text:
Pregnancy with congenital heart disease
Department of Cardiology, All India Institute of Medical Sciences, New Delhi 110029, India.
Correspondence to: Prof. Anita Saxena, Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India. E-mail:
Pregnancy is complicated by maternal cardiovascular disease in 1%-4% of cases. With advances in management of congenital heart diseases (CHDs), the survival to adulthood and childbearing age is increasing all over the world. The physiological adaptation during pregnancy adds to the hemodynamic burden of CHD, and, hence, many women are diagnosed with CHD for the first time during pregnancy, more so in developing countries. The type of underlying CHD and pre-pregnancy hemodynamics determine the risk of developing complications during pregnancy. Hence, pre-pregnancy risk stratification and counseling are a crucial part of management plan. Some of the serious CHDs are best treated in the preconception stage. The maximum chance of developing complications is between 28 and 32 weeks of gestation, during labor, and up to two weeks after delivery. Common complications in women with CHD during pregnancy and labor include heart failure, arrhythmias, bleeding/thrombosis, infective endocarditis, and rarely maternal death. Fetal complications include abortion, stillbirth, prematurity, low birth weight, and CHD. Comprehensive knowledge of these complications and their management is very important as an experienced multidisciplinary team is critical for improving outcome of these patients. Special care is required for pregnant women who have pulmonary hypertension, due to either Eisenmenger syndrome or other causes, severe valve stenosis, aortopathy associated with bicuspid aortic valve/coarctation, or severe cyanotic CHDs. Most women with CHD are at low risk, and successful pregnancy is feasible in the majority with optimal management.
Maternal cardiac diseases complicate 1%-4% of all pregnancies and are the leading cause of maternal mortality in high-income countries (HIC), constituting about 15% of all causes[1,2]. Among the cardiac diseases, congenital heart diseases (CHDs) are now the most common form seen in four-fifths of all maternal cardiac diseases[1,3]. The advancements in medical and surgical treatment of CHDs have led to improved survival of these patients to adulthood. This increased survival coupled with significant decline in incidence of rheumatic heart disease (RHD) has resulted in CHD becoming the most common cardiovascular problem during pregnancy in HIC. Despite a relative increase in pregnancy related cardiac deaths over the last two decades, the proportion of CHD-related deaths has remained relatively low. On the other hand, in low- and middle-income countries (LMIC), RHD continues to be the most common cardiovascular disease during pregnancy[6-8]. Though the data regarding maternal cardiac diseases in LMIC are scarce, global progress reports have emphasized the increasing importance of indirect maternal deaths due to preexisting heart diseases. Therefore, as the incidence of RHD declines and standards of medical care improve in these countries, maternal CHD is likely to gain more importance[7,8].
Unlike HIC where patients with CHD have excellent access to robust surgical centers, most patients with CHD in LMIC have no access to surgery[10,11]. Therefore, most patients have uncorrected CHD in LMIC. Moreover, many patients are diagnosed to have CHD for the first time during pregnancy[7,8]. This is the cause of high morbidity and worse outcomes in pregnant females with CHD in LMIC[6,7,12]. A recent study reported that the risk of maternal mortality was seven times higher in women with uncorrected CHD than corrected CHD (P = 0.01).
CHDs comprise of a broad spectrum of anatomic abnormalities but have a limited spectrum of pathophysiologic states. As pregnancy has a marked impact on the cardiovascular system, women with CHD are at high risk of developing cardiovascular complications, which affect the maternal and fetal outcomes. In one of the largest studies on pregnant women with CHD, Schlichting et al. reported that the odds of occurrence of an adverse maternal cardiac event during delivery were 2.4-27.6 times higher for women with CHD compared with women without CHD. Ramage et al. studied 2114 women with CHD and reported the risk of serious maternal morbidity during pregnancy to be 4.0% in comparison to 1.1% in women without CHD.
Optimum care for these patients requires a coordinated effort by a cardio-obstetric team as they need careful antenatal and postnatal surveillance and an individualized plan for labor and delivery. A recent large multicenter study of pregnant patients with maternal cardiac disease found that almost half of serious complications in patients are preventable and are due to failure on the part of healthcare provider to identify the high-risk patients and institute timely appropriate management. Therefore, these women require appropriate preconception assessment, risk stratification, and counseling. There exists a wide gap in quality of care between HIC and LMIC which needs to be bridged[2,3,6,7].
