Pregnancy after arterial switch repair for transposition of the great arteries
Pregnancy is considered low risk in women with transposition of the great arteries treated with an arterial switch operation without significant residual lesions. [1] Observed pregnancy outcomes after arterial switch repair for TGA have been favorable in the ROPAC (Registry of Pregnancy and Cardiac disease) cohort. [2]
Candidates for pregnancy
Pregnancy should be considered when the post-repair cardiac status is stable with no significant residual hemodynamic lesions. [1] Pregnancy should be discouraged when pregnancy risk is driven by systemic ventricular dysfunction, severe atrioventricular valve regurgitation, or severe residual lesions in other TGA repair phenotypes. [1]
Pre-conception risk assessment
Risk assessment should be performed in all women with cardiovascular disease of childbearing age using the modified WHO (mWHO) 2.0 classification. [1] Women with mWHO 2.0 class II–III or above should be evaluated and managed by a Pregnancy Heart Team from pre-pregnancy through postpartum. [1] A Pregnancy Heart Team discussion should occur for women with higher-risk (mWHO 2.0 class IV) conditions. [1]
Pre-conception evaluation elements
Pre-pregnancy evaluation should include assessment of ventricular function and residual structural lesions that could worsen with pregnancy hemodynamics. [1] Pre-pregnancy evaluation should include electrocardiographic assessment and clinical functional status assessment to identify baseline arrhythmia and heart failure risk. [1] If inherited cardiovascular disease is suspected, clinical genetic evaluation and pre-conception genetic counselling should be provided to guide risk stratification and prenatal genetic testing. [1]
Conception planning and optimization
Contraception counselling should be individualized for women with mWHO 2.0 class II and above, including emergency contraception. [1] Clinical optimization of any cardiac condition associated with pregnancy risk should be completed before conception under adult congenital heart disease and obstetric coordination. [3]
Pregnancy surveillance strategy
Transesophageal or invasive evaluation during pregnancy is not routinely required in low-risk arterial switch–repaired TGA without residual lesions. [1] Transthoracic echocardiography is recommended at 20 weeks’ gestation for women with TGA with arterial switch repair. [1] Surveillance should be intensified if ventricular function declines or if aortic regurgitation and aortic dilatation increase. [1]
Expected pregnancy-related complication risks
In low-risk TGA with arterial switch repair, ventricular arrhythmias occur in an estimated 2.5%–7% range. [1] In low-risk TGA with arterial switch repair, heart failure occurs in an estimated 2%–4% range. [1] Prematurity and fetal loss rates are reported as low in the guideline summary for this repaired subgroup. [1]
Delivery planning and postpartum monitoring
Vaginal delivery is recommended in most women with cardiovascular disease. [1] Prolonged post-partum monitoring for 48–72 hours should be considered, with early post-partum follow-up, because post-partum heart failure risk is increased. [1]
Medication and obstetric considerations
Medication should be coordinated by the Pregnancy Heart Team to align cardiovascular and obstetric management across conception, pregnancy, and postpartum. [1] Endocarditis prophylaxis specific to delivery is not recommended for pregnancy heart disease patients at baseline risk. [1] Systemic anticoagulation use should be managed according to the underlying indication and lesion-related thrombosis and bleeding risks in the shared obstetric-cardiac plan. [1]
Clinical escalation triggers during pregnancy
Escalation of surveillance and management should occur when ventricular function worsens. [1] Escalation should occur when aortic regurgitation increases. [1] Escalation should occur when aortic dilatation increases. [1] Escalation should occur when symptomatic heart failure or clinically significant arrhythmias develop. [3]