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Prolonged labor and adverse cardiac outcomes in pregnant patients with congenital heart disease

Published:November 22, 2022DOI:https://doi.org/10.1016/j.ajog.2022.11.1292
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      ABSTRACT

      BACKGROUND

      Patients with congenital heart disease (CHD) are at high risk for peripartum cardiac morbidity, yet data are limited on the impact of duration of labor on cardiac outcomes. Prolonged labor is a known risk factor for maternal morbidity, but the impact of prolonged labor on cardiac outcomes in patients with CHD has not been evaluated.

      OBJECTIVE

      Our objective was to evaluate the association between prolonged labor (≥24 hours) with peripartum adverse maternal cardiac outcomes in pregnant patients with CHD.

      STUDY DESIGN

      This was a retrospective cohort study of pregnant patients ≥18 years with CHD who received prenatal care and delivered at an academic institution between 1998-2020 with a singleton gestation. Pregnancies that ended <20 weeks gestation and patients who underwent an outright cesarean delivery without exposure to labor were excluded. The primary outcome was a composite adverse maternal cardiac outcome that occurred intrapartum or up to 6 weeks postpartum, defined as the occurrence of 1 or more of the following events: heart failure or clinical volume overload requiring diuresis, pulmonary edema, arrhythmia requiring treatment, thromboembolic complications including deep vein thrombosis or pulmonary embolism, transient ischemic attack, stroke, endocarditis, myocardial infarction, aortic dissection, cardiac arrest, or cardiac death. Outcomes were compared by prolonged (≥24 hours) versus not prolonged (<24 hours). An interaction between prolonged labor and cesarean delivery was evaluated.

      RESULTS

      229 patients were included. The median duration of labor was 14 hours and 18% of patients labored for ≥24 hours. Overall, 11.8% experienced the composite cardiac outcome with a significantly higher rate in the prolonged labor group (22% versus 9.6%, p=0.03). After adjusting for confounders including nulliparity, labor induction, gestational age, and WHO class, there was a 2.7-fold increased odds of the composite cardiac outcome for patients who experienced prolonged labor (aOR 2.7 [95% CI 1.1-7.1]). There was no significant difference in cardiac outcome between those who had a vaginal delivery versus a cesarean in labor (10.0% vs. 16.1%, p=0.18). There was, however, a significant interaction between prolonged labor and cesarean delivery: after adjustment for confounders, patients who underwent a cesarean after prolonged labor had 6.8-fold increased odds of experiencing the composite cardiac outcome compared to those who underwent a cesarean without prolonged labor (30.8% vs. 7.1%, aOR 6.8, [95% CI 1.4-32.5]), most commonly, heart failure or volume overload requiring diuresis.

      CONCLUSION

      In a cohort of pregnant patients with CHD, prolonged duration of labor ≥24 hours was significantly associated with an increased risk of an adverse peripartum cardiac outcome, especially among those who underwent a cesarean delivery after that time. These findings suggest that close attention should be paid to the duration of labor and those who require a cesarean after a prolonged labor should be monitored closely for signs of volume overload and other adverse cardiac events.

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