SCOPE OF THE ARTICLE
We highlight the current understanding of the issues related to pregnancy in women with congenital heart disease and describe the management of the issues as per existing literature.
HEMODYNAMIC CHANGES DURING PREGNANCY, DELIVERY AND POSTPARTUM PERIOD
Pregnancy and childbirth require significant adaptation of the cardiovascular system in the mother to cope with the increased metabolic demands of the mother and fetus. The various hemodynamic changes that occur during pregnancy in normal women are highlighted in Figure 1A. The usual pattern of hemodynamic adaptation to pregnancy is attenuated in women with CHD. Moreover, these hemodynamic alterations can sometimes have deleterious effects on the mother with CHD as well as on the developing fetus.
Plasma volume and cardiac output reach a maximum of 40%-50% above baseline at 32 weeks of gestation, while 75% of this increase occurs by the end of first trimester. These are then maintained at the same level throughout the pregnancy. The increase in cardiac output is initially achieved by an increase in stroke volume in the first half of pregnancy and a gradual increase in heart rate after this period[17,18]. The heart size increases while ventricular function is preserved. In women with CHD, ventricular adaptation to pregnancy may be suboptimal and can result in impaired uteroplacental flow and suboptimal fetal outcome.
There is generally a minor change in systolic blood pressure (BP), but there is a fall in diastolic BP due to hormone-induced vasodilation. Diastolic BP reaches a minimum of 10 mmHg below baseline in the second trimester of pregnancy and returns to pre-pregnancy levels by term[17,18]. In the third trimester, BP can decrease due to the compression of the inferior vena cava by the enlarged uterus, especially in the right decubitus position or while lying supine. Since the fall in BP is primarily due to the fall in systemic vascular resistance, it is likely to aggravate the right-to-left shunt in cyanotic CHD.
Patients with CHD are at higher risk of arrhythmias due to intrinsic conduction abnormalities, residual hemodynamic problems, and operative scars, and they are further burdened by the tachycardia and volume overload due to pregnancy. The occurrence of tachyarrhythmias or failure to adequately increase heart rate can cause decompensation and adverse outcomes. The incidence of arrhythmias was ~2% in one of the largest registries of pregnant CHD patients. The fragility of the arterial wall increases during pregnancy due to increased serum levels of estrogen and relaxin. This is an adaptive response during pregnancy but can result in formation of ascending aortic aneurysms or even dissection of aorta in predisposed women, e.g., women with bicuspid aortic valve, coarctation of aorta, and Marfan syndrome[23,24].
The red blood cell counts increase by 20%-30%, and the increased plasma volume causes relative anemia. There is a hypercoagulable state in late pregnancy due to an increase in vitamin K-dependent clotting factor and a reduction in free protein S. This is of particular concern in pregnant women with prosthetic heart valves, atrial fibrillation, preexisting ventricular dysfunction, or uncorrected CHD. In contrast to the 0.1% risk of thromboembolism risk in normal pregnancy, the rate of thromboembolism was found to be 1.2% in those with CHD as per a recent multicentric registry. Other obstetric issues such as hypertensive disorders of pregnancy, preeclampsia, or multiple pregnancies further increase the risk of maladaptation to hemodynamic needs and thus the risk of cardiovascular complications in susceptible patients[3,5].
Further changes in hemodynamics occur at the time of labor and delivery. Cardiac output and other hemodynamic parameters fluctuate markedly with each uterine contraction. The changes during normal labor are shown in Figure 1B. The BP and cardiac output increase during labor and post-partum. Volume shifts at the time of delivery is poorly tolerated by women with some CHD where cardiac output is highly dependent on preload. After delivery, the cardiac output and heart rate start decreasing as early as 24 h after delivery.
Most cardiovascular parameters return to preconception values within two weeks. The stroke volume, cardiac output, and heart size take a longer time and reach preconception levels by 3-6 months. In patients with CHD, cardiovascular maladaptation can persist even six months after delivery. The critical periods for a pregnant woman with CHD are gestation between 28 and 32 weeks, during labor, and up to two weeks after delivery.
PRE-PREGNANCY RISK ASSESSMENT AND COUNSELING IN MOTHERS WITH CONGENITAL HEART DISEASE
It is recommended that all women with CHD should undergo careful pre-pregnancy assessment and detailed counseling before conceiving. The counseling should include maternal cardiac and obstetric risks as well as the fetal risks. This requires a multidisciplinary team approach comprising of an obstetrician, cardiologist, neonatologist, and other specialists in some cases.
