Research

JAMA Cardiology | Original Investigation

Maternal and Fetal Outcomes of Admission for Delivery

in Women With Congenital Heart Disease
Robert M. Hayward, MD; Elyse Foster, MD; Zian H. Tseng, MD, MAS

Invited Commentary
BACKGROUND Women with congenital heart disease (CHD) may be at increased risk for Supplemental content
adverse events during pregnancy and delivery.

OBJECTIVE To compare delivery outcomes between women with and without CHD.

DESIGN, SETTING, AND PARTICIPANTS This retrospective study of inpatient delivery

admissions in the Healthcare Cost and Utilization Projects California State Inpatient Database
compared maternal and fetal outcomes between women with and without CHD by using
multivariate logistic regression. Female patients with codes for delivery from the International
Classification of Diseases, Ninth Revision, from January 1, 2005, through December 31, 2011,
were included. The association of CHD with readmission was assessed to 7 years after
delivery. Cardiovascular morbidity and mortality were hypothesized to be higher among
women with CHD. Data were analyzed from April 4, 2014, through January 23, 2017.

EXPOSURES Noncomplex and complex CHD.

MAIN OUTCOMES AND MEASURES Maternal outcomes included in-hospital arrhythmias,

eclampsia or preeclampsia, congestive heart failure (CHF), length of stay, preterm labor,
anemia complicating pregnancy, placental abnormalities, infection during labor, maternal
readmission at 1 year, and in-hospital mortality. Fetal outcomes included growth restriction,
distress, and death.

RESULTS Among 3 642 041 identified delivery admissions, 3189 women had noncomplex
CHD (mean [SD] age, 28.6 [7.6] years) and 262 had complex CHD (mean [SD] age, 26.5 [6.8]
years). Women with CHD were more likely to undergo cesarean delivery (1357 [39.3%] vs
1 164 509 women without CHD [32.0%]; P < .001). Incident CHF, atrial arrhythmias,
ventricular arrhythmias, and maternal mortality were uncommon during hospitalization, with
each occurring in fewer than 10 women with noncomplex or complex CHD (<0.5% each).
After multivariate adjustment, noncomplex CHD (odds ratio [OR], 9.7; 95% CI, 4.7-20.0) and
complex CHD (OR, 56.6; 95% CI, 17.6-182.5) were associated with greater odds of incident
CHF. Similar odds were found for atrial arrhythmias in noncomplex (OR, 8.2; 95% CI,
3.0-22.7) and complex (OR, 31.8; 95% CI, 4.3-236.3) CHD, for fetal growth restriction in
noncomplex (OR, 1.6; 95% CI, 1.3-2.0) and complex (OR, 3.5; 95% CI, 2.1-6.1) CHD, and for
hospital readmission in both CHD groups combined (OR, 3.6; 95% CI, 3.3-4.0). Complex CHD
was associated with greater adjusted odds of serious ventricular arrhythmias (OR, 31.8; Author Affiliations: Section of
Cardiac Electrophysiology, Division of
95% CI, 4.3-236.3) and maternal in-hospital mortality (OR, 79.1; 95% CI, 23.9-261.8). Cardiology, Department of Medicine,
University of California, San Francisco
CONCLUSIONS AND RELEVANCE In this study of hospital admissions for delivery in California, (Hayward, Tseng); now with Division
of Cardiovascular Medicine,
CHD was associated with incident CHF, atrial arrhythmias, and fetal growth restriction and
Department of Medicine, University
complex CHD was associated with ventricular arrhythmias and maternal in-hospital mortality, of Massachusetts Memorial Medical
although these outcomes were rare, even in women with complex CHD. These findings may Center, Worcester (Hayward);
guide monitoring decisions and risk assessment for pregnant women with CHD at the time of Division of Cardiology, Department of
Medicine, University of California,
delivery.
San Francisco (Foster).
Corresponding Author: Zian H.
Tseng, MD, MAS, Section of Cardiac
Electrophysiology, University
of California, San Francisco,
500 Parnassus Ave, Box 1354,
JAMA Cardiol. doi:10.1001/jamacardio.2017.0283 San Francisco, CA 94143
Published online April 12, 2017. (zhtseng@medicine.ucsf.edu).

