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

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

3. Our populations are changing faster then our mentalities are.3

4. 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

5. 5

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

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

9. 25

10. 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

11. 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

12. 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.

13. 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.

14. 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.

15. 31

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

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Chronic morbidity 62

25. Chronic morbidity Complications63

26. Chronic morbidity 64

27. 65

28. 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