Maternal risk stratification of women with CHD is based on the type of underlying CHD, whether the CHD has been repaired or not, the presence of residual lesions with the resulting hemodynamics, and assessment of patient specific cardiac and obstetric risk factors[1,4,5]. The assessment includes patient’s history, electrocardiogram, detailed echocardiography, oxygen saturation, and additional testing, such as exercise testing, catheterization, and advanced imaging in some cases. Maternal functional status is an important determinant of pregnancy outcome. Cardiopulmonary exercise testing performed before conception can predict maternal and neonatal outcomes in pregnant women with CHD. Lui et al. found that the peak heart rate, percentage of maximum age predicted heart rate, and chronotropic index were associated with the risk of maternal cardiac and neonatal adverse events. B-type natriuretic peptide or N-terminal pro B-type natriuretic peptide may also be helpful.
The aim of risk stratification is not only to stratify but also identify modifiable risk factors and decide whether a pre-pregnancy intervention may reduce the risk. Pre-pregnancy assessment should also include careful review of medication for teratogenic potential. Commonly used cardiac medications such as spironolactone, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, endothelin receptor antagonists, and amiodarone are contraindicated during pregnancy. Oral anticoagulant use during pregnancy is associated with increased risk of bleeding and thrombotic events as well as fetal loss and teratogenicity (warfarin). These medications may have to be stopped before conception, if considered safe for the mother[1,4].
Risk-stratification scores have been developed based on various studies to predict adverse outcomes in women with CHD. The commonly used scoring systems include the Cardiac Disease in Pregnancy (CARPREG) score, the modified World Health Organization (WHO) classification scores, and the ZAHARA score[1,29,30]. The modified WHO classification system is currently recommended by both American and European guidelines for care of women with CHD in pregnancy, although it is probably more appropriate for developed rather than developing countries.
The modified WHO classification is primarily based on underlying congenital cardiac condition, and it also includes lists of CHD that contraindicate pregnancy. The general principle of classification is given in Table 1. Women in mWHO Class IV should be advised against pregnancy. Patients with a high-risk CHD which is a contraindication for pregnancy must be counseled at a young age explaining the harmful effects of pregnancy on their hemodynamics. It is equally important to assure women with milder forms of CHD that they can go through pregnancy with a low risk. High-risk patients must be managed at centers with expertise. In general, risk of pregnancy increases with increased complexity of CHD. All women with CHD must be assessed at least once before pregnancy and then during pregnancy.
Modified World Health Organization classification of maternal cardiovascular risk
|mWHO Class||Diagnosis (if otherwise well and uncomplicated)|
|mWHO I||Small or mild pulmonary stenosis, patent ductus arteriosus, mitral valve prolapse
Successfully repaired simple lesions (atrial or ventricular septal defect, patent ductus arteriosus, anomalous pulmonary venous drainage)
Atrial or ventricular ectopic beats, isolated
|mWHO II||Unoperated atrial or ventricular septal defect
Repaired Tetralogy of Fallot
Most arrhythmias (supraventricular arrhythmias)
Turner syndrome without aortic dilatation
|mWHO II-III||Mild left ventricular impairment (EF > 45%)
Native or tissue valve disease not considered WHO I or IV (mild mitral stenosis, moderate aortic stenosis)
Marfan without aortic dilatation
Aorta < 45 mm in bicuspid aortic valve pathology
Atrioventricular septal defect
|mWHO III||Moderate left ventricular impairment (EF = 30%-45%)
Previous peripartum cardiomyopathy without any residual left ventricular impairment
Systemic right ventricle with good or mildly decreased ventricular function
Fontan circulation (if the patient is otherwise well and the cardiac condition uncomplicated)
Unrepaired cyanotic heart disease
Other complex heart disease
Moderate mitral stenosis
Severe asymptomatic aortic stenosis
Moderate aortic dilatation (40-45 mm in Marfan syndrome, 45-50 mm in bicuspid aortic valve, Turner syndrome ASI 20-25 mm/m2, Tetralogy of Fallot < 50 mm)
|mWHO IV||Pulmonary arterial hypertension
Severe systemic ventricular dysfunction (EF < 30% or NYHA Class III-IV)
Previous peripartum cardiomyopathy with any residual left ventricular impairment
Severe mitral stenosis