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 Research Original Investigation
L
abor, delivery, and the postpartum period are a time of
increased arrhythmia and heart failure incidences, even
in patients without cardiovascular disease. Possible
explanations include altered hemodynamics with myocar-
dial irritability owing to increases in intravascular volume, hy-
pokalemia, autonomic changes, and hormonal influences on
adrenergic receptor number and behavior.1-3 Maternal arrhyth-
mias increase during labor and delivery, possibly owing to vol-
ume shifts and hypertension.4 In women with arrhythmias be-
fore pregnancy, recurrence during pregnancy is common and
is associated with an increased risk for fetal complications.5
Despite these risks, a small series including women with im-
plantable cardioverter defibrillators followed up during sub-
sequent pregnancies has revealed no increase in implantable
cardioverter defibrillator shocks.6,7 Likewise, congestive heart
failure (CHF) is more common during and after pregnancy in
women without a history of cardiovascular disease.8
Owing to improvements in the treatment of congenital heart
disease (CHD), most patients with CHD now survive to adult-
hood, and more than 1 million adults are living with CHD in the
United States.9,10 As patients with CHD live longer, arrhyth-
mias are an increasing cause of morbidity and mortality.11,12 In
addition, more women with CHD are becoming pregnant, and
these patients are at increased risk for arrhythmias and CHF.13,14
We sought to evaluate contemporary maternal and fetal
outcomes in women with and without CHD during admis-
sions for delivery in California. We used the Health Care Cost
and Utilization Project (HCUP), a group of databases that
have already been used to study CHD hospitalizations and
procedures,15-19 to evaluate cardiac and other complications
of labor and delivery for women with and without CHD from
2005 through 2011.
Methods
Admissions for female patients with a diagnosis code from the
International Classification of Diseases, Ninth Revision (ICD-9),
a procedure code from the International Classification of Dis-
eases, Ninth Revision, Clinical Modification, or a diagnosis re-
lated group code for delivery20,21 from January 1, 2005, through
December 31, 2011, were identified from HCUPs California State
Inpatient Database. If an ICD-9 code for cesarean delivery was
not present and the delivery type was not specified, delivery
was categorized as vaginal. The details of the ICD-9 codes used
are listed in eTable 1 in the Supplement. Identifying patient in-
formation was anonymized before analysis, and certification
to use these deidentified HCUP data was obtained from the
Committee on Human Research at the University of Califor-
nia, San Francisco.
Diagnoses of CHD were determined by ICD-9 or Current
Procedural Terminology codes used by others previously
(eTable 2 in the Supplement).17,22-24 If a CHD diagnosis code
was present for any encounter during the study period, the pa-
tient was assigned that diagnosis for all visits. Complex CHD
included endocardial cushion defects, hypoplastic left heart
syndrome, tetralogy of Fallot, transposition of the great arter-
ies, truncus arteriousus, and univentricular heart defects. All
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Maternal and Fetal Outcomes of Admission for Delivery in CHD
Key Points
Question How do the risks and outcomes for labor and delivery
compare in women with and without congenital heart disease?
Findings In this study capturing nearly every delivery admission in
California during a 7-year period, congenital heart disease was
associated with incident heart failure, atrial arrhythmias, fetal
growth restriction, and readmission; complex congenital heart
disease was also associated with ventricular arrhythmias and
maternal in-hospital mortality, although these outcomes were
rare, even in women with congenital heart disease.
Meaning This study highlights some of the peripartum and
postpartum risks for women with CHD, findings that may guide
monitoring decisions and risk assessment for pregnant women
with CHD at the time of delivery.
other CHD defects were classified as noncomplex.22-24 Pa-
tients with complex and noncomplex CHD diagnoses were
assigned to the complex CHD group.
Maternal cardiovascular outcomes included in-hospital
atrial arrhythmias (including atrial fibrillation, atrial flutter, or
paroxysmal supraventricular tachycardia), serious ventricu-
lar arrhythmias (including paroxysmal ventricular tachycar-
dia, ventricular fibrillation, ventricular flutter, cardiac arrest,
and sudden death due to an unknown cause during the puer-
perium), eclampsia or preeclampsia, and CHF (eTable 3 in the
Supplement). Other maternal outcomes included length of stay
and in-hospital mortality. Maternal and fetal outcomes, de-
fined by others previously,25 included preterm labor, anemia
complicating pregnancy, placental abnormalities (previa,
abruptio, or accreta), infection during labor, fetal growth re-
striction, fetal distress, and fetal death.
Outcomes after discharge included readmission to the hos-
pital (after excluding admissions for subsequent delivery) for
CHF, atrial arrhythmias, and serious ventricular arrhythmias
at 1 year. Women with a primary residence outside California
were excluded from this analysis. Because these outcomes were
uncommon and because we found no significant differences
between the complex and noncomplex CHD groups, both were
analyzed as a single group for the 1-year follow-up.
Medical comorbidities were classified based on ICD-9 di-
agnosis codes for coronary artery disease, CHF, cerebrovas-
cular disease, chronic kidney disease, hypertension, diabe-
tes, and depression (eTable 4 in the Supplement).19,25 Patients
were identified as having the comorbidity of interest if the di-
agnosis code was recorded for any health care encounter from
January 1, 2005, to the admission date for delivery. Thus, these
comorbidities included comorbidities diagnosed before preg-
nancy and those diagnosed during pregnancy but before the
admission for delivery.
Statistical Analysis
Data were analyzed from April 4, 2014, through January 23,
2017. Continuous variables are presented as mean (SD); cat-
egorical variables, as percentages. Continuous variables that
were not normally distributed are presented as median (inter-
quartile range [IQR]). We compared outcomes using multivar-
iate logistic regression with the following covariates: age, race,
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 Maternal and Fetal Outcomes of Admission for Delivery in CHD Original Investigation Research

