New developments in maternal medicine. Jacky Nizard GH Pitié Salpêtrière 1

What is happening ? Medicine is improving Pregnancy in women with more severe conditions But our population has more morbidity to start with. 2

Our populations are changing faster then our mentalities are. 3

Who are our patients? Why worry? Obesity Type 2 diabetes GUCH (Grown-up congenital heart disease) Other cardiac pathologies, acquired or not Chronic neurological disorders Etc. 4

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Obesity in our department is: 19% elective cesarean section 29% cervical ripening 17% oxytocin induction 35% spontaneous labour =42% cesarean!

Results: different types of diabetes Maternal: 806,579 deliveries Neonatal: 471,227 deliveries (80.7% of deliveries in public hospitals)

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Modern medicine changed my professional beliefs. GUCH When I started my training, I was providing TOP to women who had a fetus with a single ventricle. 15 years later, I’m delivering vaginally women who have themselves a single ventricle, with a healthy fetus and a normal life. Modern medicine changed my professional beliefs. 26

GUCH 80-85% of patients born with congenital heart disease now survive to adulthood (age 16 years) An annual increase of 2500 can be anticipated according to birth rate in the UK 27

Data compiled from the statistics of the Office of Population Consensus and Surveys for England and Wales showing reported deaths from congenital heart disease in the various age groups. Data compiled from the statistics of the Office of Population Consensus and Surveys for England and Wales showing reported deaths from congenital heart disease in the various age groups. In 1958 death was most common in infancy and by 1986 deaths were more common over age 20 years. BMJ Publishing Group Ltd and British Cardiovascular Society Heart 2002;88:i1-i14 Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

Data compiled from the statistics of the Office of Population Consensus and Surveys for England and Wales showing reported deaths from congenital heart disease in the various age groups. In 1958 death was most common in infancy and by 1986 deaths were more common over age 20 years. BMJ Publishing Group Ltd and British Cardiovascular Society Heart 2002;88:i1-i14 Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

Data compiled from the statistics of the Office of Population Consensus and Surveys for England and Wales showing reported deaths from congenital heart disease in the various age groups. In 1958 death was most common in infancy and by 1986 deaths were more common over age 20 years. BMJ Publishing Group Ltd and British Cardiovascular Society Heart 2002;88:i1-i14 Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

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M&M National inquiry to the 22 referral centers on congenital heart disease (M3C) >1997-2015; retrospective Only 7 centers had cases Questionnaires to cardiologists & OG 32

RESULTS 28 pregnancies in 20 patients 8 elective abortions 2 miscarriages (8 & 15 WG) 18 (64%) pregnancies > 20WG No stillbirth Median GA at delivery 33+3WG (28-38) 17 had Eisenmenger syndrome and 3 segmental pulmonary hypertension 33

All (n=4) but one heart failure occurred in the PP RESULTS All (n=4) but one heart failure occurred in the PP 40

All (n=4) but one heart failure occurred in the PP RESULTS All (n=4) but one heart failure occurred in the PP One led to a maternal death at D10 PP 41

All (n=4) but one heart failure occurred in the PP RESULTS All (n=4) but one heart failure occurred in the PP One led to a maternal death at D10 PP 2 (10%) patients died at age 37 and 45, 4 and 16 years after delivery. 42

5% mortality rate, 95% CI (1.3 to 24.9) RESULTS All (n=4) but one heart failure occurred in the PP 5% mortality rate, 95% CI (1.3 to 24.9) One led to a maternal death at D10 PP 2 (10%) patients died at age 37 and 45, 4 and 16 years after delivery. 43

Largest series (series of case reports before) Comments Largest series (series of case reports before) Mortality down from 50 to 28 to 5% Probably due to multidisciplinary teamwork between cardiologists, anesthetists, pediatricians, obstetricians… 44

Marternal morbidity is high Perinatal morbidity is high (IUGR) Comments BUT Still 5% Marternal morbidity is high Perinatal morbidity is high (IUGR) Prematurity is high Correlates with O2 sat < 85% 45

Chronic morbidity 62

Chronic morbidity Complications 63

Chronic morbidity 64

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Specificities of the postpartum? Specific risks for the neonates? Implications for us? Counseling +++ TOP? Antenatal care? Treatment? When deliver? How? Pain management? Where? Specificities of the postpartum? Specific risks for the neonates? 66