Severe symptomatic aortic stenosis
Systemic right ventricle with moderate or severely decreased ventricular function
Severe aortic dilatation (> 45 mm in Marfan syndrome, > 50 mm in bicuspid aortic valve, Turner syndrome ASI > 25 mm/m2, Tetralogy of Fallot > 50 mm)
Fontan with any complication
|WHO Class||mWHO I||mWHO II||mWHO II-III||mWHO III||mWHO IV|
|Risk||No detectable increased risk of maternal mortality and no/mild increased risk in morbidity||Small increased risk of maternal mortality or moderate increase in morbidity||Intermediate increased risk of maternal mortality or moderate to severe increase in morbidity||Significantly increased risk of maternal mortality or severe morbidity||Extremely high risk of maternal mortality or severe morbidity|
|Maternal cardiac event rate||2.5%-5%||5.7%-10.5%||10%-19%||19%-27%||40%-100%|
|Counseling||Yes||Yes||Yes||Yes, expert counseling required||Yes, pregnancy contraindicated: if pregnancy occurs, termination should be discussed|
|Care during pregnancy||Local hospital||Local hospital||Referral hospital||Expert center for pregnancy and cardiac disease||Expert center for pregnancy and cardiac disease|
|Minimal follow-up visits during pregnancy||Once or twice||Once per trimester||Bimonthly||Monthly or bimonthly||Monthly|
|Location of delivery||Local hospital||Local hospital||Referral hospital||Expert center for pregnancy and cardiac disease||Expert center for pregnancy and cardiac disease|
The fetal risks mainly include the risk of prematurity, low birth weight/small for gestational age, fetal/neonatal death, and the risk of recurrence of CHD. Maternal and neonatal events are highly correlated. The risk of adverse fetal/neonatal outcome is closely correlated with the severity of impairment of maternal hemodynamics due to the direct effect on uteroplacental blood flow. Fetal/neonatal mortality is more frequent in women with CHD (4%) than in the general population. The risk of adverse outcomes for fetus in maternal CHD is quite high in women with severe forms, such as univentricular physiology, Eisenmenger physiology, and unrepaired cyanotic defects. In women with cyanotic CHD, cyanosis poses a significant risk to the fetus, and a live birth is highly unlikely (< 12%) if oxygen saturation is below 85%, while more than 90% of fetuses survive to birth if maternal arterial saturation is more than 90%. Some important risk predictors of neonatal events include mothers with left heart obstruction, mechanical heart valve prosthesis, use of oral anticoagulants, and, most importantly, maternal New York Heart Association (NYHA) Class III/IV at baseline.
Risk of transmission of CHD in presence of a positive family history (up to third degree relatives) is variable depending on maternal CHD type, presence of a syndrome, and other factors but is in the range of 3%-7% and slightly higher when the affected member is the mother [Table 2][32,33]. The recurrence risk is also higher with heterotaxy, conotruncal anomalies, atrioventricular septal defect, and obstructive lesions of the left ventricular outflow tract. Therefore, the chance of recurrence of CHD in offspring should be discussed with all women with CHD. It is important to record a detailed family history and examine for syndromic features as these can help in identifying subtle syndromes and inheritance patterns.
Risk of CHD recurrence in the fetus
|Type of CHD in mother||Risk of recurrence|
|Tetralogy of Fallot||2.0-4.5|
|Patent ductus arteriosus||4.1|
|Coarctation of aorta||4.1-6.3|
|Atrial septal defect||4.6-11|
|Ventricular septal defect||6.0-15.6|
|Atrioventricular septal defect||7.9-13.9|
|22q11 deletion syndrome||50|
The etiology of CHD is multifactorial, with only 20%-30% of CHD cases having an identifiable genetic or environmental cause. In addition, most genetic mutations in patients with CHD are sporadic. Nevertheless, genetic testing using cord blood samples can be offered to all women with CHD with discussion of the advantages and limitations of genetic testing. An important advantage of genetic testing is that it can help in recognition or prediction of extracardiac comorbid conditions which can affect long-term outcome and thus allow more accurate prognostication in some cases. Newer genetic tests such as chromosomal microarray and next generation sequencing are now in widespread use and have increased the chances of identifying genetic etiology of CHD but have the limitation of identifying variants of unknown significance.
Assessment for other risk factors (parental obesity, diabetes, hypertension, infections, alcohol, smoking, and teratogenic medications) that can compromise fetal well-being and increase the risk of fetal birth defects should also be routinely done.