Table 1. Baseline Characteristics of Women Admitted for Deliveriesa

Patient Group, No. (%)

No CHD Noncomplex CHD Complex CHD
Characteristic (n = 3 638 590) (n = 3189) (n = 262) P Valueb
Age, mean (SD), y 28.3 (6.6) 28.6 (7.6) 26.5 (6.8) <.001
Race or ethnicity
Asian or Pacific Islander 380 592 (10.8) 293 (9.3) 25 (9.6)
Black 187 794 (5.4) 218 (6.9) 13 (5.0)
Hispanic 1 765 517 (50.3) 1314 (41.7) 100 (38.5)
<.001
Native American 5428 (0.2) 13 (0.4) 0
White 1 058 119 (30.1) 1173 (37.2) 107 (41.2)
Other 114 822 (3.3) 140 (4.4) 15 (5.8)
Cesarean delivery 1 164 509 (32.0) 1236 (38.8) 121 (46.2) <.001
Multiple birth 55 745 (1.5) 63 (1.9) <10c .20 Abbreviations: AF, atrial fibrillation;
CHF 4517 (0.1) 111 (3.5) 19 (7.3) <.001 AFL, atrial flutter; CHD, congenital
Hypertension 37 930 (1.0) 202 (6.3) 14 (5.3) <.001 heart disease; CHF, congestive heart
failure; SCA, sudden cardiac arrest;
Diabetes 37 270 (1.0) 118 (3.7) 16 (6.1) <.001 SVT, supraventricular tachycardia;
Depression 35 728 (1.0) 82 (2.6) <10c <.001 VF, ventricular fibrillation;
History of AF, AFL, or SVT 1796 (0.05) 41 (1.3) <10c <.001 VT, ventricular tachycardia.
a
History of VT, VF, or SCA 744 (0.02) <10c <10c <.001 Owing to missing data, totals may
not equal column heads.
Hospital delivery volume quartile b
Calculated using Pearson 2 test.
Lowest 1323 (0.04) 10 (0.3) 0 c
Health Care Cost and Utilization
Second 242 539 (6.7) 182 (5.7) 13 (5.0) Project policy prohibits reporting
<.001
Third 1 003 283 (27.6) 874 (27.4) 81 (30.9) cell frequencies of less than 10, but
each frequency was more common
Highest 2 391 445 (65.7) 2123 (66.6) 168 (64.1)
than for women without CHD.

