Women with heart disease who are pregnant with twins have twice the risk of heart failure, with prior diagnosis of cardiomyopathy associated with even greater risk, a study has found.
Using data from the Registry of Pregnancy and Cardiac disease (ROPAC), a prospective global registry of pregnant women with heart disease, the investigators compared outcomes in women with twin gestations (n=96) to those with singleton pregnancies (5,643).
The team found that the risk of heart disease was significantly higher in women with twin pregnancies, with at 25% versus 11.2% developing the condition (p<0.001).
Other cardiac symptoms were similar between the two groups, with no differences in maternal mortality, arrhythmia, endocarditis, thrombosis, dissection, acute coronary syndrome or hospital admission for cardiac reasons.
Also of note, the study found that while women with valvular or congenital heart disease experienced heart failure during pregnancy, those with CMP exclusively developed the condition during delivery or postpartum, indicating a need for close management of these patients during these periods.
“These data make it clear that it is critically important to pay very close attention to fluid balance in women with CMP delivering twins, and, as importantly, to watch for early signs of developing HF and to intervene promptly to optimise the situation,” the researchers said.
“Practically, keeping these patients in a high dependency unit under close observation for at least 48 hours postdelivery would seem a sensible precaution,” they added.
The study also showed that among 10 women with CMP and twin gestation, seven developed HF (70%), according to the study, which was published in Heart [link here].
“In the current series, the largest study to date of twin pregnancies in women with heart disease, being pregnant with twins was a risk factor for HF, both when analysing the entire group and when considering only those with a pre-pregnancy diagnosis of heart disease,” the researchers said.
“This makes it clear that a twin pregnancy is a significant risk factor for HF in women with heart disease.”
Findings ‘practice-changing’
In a linked editorial [link here], cardiologists including Dr Claudia Montanaro of the Imperial College London and Royal Brompton Hospital, observe that “twin pregnancy represents a uniquely high circulatory challenge that pushes maternal cardiac reserve to its limits.”
Dr Claudia Montanaro
The ROPAC findings revealed that HF occurred “even in some women without overt dysfunction,” they noted, suggesting that standard evaluations might overestimate the body’s ability to cope with additional stressors.
With heart failure cases focused on the third trimester and early postpartum period, the editorial authors emphasised that “surveillance cannot stop at delivery.”
“The clinical messages are immediate and practice changing and involve not only pre-pregnancy counselling and antenatal surveillance but also delivery planning and postpartum care,” they added. “Twin pregnancies in the structural heart disease population should be treated as high risk by default, with early and more frequent cardio-obstetric follow-ups.”
Management should involve echocardiography and laboratory tests, which should be offered even to women with mild dysfunction, they argued. In addition, they advised multidisciplinary planning involving obstetrics, cardiology and anaesthesia.
“When a woman with cardiac disease is carrying twins, her risk profile is no longer the same,” they concluded. “Prevention, anticipatory monitoring and shared decision-making become essential, not optional.”