A multidisciplinary management plan should be devised and discussed with the patient and her family. It is extremely important in setting appropriate expectations and minimizing complications. In addition to the general recommendations, specific topics of discussion during counseling include education on maternal and fetal risks, pre-pregnancy optimization plan, modification of medications, planned schedule of cardiac evaluation and testing during pregnancy and in the peripartum time period, mode of delivery, and possible persistence of cardiovascular abnormalities after pregnancy when applicable.
DIAGNOSIS OF CHD DURING PREGNANCY
The physiological adaptations occurring during pregnancy make the clinical diagnosis of CHD challenging. It is usual to have some exertional dyspnea and fatigue during pregnancy. Edema of feet can be seen in 80% of healthy pregnant women. However, many disorders can be identified by a thorough history and physical examination. Unexplained dyspnea, pathological murmurs, presence of cyanosis, etc. must not be ignored as they are indicators of underlying CHD, and an echocardiography is indicated in these cases.
Echocardiography is a widely available imaging tool which gives diagnosis of CHD with great accuracy. Mild dilatation of cardiac chambers could be a normal finding during pregnancy. An exercise test, although best performed prior to planning pregnancy, can also be performed in asymptomatic pregnant patients with underlying CHD. It is recommended to perform a submaximal exercise to attain 80% of the predicted maximal heart rate. The developing fetus is vulnerable (highest during first trimester) to develop neurological abnormalities, growth restriction, and malignancies on ionizing radiation exposure, and, hence, chest radiograph and computed tomography must be avoided if possible[1,35].
In LMIC, women often present for the first time with clinical features of heart disease when already pregnant. When these patients present with symptoms in the emergency room for the first time, the treating physician should formulate a diagnostic impression based on the cursory history and focused examination, supplemented by electrocardiogram for planning immediate management to stabilize the patient. Chest radiography should be avoided if possible. The physician should identify the subgroup in which the patient falls, i.e., cyanotic or acyanotic (shunt/obstructive) disease with increased or decreased pulmonary blood flow, followed by identification of precipitating cause (anemia, polycythemia, infective endocarditis, arrhythmia, physiological changes of pregnancy, ventricular dysfunction, thromboembolism, etc.) for presenting symptoms. Once stabilized, patients should undergo detailed echocardiography followed by other imaging, as deemed necessary.
These patients need complete assessment by a multidisciplinary team and risk stratification as is performed preconception. Periodic follow-ups should be planned as per the risk stratification [Table 1A and B]. If the assessment reveals a high-risk condition, termination of pregnancy should be recommended early in pregnancy. However, termination of pregnancy also carries risks in women with high-risk lesions and should be performed at a center with the necessary expertise.
MANAGEMENT OF PREGNANCY IN WOMEN WITH CONGENITAL HEART DISEASE
For each case, a clear follow-up and delivery plan should be made and discussed with the patient. The frequency of follow-up visits depends on the risk assessment. The European Society of Cardiology has given recommendations for management of CHD during pregnancy [Table 1B]. High-risk pregnancies are best managed by an experienced multidisciplinary team in a tertiary care center, while those with low risk can be managed in state-level regional centers. The patient and her family should be educated about the anticipated symptoms and need for frequent assessment. In addition, fetal echocardiography should be offered to all mothers with CHD between 18 and 22 weeks of gestation. It may be performed earlier if there is suspicion of CHD on ultrasonography. The fetal echocardiography protocol should include complete sequential segmental analysis and should not be limited to screening views. It is important to highlight that the recurrence of CHD in the fetus may not be identical to the CHD type in the affected family member.
Timing and mode of delivery
The timing of delivery depends on maternal hemodynamic status and obstetric evaluation including cervical assessment, fetal well-being, and fetal lung maturity. Guidelines recommend elective induction of labor at 40 weeks of gestation under controlled conditions in all women with cardiac disease as it reduces the risk of emergency caesarean delivery and the risk of stillbirth. The obstetrician should be wary of the adverse effects of inducing drugs such as misoprostol (arrhythmias and coronary vasospasm), oxytocin (systemic hypotension), and prostaglandin F analogs (systemic hypotension and increase in pulmonary pressure), and their use needs to be individualized. Mechanical methods such as artificial rupture of membranes and cervical ripening balloon might be preferable for induction of labor in some of the patients.
Vaginal delivery, often with epidural analgesia, is the preferred mode of delivery for the majority of women with CHD[1,36]. Vaginal delivery is associated with lesser blood loss and lesser risk of infection and venous thromboembolism. The indications for caesarean delivery are few and listed in Table 3. Epidural analgesia can be used to provide anesthesia for caesarean delivery as well, but it can cause systemic hypotension and therefore must be carefully titrated, especially in patients with left heart obstruction and diminished ventricular function.