cesarean delivery, multiple birth, maternal history of CHF, hy-
pertension, coronary artery disease, chronic kidney disease, dia-
betes, and cerebrovascular disease. We assessed the association
of CHD with readmission to the hospital for reasons other than
subsequent delivery by using survival analysis, with failure de-
fined as readmission to the hospital to 7 years after delivery.
Women without a readmission were administratively censored
on December 31, 2011. The association of CHD with the hazard
of readmission was evaluated with Cox proportional hazards
modeling. Beginning with an a priori set of predictors, backward
selection was used to remove covariates with P < .1 in adjusted
analyses. Two-tailed P < .05 was considered to be statistically
significant. Owing to HCUP publication requirements,26 cell sizes
of less than 10 are not reported, although the exact number is
used in the analyses. Statistical analyses were performed using
STATA/SE software (version 13.1; StataCorp).
Results
Of a total of 27 907 535 inpatient hospitalizations in Califor-
nia from January 1, 2005, through December 31, 2011, we iden-
tified 3 642 041 admissions for women with a delivery diag-
nosis. After including codes for multiple births, we identified
3 702 838 live births accounting for 98.4% of all live births in
California during the 7-year period.27
Among these admissions for delivery, we identified 3189
women with noncomplex CHD (mean [SD] age, 28.6 [7.6] years)
and 262 women with complex CHD (mean [SD] age, 26.5 [6.8]
years) (Table 1) with a variety of congenital defects (eTable 5
in the Supplement). The remaining 3 638 590 women with-
out CHD (mean [SD] age, 28.3 [6.6] years) comprised the com-
parison group. A history of CHF was more common in women
with CHD (19 [7.3%] with complex CHD, 111 [3.5%] with non-
complex CHD, and 4517 [0.1%] without CHD; P < .001). A his-
tory of arrhythmias was rare in all groups but somewhat more
common in women with CHD.
In-Hospital Maternal and Fetal Outcomes
Women with CHD were more likely to undergo cesarean de-
livery (121 [46.2%] with complex CHD, 1236 [38.8%] with non-
complex CHD, and 1 164 509 [32.0%] without CHD; P < .001).
For tetralogy of Fallot, 56 of 102 women with CHD (54.9%) un-
derwent cesarean delivery (eTable 5 in the Supplement).
Median length of stay was longer for women with CHD com-
pared with women without CHD (3 [IQR, 2-4] vs 2 [IQR, 2-3]
days; P < .001). In addition, 29 women with complex CHD (11.1%)
and 191 women with noncomplex CHD (6.0%) were admitted
for longer than 7 days, compared with only 49 089 women with-
out CHD (1.3%). After multivariate adjustment, CHD was asso-
ciated with greater odds of admissions longer than 1 week
(Table 2). Preeclampsia or eclampsia was observed in 19 women
with complex CHD (7.3%), 182 women with noncomplex CHD
(5.7%), and 122 539 women without CHD (3.4%). After multi-
variate adjustment, noncomplex CHD was significantly asso-
ciated with increased odds of preeclampsia or eclampsia (OR,
1.3; 95% CI, 1.1-1.5; P = .003); the association for complex CHD
was not significant (OR, 1.5; 95% CI, 0.9-2.4; P = .12).
Incident CHF, atrial arrhythmias, serious ventricular ar-
rhythmias, and maternal mortality were uncommon during

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 Research Original Investigation Maternal and Fetal Outcomes of Admission for Delivery in CHD

