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Background Pregnant women with mechanical heart valves are at significant risk of obstetric/cardiac complications. This study compares the anticoagulation management in two obstetric cardiac centres. Methods Retrospective case-note review from Chelsea and Westminster/Royal Brompton Hospitals (CR) and Erasmus Medical Centre (EMC). Main outcome measure was mechanical heart valve thrombosis. Results Nineteen pregnancies from CR and 25 pregnancies from EMC were included. Most women were on low-molecular-weight heparin (LMWH) throughout pregnancy at CR, whereas at EMC most had LMWH in the first trimester and vitamin K antagonists in subsequent trimesters. Peak anti-factor Xa were performed monthly at CR, levels 0.39–1.51 IU/mL (mean 0.82 IU/mL). Anticoagulation management peri-partum was inconsistent. Delivery was mainly by caesarean section at CR (74%) and vaginal delivery at EMC (64%). No maternal deaths and only one mechanical heart valve thrombosis at CR. Two mechanical heart valve thromboses and one maternal death at EMC. Conclusion Peri-partum anticoagulation strategies, anticoagulation monitoring and mode of delivery inconsistencies reported.

Objective To examine the antenatal imaging features, intrapartum findings and early postpartum course of pregnancies with trisomy 21 (T21). Design Ten-year retrospective review Setting A tertiary hospital in the United Kingdom Population Women with a pregnancy affected by T21, who did not have a termination. Methods Women with pregnancies diagnosed with T21 on: antenatal karyotyping; karyotyping of post-mortem tissue and postnatal karyotype samples, from February 2010-2020. Main Outcome Measures Antenatal imaging findings, fetal growth restriction (FGR), birthweight, mode of delivery, and early neonatal outcomes. Results Seventy-six women with a fetus affected by T21 were identified. There were 6 intrauterine deaths, and 70 livebirths. Thirty-eight (50%) had an antenatal diagnosis and twenty-five (33%) had a suspected diagnosis but declined further testing. The diagnosis was unanticipated in 13 (17%). Cardiac anomalies (n=27) were the most common antenatal anomaly. Doppler abnormalities were apparent in 48/73 (68%). Eighteen (25.7%) had ultrasound evidence of FGR. The majority delivered by Caesarean section, and 21.4% of babies weighed below the 3rd percentile at delivery. Fifty-eight (82%) were admitted to the neonatal unit. Forty-three (61%) required respiratory support and fifty-five (78%) either needed naso-gastric feeding or were nil by mouth. Mean PAPP-A values were significantly lower in cases with abnormal Dopplers, FGR, congenital anomalies and with a birthweight below the 10th percentile. Conclusions Fetuses with T21 have high rates of placental insufficiency. FGR and Doppler abnormalities are common. Postnatally, the majority will require respiratory and feeding support. Antenatal counselling and protocols should reflect these risks. Funding None

Clinicians are faced with multiple diagnostic and treatment challenges when managing pregnant women with urolithiasis. Anatomical and physiological changes during pregnancy have to be taken into account whilst simultaneously considering both the expectant mother and the foetus. Ultrasonography remains the first-choice imaging modality, notwithstanding its potentially poor diagnostic accuracy. There is currently no consensus on second-line investigation for suspected urolithiasis. Low-dose non-contrast CT is highly sensitive, but the long-term effects of ionizing radiation on the foetus remain unknown. As far as treatment is concerned, expectant therapy is the primary option for management in the majority of cases. Percutaneous nephrostomy or ureteric stent placements are safe temporizing measures in relieving an acutely obstructed system and should be expedited in the presence of sepsis. Studies have shown ureteroscopy to be safe and effective during pregnancy with no significant risk to the foetus. It is important for the clinician to explain clearly the risks associated with the investigation and management options to the pregnant patient, including an acknowledgement that some of these remain unquantified, or even unknown.

What you need to know One in 125 people is born with congenital heart disease.1 For women with the condition, pregnancy induced cardiovascular stress can cause complications such as arrhythmia, heart failure, and thromboembolism.2 The UK Confidential Enquiry into maternal deaths found that of 910 maternal deaths between 2009 and 2014,3 205 (22.5%) were caused by heart disease, and a minority from congenital heart disease. Clinicians in primary and emergency care increasingly encounter women with congenital heart disease who are planning pregnancy or who are pregnant at presentation. These women might seek information about the risks pregnancy poses to their own health, and to the health of the fetus. In this article, we highlight aspects of pre-conception, antenatal, and postpartum care for women with congenital heart disease.3 ### Sources and selection criteria We searched PubMed for relevant English language publications over the past 10 years using the search terms “pregnancy” and “preconception,” individually combined with “heart disease” and “cardiac disease.” All abstracts were reviewed and we selected the most relevant papers for this article. We have drawn recommendations from the European Society of Cardiology Pregnancy Guideline and the American Heart Association Guideline. The European Registry on Heart Disease is the largest published cohort of women with pregnancy complicated by heart disease. In 2012, of 1321 pregnant women with heart disease, 66% had congenital heart disease.4 Approximately one third of those women had simple shunt lesions, such as ventricular or atrial septal defects (fig 1), and the rest had …