Indications for caesarean delivery in women with congenital heart disease
|Indications for caesarean delivery|
|Significant aortopathy with ascending aorta dilation > 45 mm|
|Severe forms of pulmonary hypertension (including Eisenmenger’s syndrome)|
|Severe left heart obstruction|
|Severe ventricular dysfunction with heart failure|
|Pre-term labor on oral anticoagulation|
Mobilization of patient may facilitate fetal head descent, and a lateral decubitus position during labor can decrease the hemodynamic impact of inferior vena cava compression. Early epidural catheter placement to reduce labor pain can help in reducing hemodynamic load of labor. Historically, patients with significant cardiac disease have been dissuaded from doing the Valsalva maneuver due to associated increase in oxygen consumption and decrease in venous return. However, some studies have shown that allowing passive head descent and assisting the second stage of labor (use of forceps/ventouse to reduce maternal effort and epidural analgesia which suppresses Valsalva reflex due to fetal pelvic descent) can prolong labor and may be associated with a higher risk of postpartum hemorrhage and high-degree vaginal or cervical laceration. Therefore, it should be reserved for patients at highest risk.
Patients requiring hydration should receive intravenous crystalloids with closely monitored fluid balance. All patients with intracardiac right-to-left shunts must have filters in intravenous lines to prevent paradoxical air embolization. In patients with uncorrected or partially corrected complex CHD, it is vital to maintain balance of systemic and pulmonary blood flow. A decrease in systemic vascular resistance or an increase in pulmonary vascular resistance can lead to increased right-to-left shunting, thus increasing hypoxemia and increasing the risk of maternal and fetal death.
No antibiotic prophylaxis is recommended against infective endocarditis (IE) for vaginal delivery. Maternal BP, saturation, and heart rate should be monitored in all women with CHD and invasive cardiac monitoring is rarely required. Patients with history of arrhythmias and symptomatic ventricular dysfunction should have continuous ECG monitoring. Continuous fetal heart rate monitoring is recommended.
Although the risk of serious cardiac events was higher in the antepartum period (66%), intrapartum and postpartum period accounted for one-third of all serious cardiac events in a recent study by Pfaller et al. Therefore, patients with CHD should continue to receive good care in the peripartum period as well, as fatal events are well known to occur during this period. Significant hemodynamic changes and fluid shifts in the first 24-48 h after delivery can precipitate heart failure; hence, intensive hemodynamic monitoring should be continued for at least 24-48 h in at-risk patients. Cardiac rhythm and saturation should be monitored in high-risk patients. Good hydration must be maintained especially in patients with cyanotic CHD and for this intravenous fluid administration may be necessary. Care must be taken to prevent air embolism. Meticulous leg care, elastic support stockings, and early ambulation are important to reduce the risk of thromboembolism. Hemoglobin values must be optimized, by blood transfusions if required. Symptoms and signs of apparently minor problems must be taken seriously and managed promptly. Ergometrine is best avoided in the third stage of labor. Lactation should be encouraged whenever possible as it is associated with a low risk of bacteremia secondary to mastitis. In women with moderate to severe CHD, mixed feeding (artificial and breast feeding) is better than breastfeeding alone.
Interventions for CHD during pregnancy
The decision to perform intervention during pregnancy requires careful assessment by the cardio-obstetric team. The indication of intervention is usually severe cardiac failure with significant risk to both the mother and fetus. Procedures should be performed by experienced teams at tertiary care centers only.
Women with CHD having an absolute indication for percutaneous intervention (e.g., symptomatic severe aortic stenosis/severe pulmonary stenosis/coarctation of aorta, mitral stenosis, and refractory arrhythmias amenable to ablation) should preferably undergo the procedure in the second trimester. This is because organogenesis is complete by this time and the uterus is still small and away from the chest which is exposed to radiation. The principle of “as low as reasonably achievable” radiation dose must be followed. Some of the maneuvers for minimizing radiation exposure include use of alternative imaging such as echocardiography, using low-dose fluoroscopy, avoiding oblique and lateral projections, and minimizing the area exposed and fluoroscopy time[1,39]. Abdominal shielding also helps to lower the radiation dose to the fetus.