Table 2. Maternal and Fetal In-Hospital Outcomes

Patient Group, No. (%) Noncomplex vs No CHD Complex vs No CHD

No CHD Noncomplex CHD Complex CHD AOR
Outcome (n = 3 638 583) (n = 3189) (n = 262) (95% CI) P Valuea AOR (95% CI) P Valuea
Maternal
LOS, median (IQR), d 2 (2-3) 3 (2-4) 3 (2-4)
LOS>7 d 49 089 (1.3) 191 (6.0) 29 (11.1) 2.8 (2.3-3.3) <.001 6.7 (4.4-10.1) <.001
Preeclampsia or eclampsia 122 539 (3.4) 182 (5.7) 19 (7.3) 1.3 (1.1-1.5) .003 1.5 (0.9-2.4) .12
Preterm labor 235 834 (6.5) 356 (11.2) 49 (18.7) 1.6 (1.4-1.8) <.001 3.0 (2.2-4.1) <.001
Anemia complicating 296 207 (8.1) 446 (14.0) 39 (14.9) 1.5 (1.4-1.7) <.001 1.6 (1.1-2.3) .007
pregnancy
Placental abnormalities 75 043 (2.1) 85 (2.7) <10b 1.2 (0.95-1.5) .14 1.6 (0.8-3.0) .20
Infection during labor 143 333 (3.9) 151 (4.7) 16 (6.1) 1.2 (1.01-1.4) .04 1.5 (0.9-2.5) .13
Incident CHF 508 (0.01) <10b <10b 9.7 (4.7-20.0) <.001 56.6 (17.6-182.5) <.001
Incident AF, AFL, or SVT 253 (0.01) <10b <10b 8.2 (3.0-22.7) <.001 31.8 (4.3-236.3) .001
b
Incident VT, VF, or SCA 744 (0.02) <10 <10b 1.9 (0.7-5.1) .23 35.3 (13.4-93.5) <.001
In-hospital mortality 1143 (0.03) <10b (0.2) <10b 1.7 (0.8-4.0) .19 79.1 (23.9-261.8) <.001
Fetal/neonatal
Growth restriction 48 765 (1.3) 76 (2.4) 14 (5.3) 1.6 (1.3-2.0) <.001 3.5 (2.1-6.1) <.001
Distress 526 343 (14.5) 490 (15.4) 49 (18.7) 1.1 (1.0-1.2) .34 1.3 (0.9-1.7) .15
Death 13 017 (0.36) 22 (0.69) 0 1.7 (1.09-2.64) .02
Abbreviations: AF, atrial fibrillation; AFL, atrial flutter; AOR, adjusted odds ratio; CHD, congenital heart disease; CHF, congestive heart failure; IQR, interquartile
range; LOS, length of stay; SCA, sudden cardiac arrest; SVT, supraventricular tachycardia; VF, ventricular fibrillation; VT, ventricular tachycardia.
a
Calculated using multivariate logistic regression.
b
Although Health Care Cost and Utilization Project policy prohibits reporting cell frequencies less than 10, actual numbers were known to investigators and used for
analyses.

Fetal growth restriction was reported in 14 women with

Table 3. Maternal Outcomes at 1 Yeara
complex CHD (5.3%), 76 women with noncomplex CHD (2.4%),
No CHD CHD CHD vs No CHD,
Outcome (n = 2 807 672) (n = 3106)b AOR (95% CI) and 48 765 women without CHD (1.3%). After multivariate ad-
Any readmission 119 441 (4.3) 544 (17.5) 3.6 (3.3-4.0) justment, noncomplex CHD (OR, 1.6; 95% CI, 1.3-2.0; P < .001)
Readmission for CHF 689 (0.02) 19 (0.6) 6.7 (4.0-11.1) and complex CHD (OR, 3.5; 95% CI, 2.1-6.1; P < .001) were as-
Readmission for atrial 736 (0.03) 32 (1.0) 10.9 (7.0-17.1) sociated with greater odds of fetal growth restriction. Fetal
arrhythmiasc death occurred in no deliveries for women with complex CHD,
Readmission for serious 543 (0.02) 15 (0.5) 6.2 (3.5-11.2) 22 deliveries for women with noncomplex CHD (0.7%), and
ventricular arrhythmias
13 017 deliveries for women without CHD (0.4%). After mul-
Abbreviations: AOR, adjusted odds ratio; CHD, congenital heart disease;
tivariate adjustment, noncomplex CHD was associated with
CHF, congestive heart failure.
a greater odds of fetal death compared with women without CHD
Excludes admissions for subsequent delivery and women with a primary
residence outside California. (OR, 1.7; 95% CI, 1.1-2.6; P = .02).
b
Noncomplex CHD and complex CHD were pooled owing to small numbers of
outcomes and the fact that the 2 groups were not significantly different. Maternal Outcomes After Hospital Discharge
Groups were compared with 2 tests, and all differences were statistically When women were followed up after discharge, 30 155 women
significant (P < .001). without CHD (1.1%) and 166 women with CHD (5.6%) were re-
c
Includes atrial fibrillation, atrial flutter, or paroxysmal supraventricular admitted to the hospital within 30 days (P < .001); the read-
tachycardia.
mission rate exclusive of subsequent deliveries remained
higher for women with CHD at 1 year (OR, 3.6; 95% CI, 3.3-
hospitalization, each occurring in fewer than 0.5% of women 4.0; P < .001) (Table 3) and to 7 years after discharge (2 = 3941,
with CHD (Table 2). After multivariate adjustment, noncom- P < .001, log-rank test for comparing complex CHD, noncom-
plex CHD (OR, 9.7; 95% CI, 4.7-20.0; P < .001) and complex CHD plex CHD, and no CHD) (Figure 1). At 1 year, readmissions for
(OR, 56.6; 95% CI, 17.6-182.5; P < .001) were associated with CHF (OR, 6.7; 95% CI, 4.0-11.1; P < .001), atrial arrhythmias (OR,
greater odds of CHF. Similar associations for noncomplex CHD 10.9; 95% CI, 7.0-17.1; P < .001), and serious ventricular ar-
(OR, 8.2; 95% CI, 3.0-22.7; P < .001) and complex CHD (OR, 31.8; rhythmias (OR, 6.2; 95% CI, 3.5-11.2; P < .001) were more com-
95% CI, 4.3-236.3; P = .001) were found for atrial arrhyth- mon for women with CHD than for those without (Table 3). For
mias. After multivariate adjustment, only complex CHD was readmissions within 1 year of delivery, the 10 most common
associated with greater odds of serious ventricular arrhyth- diagnoses were noncardiac for women without CHD, whereas
mias (OR, 35.3; 95% CI, 13.4-93.5; P < .001) or maternal in- for women with CHD, 3 of the top 10 were cardiac (CHF, ostium
hospital mortality (OR, 79.1; 95% CI, 23.9-261.8; P < .001) secundum, atrial septal defect, and chest pain). After multi-
(Table 2). variate analysis, noncomplex CHD (hazard ratio, 3.88; 95% CI,

