be kept in mind.