Cardiac surgery under cardiopulmonary bypass
Open heart surgery is recommended only if medical therapy and percutaneous intervention fail and the mother’s life is threatened. Some of the indications for surgery during pregnancy include aortic aneurysm with impending rupture, worsening heart failure due to infective endocarditis, and severe symptomatic left heart obstruction. Optimal time for surgery is between 13 and 28 weeks of gestation. When gestational age is more than 28 weeks, delivery after fetal lung maturity induction should be considered before cardiac surgery. Surgery under cardiopulmonary bypass (CPB) carries about 20% risk of fetal loss, while the maternal mortality is not higher than usual. To diminish the risk of fetal loss during CPB, it is recommended to minimize CPB time, maintain pump flow > 2.5 L/min/m2 and perfusion pressure of
MANAGEMENT OF COMMON COMPLICATIONS SEEN IN WOMEN WITH CHD
The results from the European registry revealed the overall incidence of heart failure as 6.6% of all pregnant women with CHD, with a higher risk of 8.7% in those with uncorrected CHD[12,22]. The peak incidence of heart failure is towards the end of the second trimester and during or just after delivery. It should be emphasized that the manifestation of heart failure may differ between different CHDs. Women with systemic right ventricle (RV), history of Fontan surgery, and dysfunctional RV after Tetralogy of Fallot repair are more predisposed to develop heart failure. Reversible factors such as arrhythmia and anemia should be actively looked for. Management includes bed rest, supplemental oxygen, fluid balance, and careful diuretic use. Some of the drugs used in the treatment of heart failure, such as angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and spironolactone, are contraindicated during pregnancy, although beta-blockers can be used if indicated. Hydralazine and nitrates can be used for afterload reduction, but angiotensin converting enzyme inhibitors are best started after delivery. In the case of refractory heart failure in the mother, baby should be delivered irrespective of duration of gestation. Corticosteroid use for fetal lung maturity is avoided due to risk of fluid retention and worsening of heart failure.
Arrhythmias are one of the common complications in adults with CHD and complicate a substantial number of pregnancies[3,22,29]. The most common types of tachyarrhythmias are intra-atrial re-entrant tachycardia caused by atrial scars, and atrial fibrillation. The incidence of arrhythmia depends on time since surgery, underlying cardiac condition, and aging. Tachyarrhythmias can be associated with life threatening symptoms and increase the risk of thromboembolic complications and occurrence of heart failure. Therefore, in women with significant tachyarrhythmias, catheter ablation or implantable cardiac defibrillator implantation should be performed before conception, if clinically indicated. If the indication emerges during pregnancy, then it is recommended to use echocardiographic guidance and 3D mapping to prevent radiation-induced fetal adverse effects.
Direct cardioversion is recommended in the case of hemodynamically unstable arrhythmias and is reported to be safe and effective during pregnancy. Regarding antiarrhythmic therapy, beta-blockers are the first choice for most arrhythmias as most other anti-arrhythmic drugs come under United States Food and Drug Administration category C and therefore their use depends on the risk-benefit ratio[5,20].
Women with prosthetic heart valves, previous history of thromboembolic complications, or high-risk anatomy such as post-Fontan surgery may require anticoagulation during pregnancy. It is important to highlight that all anticoagulant regimes have an inherent risk of causing subplacental bleed leading to pregnancy loss. Anticoagulation with warfarin provides the lowest risk for thrombosis but has a risk of causing warfarin embryopathy if used in the first trimester. Current guidelines recommend continuation of warfarin throughout pregnancy in women requiring low doses (< 5 mg) to maintain therapeutic international normalized ratio due to low risk of embryopathy[1,42]. These women should be mandatorily switched to unfractionated heparin after 36 weeks of gestation due to the risk of lethal intracranial hemorrhage in the fetus during vaginal delivery.
IE is rare with an annual incidence of 1 per 1000 in patients with CHD. Women with uncorrected cyanotic CHD or repaired CHD using artificial patch or prosthetic valve or previous history of endocarditis are eligible for IE prophylaxis, but the guidelines do not recommend antibiotic prophylaxis during delivery due to lack of convincing evidence. The diagnosis and treatment of IE during pregnancy is the same as in the non-pregnant patient, but due consideration needs to be given to fetotoxic potential of antibiotics.