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 Maternal and Fetal Outcomes of Admission for Delivery in CHD Original Investigation Research

3.66-4.12) and complex CHD (hazard ratio, 4.51; 95% CI, 3.70- than 98% of all live births, women with CHD were more likely
5.49) had the largest association with increasing the hazard of to have a history of CHF, undergo cesarean delivery, and have
readmission (Figure 2). longer lengths of stay. Incident maternal CHF, arrhythmias, and
mortality were uncommon for all groups of women, but the
odds of these outcomes were substantially greater for women
Discussion with complex CHD. The adjusted odds of CHF, atrial arrhyth-
In this study of more than 3.6 million admissions for delivery mias, and maternal death were also increased for women with
in California during a 7-year period that accounted for more noncomplex CHD. At 1 year, readmissions for CHF, atrial ar-
rhythmias, and serious ventricular arrhythmias were more
Figure 1. Cumulative Proportion of Women Readmitted After Delivery
common for women with CHD. After multivariate analysis, CHD
1.0 had a greater associaton with increasing the hazard of read-
P <.001
mission than did diabetes, chronic kidney disease, or hyper-
0.8 tension. Despite these associations, the absolute risks for ad-
verse cardiovascular outcomes among women with CHD were
Proportion Readmitted

0.6
still low. The risks for incident CHF, supraventricular arrhyth-
Complex CHD mias, serious ventricular arrhythmias, and maternal in-
Noncomplex CHD hospital mortality were less than 0.5% among women with
0.4
CHD. The magnitude of the increases in relative risk among
women with CHD appears to be high in part owing to com-
0.2
parisons against the rare levels of these complications in the
No CHD general population.
0
0 500 1000 1500 2000
Women with CHD more often underwent cesarean deliv-
Time After Delivery, d ery, but the underlying reasons for this difference are unclear.
Cesarean delivery is more commonly used in mothers who have
Includes admissions other than for subsequent delivery. P values comparing delivered by cesarean delivery previously and in cases of breech
equality of survivor functions for complex, noncomplex, and no congenital
presentation, dystocia, and fetal distress.28-30 Women with CHD
heart disease (CHD) were calculated using log-rank test (2 = 3941; P < .01).
were not more likely to have codes for fetal distress; therefore,

