title: A contemporary approach to the obstetric management of women with heart disease.
abstract: OBJECTIVE
  Recommendations for the peripartum obstetric management of women with heart disease have included early induction of labour, shortening the second stage of labour during vaginal delivery, and low threshold for elective Caesarean section, although such techniques may result in complications. The objective of this study was to determine whether a less aggressive approach without routine preterm induction, shortening of the second stage, or Caesarean section adversely affects the mother or neonate.
  
  
  METHODS
  We examined peripartum obstetric management and its relationship with adverse maternal and neonatal outcomes in 1677 pregnancies: 559 in women with heart disease and 1118 in women without heart disease (control subjects). Logistic regression with propensity matching was used to compare outcomes in women with and without heart disease.
  
  
  RESULTS
  Women with heart disease were more likely than control subjects to undergo induction of labour (P < 0.001). Induction of labour tended to be at term and for logistical reasons, not for the indication of maternal heart disease. Assisted vaginal deliveries were more common in women with heart disease (29% vs. 11%, P < 0.001) than in those without, and the second stage of labour was also more prolonged in women with heart disease. Rates  of Caesarean section were similar in both groups (P = 0.66).  A significant proportion of women with heart disease had unassisted vaginal deliveries. Invasive cardiac monitoring was rarely used. Adverse maternal cardiac events at delivery were rare (2% of pregnancies) and were not associated with mode of delivery. In multivariate analysis, maternal heart disease was not predictive of adverse neonatal events or third- or fourth- degree lacerations. Maternal heart disease was associated with postpartum hemorrhage, but this was not related to assisted delivery or prolonged second stage of labour.
  
  
  CONCLUSIONS
  This large study has shown that in women with heart disease, avoidance of early induction of labour, rare use of Caesarean section for cardiac indications, and selective use of invasive monitoring produces safe obstetric outcomes.
authors.affiliation: University of Toronto Pregnancy and Heart Disease Research Program, Mount Sinai Hospital, Toronto ON.
authors.forename: Julie E
authors.initials: JE
authors.lastname: Robertson
authors.affiliation: University of Toronto Pregnancy and Heart Disease Research Program, Toronto General Hospital, Toronto ON.
authors.forename: Candice K
authors.initials: CK
authors.lastname: Silversides
authors.affiliation: University of Toronto Pregnancy and Heart Disease Research Program, Toronto General Hospital, Toronto ON.
authors.forename: May
authors.initials: M
authors.lastname: Ling Mah
authors.affiliation: University of Toronto Pregnancy and Heart Disease Research Program, Mount Sinai Hospital, Toronto ON.
authors.forename: Julia
authors.initials: J
authors.lastname: Kulikowski
authors.affiliation: University of Toronto Pregnancy and Heart Disease Research Program, Mount Sinai Hospital, Toronto ON.
authors.forename: Cynthia
authors.initials: C
authors.lastname: Maxwell
authors.affiliation: University of Toronto Pregnancy and Heart Disease Research Program, Toronto General Hospital, Toronto ON.
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Wald
authors.affiliation: University of Toronto Pregnancy and Heart Disease Research Program, Toronto General Hospital, Toronto ON.
authors.forename: Jack M
authors.initials: JM
authors.lastname: Colman
authors.affiliation: University of Toronto Pregnancy and Heart Disease Research Program, London Health Sciences Centre, London ON.
authors.forename: Samuel C
authors.initials: SC
authors.lastname: Siu
authors.affiliation: University of Toronto Pregnancy and Heart Disease Research Program, Mount Sinai Hospital, Toronto ON.
authors.forename: Mathew
authors.initials: M
authors.lastname: Sermer
mesh_terms: D002585:Cesarean Section / Q000706:statistics & numerical data; D036861:Delivery, Obstetric / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D006331:Heart Diseases / Q000150:complications* / Q000628:therapy*; D006801:Humans; D007231:Infant, Newborn; D007751:Labor, Induced / Q000706:statistics & numerical data; D018743:Perinatal Care / Q000379:methods; D058725:Peripartum Period; D011181:Postnatal Care / Q000379:methods; D006473:Postpartum Hemorrhage / Q000453:epidemiology; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000628:therapy*; D011256:Pregnancy Outcome; D011295:Prenatal Care / Q000379:methods*