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The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Pregnancy outcomes in heart transplant recipients

Published:February 13, 2020DOI:https://doi.org/10.1016/j.healun.2020.02.005

      BACKGROUND

      The population of female heart transplant recipients of reproductive age is growing, and counseling regarding reproductive decisions is important. We describe maternal and fetal outcomes of pregnancy in the Transplant Pregnancy Registry International.

      METHODS

      Data regarding pregnancies between 1987 and 2016 were collected via questionnaires, phone interviews, and medical records review. Demographics, comorbidities, changes in immunosuppressive regimens, rejection episodes during pregnancy, data on maternal retransplants, and deaths were recorded.

      RESULTS

      A total of 91 patients reported 157 pregnancies. Mean maternal age at conception was 27 ± 5.6 years. The most common indications for transplant were congenital heart disease (22%) and viral myocarditis (18%). Average transplant to conception interval was 7 ± 6.1 years. Immunosuppression was calcineurin inhibitor–based in almost all patients, with 20% of recipients taking mycophenolic acid (MPA) while pregnant. Complications during pregnancy included pre-eclampsia (23%) and infections (14%). Rejection was reported during 9% of pregnancies and within 3 months postpartum in 7%. Livebirths occurred in 69%, with no neonatal deaths. Miscarriages occurred in 26% of pregnancies, 49% of which had MPA exposure. Mean follow-up post pregnancy was 8.9 ± 6.5 years. At last follow-up, 30 recipients had died, an average of 9.4 ± 6.2 years after pregnancy. The most common causes included allograft vasculopathy and rejection.

      CONCLUSIONS

      This is the largest reported series of pregnancies in heart transplant recipients and demonstrates that two thirds of pregnancies reported are successful. MPA exposure is associated with increased risk of teratogenicity and miscarriage. Pre-pregnancy counseling should include discussions of risk of MPA exposure, rejection, graft dysfunction, and maternal survival.

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      References

        • Lund LH
        • Edwards LB
        • Kucheryavaya AY
        • et al.
        The registry of the International Society for Heart and Lung Transplantation: thirtieth official adult heart transplant report—2013; focus theme: age.
        J Heart Lung Transplant. 2013; 32: 951-964
        • Rossano JW
        • Dipchand AI
        • Edwards LB
        • et al.
        The registry of the International Society for Heart and Lung Transplantation: nineteenth pediatric heart transplantation report-2016; focus theme: primary diagnostic indications for transplant.
        J Heart Lung Transplant. 2016; 35: 1185-1195
        • Abdalla M
        • Mancini DM
        Management of pregnancy in the post-cardiac transplant patient.
        Semin Perinatol. 2014; 38: 318-325
        • Vos R
        • Ruttens D
        • Verleden SE
        • et al.
        Pregnancy after heart and lung transplantation.
        Best Pract Res Clin Obstet Gynaecol. 2014; 28: 1146-1162
        • Coscia LA
        • Constantinescu S
        • Armenti DP
        • Moritz MJ
        The 25th Anniversary of the National Transplantation Pregnancy Registry.
        Clin Transpl. 2015; 31: 57-68
        • Sibanda N
        • Briggs JD
        • Davison JM
        • Johnson RJ
        • Rudge CJ
        Pregnancy after organ transplantation: a report from the UK Transplant Pregnancy Registry.
        Transplantation. 2007; 83: 1301-1307
        • Scott JR
        • Wagoner LE
        • Olsen SL
        • Taylor DO
        • Renlund DG
        Pregnancy in heart transplant recipients: management and outcome.
        Obstet Gynecol. 1993; 82: 324-327
        • Mohamed-Ahmed O
        • Nelson-Piercy C
        • Bramham K
        • et al.
        Pregnancy outcomes in liver and cardiothoracic transplant recipients: a UK national cohort study.
        PLoS One. 2014; 9: e89151
        • Morini A
        • Spina V
        • Aleandri V
        • Cantonetti G
        • Lambiasi A
        • Papalia U
        Pregnancy after heart transplant: update and case report.
        Hum Reprod. 1998; 13: 749-757
      1. Advarra. Available at: https://www.advarra.com/.

      2. ISHLT Adult Heart Transplantation Statistics. Available at: https://ishltregistries.org/registries/slides.asp.

        • Fridman M
        • Korst LM
        • Chow J
        • Lawton E
        • Mitchell C
        • Gregory KD
        Trends in maternal morbidity before and during pregnancy in California.
        Am J Public Health. 2014; 104: S49-S57
        • Ananth CV
        • Keyes KM
        • Wapner RJ
        Pre-eclampsia rates in the United States, 1980-2010: age-period-cohort analysis.
        BMJ. 2013; 347: f6564
        • Ma KK
        • Petroff MG
        • Coscia LA
        • Armenti VT
        • Adams Waldorf KMA
        Complex chimerism: pregnancy after solid organ transplantation.
        Chimerism. 2013; 4: 71-77
        • Zheng S
        • Easterling TR
        • Umans JG
        • et al.
        Pharmacokinetics of tacrolimus during pregnancy.
        Ther Drug Monitor. 2012; 34: 660-670
        • Wang X
        • Chen C
        • Wang L
        • Chen D
        • Guang W
        • French J
        Conception, early pregnancy loss and time to clinical pregnancy: a population based prospective study.
        Fertil Steril. 2003; 79: 577-584
        • Murphy SL
        • Mathews TJ
        • Martin JA
        • Minkovitz CS
        • Strobino DM
        Annual summary of vital statistics: 2013-2014.
        Pediatrics. 2017; 139
        • Martin JA
        • Hamilton BE
        • Osterman MJ
        • Driscoll AK
        • Mathews TJ
        Births: final data for 2015.
        Natl Vital Stat Rep. 2017; 66: 1
        • Coscia LA
        • Armenti DP
        • King RW
        • Sifontis NM
        • Constantinescu S
        • Moritz MJ
        Update on the teratogenicity of maternal mycophenolate mofetil.
        J Pediatr Genet. 2015; 4: 42-55
        • Whittemore R
        • Wells JA
        • Castellsague X
        A second-generation study of 427 probands with congenital heart defects and their 837 children.
        J Am Coll Cardiol. 1994; 23: 1459-1467
        • Rasmusson K
        • Brunisholz K
        • Budge D
        • et al.
        Peripartum cardiomyopathy: post-transplant outcomes from the united network for organ sharing database.
        J Heart Lung Transplant. 2012; 31: 180-186