Figure 2. Multivariate Analysis for Hospital Readmission

Covariate HR (95% CI) P Value

No CHD 1 [Reference] NA
Complex CHD 4.51 (3.70-5.49) <.001
Noncomplex CHD 3.88 (3.66-4.12) <.001
Age, y
<18 1.34 (1.32-1.36) <.001
18-29 1 [Reference] NA
30-39 0.80 (0.79-0.80) <.001
40 1.25 (1.23-1.27) <.001
Race
White 1 [Reference] NA
Black 1.63 (1.61-1.65) <.001
Hispanic 1.16 (1.15-1.17) <.001
Asian or Pacific Islander 0.68 (0.67-0.69) <.001
Native American 2.24 (2.10-2.39) <.001
Other 1.40 (1.37-1.43) <.001
Cesarean delivery 1.17 (1.16-1.17) <.001
Multiple birth 1.03 (1.00-1.06) .03
Hospital delivery volume
Lowest quartile 1.04 (1.02-1.05) <.001
Second quartile 1.01 (0.99-1.02) .30
Third quartile 0.98 (0.97-0.99) <.001
Highest quartile 1 [Reference] NA
Comorbidities
CHF 1.66 (1.57-1.76) <.001
Hypertension 2.63 (1.57-2.69) <.001
Coronary artery disease 1.58 (1.49-1.68) <.001
Cerebrovascular disease 1.56 (1.45-1.68) <.001
Chronic kidney disease 2.71 (2.57-2.86) <.001 Includes admissions other than for
Diabetes 2.38 (2.32-2.44) <.001 subsequent delivery. CHD indicates
congenital heart disease;
0 1 2 3 4 5 6 CHF, congestive heart failure;
HR (95% CI) HR, hazard ratio; and NA, not
applicable.

