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.