Successful pregnancy outcome in patient with cardiac transplantation

Deniz Karcaaltincaba; Mehmet Emin Ozdogan; Ezgi Turgut; Halis Ozdemir; Gülten Tacoy; Gözde Inan

doi:10.1515/crpm-2021-0041

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Successful pregnancy outcome in patient with cardiac transplantation

Deniz Karcaaltincaba , Mehmet Emin Ozdogan , Ezgi Turgut , Halis Ozdemir , Gülten Tacoy and Gözde Inan

Published/Copyright: September 14, 2021

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From the journal Case Reports in Perinatal Medicine Volume 10 Issue 1

Abstract

Objectives

The population of female heart transplant recipients of reproductive age is increasing and pregnancy follow-up of these patients is important.

Case presentation

A 30-year-old patient who had a heart transplant due to viral myocarditis became pregnant spontaneously. A close follow-up by a multidisciplinary team allowed a normal pregnancy without maternal or fetal complications and the delivery of a healthy infant.

Conclusions

Successful pregnancy outcomes are possible in women who had a heart transplant. Careful and close surveillance by a multidisciplinary team is mandatory.

Keywords: cardiac transplantation; dilated cardiomyopathy; multidisiplinary team; pregnancy

Introduction

There is a growing population of surviving young women with cardiac transplantation. Pregnancies after transplantation carry a high risk to the patient, fetus, and allograft. These patients need to be closely monitored by an integrated team that includes a cardiovascular surgeon, cardiologist, and perinatologist in specialized centers [1]. Preconceptional counseling is recommended both for the evaluation of allograft dysfunction or vasculopathy and for the risk of recurrence of similar heart disease in the fetus. Maternal risks are allograft rejection, infection, hypertension, and preeclampsia. Fetal risks include spontaneous abortion, premature delivery, and low birth weight [2]. We report a case of successful pregnancy in the cardiac transplant recipient which is the first case in Turkey.

Case presentation

A 30-year-old patient was first evaluated preconceptionally. She underwent cardiac transplantation due to viral myocarditis and dilated cardiomyopathy 11 years ago. Since then she was under immunosuppressive therapy and no allograft rejection has been noted. The patient was informed about potential risks during pregnancy. Based on the immunosuppressive drugs blood levels, dosages were adjusted (cyclosporine A [CsA] 250 mg/day, azathioprine 200 mg/day, and low dose prednisolone). She got pregnant spontaneously. She was carefully followed up during pregnancy by the cardiovascular surgeon, cardiologist, and an obstetrics team experienced in high-risk pregnancies. At the beginning of pregnancy, blood tests were normal (Hemoglobin (Hgb): 11.2 g/dL, platelet: 210.000/mm³, white blood cell (WBC): 5,650/mm³, aspartate aminotransferase (AST): 16 U/L, alanine aminotransferase (ALT): 11 U/L, creatinine (Cr): 0.54 mg/dL, blood urea nitrogen (BUN): 14 mg/dL). She was prescribed 100 mg/day aspirin during pregnancy. She received daily oral iron as 60 mg elemental iron after 20th weeks. The transthoracic echocardiography revealed normal left ventricular systolic (Left ventricular ejection fraction (LVEF) at 67%) and diastolic function. During pregnancy, CsA blood level remained therapeutic dose (45–130 ng/mL). The fetal anomaly was not observed in the ultrasound examinations and any pregnancy complication such as growth restriction and preterm delivery did not exist, only had mild hypertension at 38th weeks of gestation. Before delivery, she had no cardiovascular complaint with normal left ventricular function. She delivered a normal male infant of 2,970 g, APGAR score of 9/10 with the cesarean section under general anesthesia. She was carefully monitored postpartum. She was discharged on the 6th day postpartum without any complication.

Discussion

The first pregnancy after cardiac transplantation was reported in 1988 [3]. Cardiac transplantations have been performed worldwide in many women of childbearing age [2, 4]. Guidelines recommend avoiding pregnancy in the first 12 months following transplantation due to the higher risks of rejection and the potential fetal side effects of an aggressive immunosuppression regimen [1].

Many physiologic adaptive changes which occur during pregnancy may lead to clinical problems. Significant potential concerns are rejection, infection, hypertension, preeclampsia, and even death. Maternal death during pregnancy has been reported secondary to acute graft rejection and postpartum hemorrhage [5]. Rejection which was reported in 11% during pregnancy, could be the result of factors, including hemodynamic, immunological changes of pregnancy, and the dilution of immunosuppressive agents secondary to increase in plasma volume [6]. Asymptomatic urinary tract infection is frequently seen during pregnancy and routine urine cultures should be screened. There is an increased risk of preeclampsia (14–18%) [7]. Punnoose et al. [8] reported 91 heart transplant patients with 157 pregnancies. In this study, the most common complications during pregnancy included pre-eclampsia (23%) and infections (14%). Close blood pressure evaluation and low-dose aspirin are recommended. Hypertension and preeclampsia are major factors responsible for the increased prevalence of preterm delivery and fetal growth restriction [6]. Preterm birth rates between 15 and 25% have been reported in studies [5]. Our patient was closely monitored. She had mild gestational hypertension and healthy term birth without preeclampsia.

Most currently used immunosuppressant medications cross the placenta but are considered safe for use in pregnancy. Mycophenolate mofetil poses a high-risk of teratogenicity and should stop before conception [9].

Although the mode of delivery should be decided by obstetric indications, the cesarean section rate is reported high as 40–45% [10]. Regional anesthesia has been used for both vaginal and cesarean delivery. However, we preferred general anesthesia due to the risk of hypotension during regional anesthesia. Blood pressure and pulse were kept stable during general anesthesia to overcome cardiac negative effects.

Cardiac transplant recipients should be carefully monitored postpartum due to increased cardiac output in the immediate postpartum period with uterine involution. Serial electrocardiograms, echocardiograms, and isoenzymes are helpful during this high risk period [11].

Conclusions

We report the first case of a cardiac transplant patient with a live birth in Turkey. Pregnancy in women following cardiac transplantation is of high risk, and a dedicated multidisciplinary team comprising a transplant physician, an obstetrician with experience in maternal and fetal medicine, and an obstetric anesthesiologist is necessary to optimize maternal, fetal, and neonatal outcomes.

Corresponding author: Ezgi Turgut, Department of Obstetrics and Gynecology, Gazi University, Faculty of Medicine, Ankara, Turkey, Phone: +905065262353, E-mail: ezgi_sariakcali@hotmail.com

Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Informed consent was obtained from all individuals included in this study.
Ethical approval: The local Institutional Review Board deemed the study exempt from review.

References

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Received: 2021-05-04

Accepted: 2021-09-01

Published Online: 2021-09-14

Articles in the same Issue

https://doi.org/10.1515/crpm-2021-0041

Keywords for this article

cardiac transplantation; dilated cardiomyopathy; multidisiplinary team; pregnancy