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 Research Original Investigation
increased use of cesarean delivery does not seem to be attrib-
utable to fetal instability. Cesarean deliveries may have been
more likely to be planned owing to physician and/or patient pref-
erence because of the belief that the procedure has less effect
on maternal physiology, although at present no definitive data
on this issue exist. We found a higher rate of cesarean delivery
among women with CHD (46.2% for complex CHD and 38.8%
for noncomplex CHD) than did other studies. In a multicenter
cohort of mothers with CHD from more than a decade ago, Siu
and colleagues31 found that 27% of births were by cesarean de-
livery and 96% of these were for obstetric indications (com-
pared with maternal cardiac status indication in only 4%).
We also found significantly greater odds of preeclampsia or
eclampsia in women with noncomplex CHD and increased odds
in women with complex CHD. Reduced placental perfusion may
cause preeclampsia,32 which could be more common in wom-
en with CHD. Studies have shown that compared with the gen-
eral population and women with repaired defects, women with
an unrepaired atrial septal defect or ventricular septal defect have
an increased risk for preeclampsia.33,34 In addition, even in wom-
en with CHD, preeclampsia or eclampsia is uncommon and only
occurred in 7.3% of women in our complex CHD group.
Compared with the studies by Karamlou and colleagues35
and Thompson and colleagues,36 our study captured nearly ev-
ery birth in California, as opposed to a representative sample
of the United States obtained from the HCUP Nationwide In-
patient Sample. All 3 studies found higher rates of cesarean de-
livery and cardiac complications among women with CHD. Be-
cause of differences between the databases, the present study
was also able to ascertain serious complications requiring re-
admission after discharge.
Cardiac complications were less commonly observed in this
study than in the study by Siu and colleagues,31 who reported
a primary cardiac event in 13% of completed pregnancies. How-
ever, more than half of these events occurred in the prepar-
tum period, which was not evaluated in the present study. One
review13 found cardiac events in 1.9%, CHF in 4.8%, and ar-
rhythmias in 4.5% of deliveries in women with CHD. A Dutch
national study of CHD37 identified cardiovascular events at 1
year in 6.4% of pregnancies, and 9 of 11 events were new-
onset arrhythmias. In our contemporary statewide study of
nearly every delivery to mothers with CHD, arrhythmias oc-
curred in approximately 1% of women.
Prior studies of women with CHD have found that their off-
spring are at increased risk for premature birth, being small for
gestational age, and neonatal mortality.13,38,39 We found greater
odds of fetal growth restriction for women with CHD and
greater odds of fetal death for women with noncomplex CHD.
Patients with complex disease are at particular risk for intra-
uterine growth restriction, and monitoring for such compli-
cations requires vigilance by obstetricians. Owing to coding re-
strictions, we could not examine prematurity as an end point
or as a mediator of the association between maternal CHD and
neonatal mortality. Prior studies have also shown that miscar-
ARTICLE INFORMATION Published Online: April 12, 2017.
Accepted for Publication: January 25, 2017. doi:10.1001/jamacardio.2017.0283
E6 JAMA Cardiology Published online April 12, 2017 (Reprinted)
Copyright 2017 American Medical Association. All rights reserved.
Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/cardiology/0/ by Roberto Lopez Mata on 04/12/2017
Maternal and Fetal Outcomes of Admission for Delivery in CHD
riages and terminations for medical reasons are more com-
mon in women with CHD,13,38 but this study did not capture
any outcomes before the time of delivery.
This study also found a higher risk for maternal readmis-
sion among mothers with CHD at 30 days and 1 and 7 years.
Although we examined the cause of readmission at 1 year, we
did not do so at 7 years, and the higher readmission rates across
long-term follow-up may be attributable to the natural his-
tory of CHD and not to complications of pregnancy.
Limitations
Despite the large number of women with CHD captured in the
study, this study has several limitations. First, ICD-9 codes have
imperfect sensitivity and specificity,40 and CHD may have been
undercoded. However, undercoding is unlikely to bias the re-
sults, because even a small number of women with CHD mis-
classified as not having CHD would not have a sizable effect on
summary estimates of more than 3.6 million women. Second,
the administrative nature of the database does not allow the
medical records of mothers and neonates to be linked to deter-
mine the long-term health outcomes of these infants. Third, this
analysis captured only women who chose to become pregnant
and carried pregnancies to term. We did not evaluate women
who chose not to become pregnant or who did not carry preg-
nancies to term, which may account for approximately 20% of
pregnancies among women with CHD.13 Fourth, the number of
women with CHD who delivered at low-volume centers was
small, and multivariate analysis did not demonstrate an asso-
ciation of hospital delivery volume with outcomes for women
with CHD. Fifth, the inpatient nature of this database did not
allow us to capture intensity or quality of care before and after
delivery. In a recent study of cardiovascular deaths related to
pregnancy in California, health care professional factors were
found to play a role in most cardiovascular deaths.41 Finally, for
the follow-up analysis, only women who were readmitted to a
California hospital were captured; therefore, women who moved
or died outside the hospital were not captured.
Conclusions
In this study of nearly all women admitted to California hos-
pitals for delivery during a 7-year period, women with CHD
were more likely to undergo cesarean delivery and have a lon-
ger length of stay. Incident maternal CHF, arrhythmias, and
mortality were uncommon in all groups of women, but CHD
was significantly associated with incident CHF, atrial arrhyth-
mias, fetal growth restriction, and hospital readmission. Com-
plex CHD was a significant predictor of ventricular arrhyth-
mias and maternal in-hospital mortality. These results may
guide monitoring decisions and risk assessment for pregnant
women with CHD at the time of delivery. Given the higher rate
of cardiac and obstetrical complications, pregnant women with
CHD should be treated in a center with expertise in adult CHD.
Author Contributions: Drs Hayward and Tseng had
full access to all the data in the study and take
jamacardiology.com
 Maternal and Fetal Outcomes of Admission for Delivery in CHD
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data:
Hayward.
Drafting of the manuscript: Hayward, Tseng.
Critical revision of the manuscript for important
intellectual content: Hayward, Foster.
Statistical analysis: Hayward.
Study supervision: Foster, Tseng.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest.
Dr Hayward reports receiving educational travel
grants from Medtronic and Boston Scientific.
Dr Foster reports receiving research support from
Abbott Vascular. Dr Tseng reports receiving minor
honoraria from Biotronik. No other disclosures were
reported.
Funding/Support: This work was supported in part
by 5R01 HL102090 from the National Heart, Lung,
and Blood Institute, National Institutes of Health
(Dr Tseng).
Role of the Funder/Sponsor: The sponsor had no
role in the design and conduct of the study;
collection, management, analysis, or interpretation
of the data; preparation, review, or approval of the
manuscript; or decision to submit the manuscript
for publication.
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