Maternal Outcomes With Pregnancy In Heart Transplant Recipients

Background There is a growing demographic of female post-heart transplant recipients who are surviving to childbearing age. Pregnancy is typically not advised for patients within one-year post-transplant and is reviewed on a case by case basis thereafter. As post-transplant outcomes continue to improve, preconception counseling is imperative to guide maternal and fetal safety during pregnancy. Methods A cohort of five women with a total of six pregnancies were assessed at Cleveland Clinic and followed through pregnancy. These baseline patient characteristics were reviewed; heart transplant indication, immunosuppression regimen, history of rejection, stability of graft function, pre-pregnancy ejection fraction, and medical comorbidities such as uncontrolled hypertension and diabetes. Postpartum outcomes evaluated included delivery complications, acute antibody-mediated rejection, time to maternal death, fetal demise, and neonatal congenital defects. Results Average transplant to conception interval was 11 years. Two pregnancies were unplanned. One pregnancy was complicated by pre-eclampsia and one by intrauterine growth restriction. One maternal death occurred during pregnancy due to cardiogenic shock secondary to graft antibody-mediated rejection. Peripartum cardiomyopathy was the transplant indication in this patient. No additional cases of rejection were noted within 3 months of delivery. Out of the six pregnancies, fetal outcomes ranged from one fetal demise secondary to maternal demise and one preterm birth. No infants with low weight or congenital defects were noted. Conclusion It is crucial to identify heart transplant patients of reproductive age to provide preconception counseling to highlight baseline risk of poor maternal and fetal outcome on factors such as transplant to conception interval, prior rejection, graft dysfunction, and comorbidities. Guidance should be geared towards optimizing the patient relating to her transplant and accompanying medical conditions. It is vital to utilize a multidisciplinary cardio-obstetric team to minimize maternal and fetal complications. There is a growing demographic of female post-heart transplant recipients who are surviving to childbearing age. Pregnancy is typically not advised for patients within one-year post-transplant and is reviewed on a case by case basis thereafter. As post-transplant outcomes continue to improve, preconception counseling is imperative to guide maternal and fetal safety during pregnancy. A cohort of five women with a total of six pregnancies were assessed at Cleveland Clinic and followed through pregnancy. These baseline patient characteristics were reviewed; heart transplant indication, immunosuppression regimen, history of rejection, stability of graft function, pre-pregnancy ejection fraction, and medical comorbidities such as uncontrolled hypertension and diabetes. Postpartum outcomes evaluated included delivery complications, acute antibody-mediated rejection, time to maternal death, fetal demise, and neonatal congenital defects. Average transplant to conception interval was 11 years. Two pregnancies were unplanned. One pregnancy was complicated by pre-eclampsia and one by intrauterine growth restriction. One maternal death occurred during pregnancy due to cardiogenic shock secondary to graft antibody-mediated rejection. Peripartum cardiomyopathy was the transplant indication in this patient. No additional cases of rejection were noted within 3 months of delivery. Out of the six pregnancies, fetal outcomes ranged from one fetal demise secondary to maternal demise and one preterm birth. No infants with low weight or congenital defects were noted. It is crucial to identify heart transplant patients of reproductive age to provide preconception counseling to highlight baseline risk of poor maternal and fetal outcome on factors such as transplant to conception interval, prior rejection, graft dysfunction, and comorbidities. Guidance should be geared towards optimizing the patient relating to her transplant and accompanying medical conditions. It is vital to utilize a multidisciplinary cardio-obstetric team to minimize maternal and fetal complications.