MANAGEMENT OF SPECIFIC CONGENITAL HEART DISEASES
Pulmonary hypertension and Eisenmenger syndrome
Pulmonary hypertension (PH) in the mother could be due to Eisenmenger syndrome, idiopathic pulmonary arterial hypertension and PH related to lungs, or left heart disease. Maternal mortality has classically been reported to be very high in these patients (16%-30% for PH and 20%-50% for Eisenmenger syndrome), but the recent European registry results are optimistic with < 5% mortality in their cohort of 151 pregnant women with PH[44-47]. The greatest risk of mortality is during the first six weeks after delivery. The common causes of death include pulmonary hypertensive crisis, pulmonary thrombosis, or refractory right heart failure. Maternal death may occur even in patients with few symptoms before pregnancy. Although there is no safe cut-off for elevated pulmonary arterial pressure, patients with mild PH may tolerate the pregnancy well. However, the recommendation to avoid pregnancy remains, and, if pregnancy occurs, termination is advisable. There is increased fetal and neonatal mortality (0-30%) with the severity of reduction in maternal cardiac output and degree of hypoxemia being the most important predictors.
If the patient chooses to continue pregnancy, extreme care during pregnancy, delivery, and in the postpartum period must be exercised. These patients are particularly at risk for thromboembolism, bleeding complications, and heart failure. Bed rest, meticulous fluid balance, and supplemental oxygen help. Phosphodiesterase inhibitors are often prescribed, with the addition of prostanoids in patients with persistent symptoms. Anticoagulation should be carefully considered as it may induce hemoptysis. Iron deficiency is common and should be treated with supplemental iron. Vaginal delivery or planned caesarean delivery are preferred over emergency caesarean delivery. Regional anesthesia is preferred over general anesthesia. Delivery should be performed in an experienced tertiary center.
Cyanotic Congenital heart disease with pulmonary stenosis
In women with repaired Tetralogy of Fallot, pulmonary regurgitation is the most common residual lesion and is generally tolerated well in pregnancy unless associated with RV dysfunction. Akagi et al. reported data from 143 pregnancies in patients with repaired Tetralogy of Fallot. There were no maternal deaths, but a minority of patients had heart failure (11%), worsening of arrhythmia (8%), premature birth (10%), and miscarriage (5%). In general, patients eligible for pulmonary valve replacement or other interventions should undergo procedure before conceiving for best outcomes.
On the other hand, in patients with uncorrected CHD, the maternal outcome is determined by the underlying condition and ventricular function while the fetal outcome is predominantly determined by the saturation level regardless of the anatomical complexity. Maternal complications (heart failure, thrombosis, arrhythmias, and endocarditis) can occur in almost one-third of women and pregnancy should be discouraged in such patients. However, in those who have already conceived, patients should be advised to restrict physical activity and use compression stockings to prevent venous stasis (to avoid paradoxical embolism). Thromboprophylaxis with low molecular weight heparin should be considered if there are no contraindications. Vaginal delivery is advisable unless there is an obstetric indication for caesarean delivery.
Left ventricular outflow tract obstruction
The morbidity and mortality in left ventricular outflow tract obstruction is related to the severity of obstruction and symptom status. The risk of obstetric complications is increased in patients with severe aortic stenosis. Preterm delivery, fetal growth retardation, and low birth weight occur in 20%-25% of offspring of mothers with moderate and severe AS, although miscarriages and fetal death rates are < 5%. Severe symptomatic left ventricular outflow tract obstruction is an absolute contraindication for pregnancy. Even asymptomatic patients with severe left ventricular outflow tract obstruction and impaired LV function or a pathological exercise test should be counseled against pregnancy. These patients should undergo intervention before conceiving. Asymptomatic patients with severe valvular aortic stenosis and normal left ventricular function may tolerate pregnancy well provided they remain asymptomatic. Guidelines recommend exercise testing in these asymptomatic patients before pregnancy to evaluate exercise tolerance, BP response, and arrhythmias. Those with bicuspid aortic valve and associated dilated aorta are at risk of aortic dissection and pregnancy is contraindicated if ascending aorta diameter is
Activities should be restricted during pregnancy. Severely symptomatic patients not responding to medical therapy may have to undergo balloon valvuloplasty to relieve their symptoms. Elective caesarean delivery under general anesthesia is preferred in severe symptomatic aortic stenosis patients, while vaginal delivery is favored in asymptomatic severe and in non-severe cases.
Coarctation of aorta
Women with unrepaired coarctation of aorta (CoA), and those with residual lesions (persistent hypertension, re-coarctation, aortic aneurysms, aortopathy, and aortic valve disease) have an increased risk of dissection, rupture of aorta, and cerebral aneurysms during pregnancy and delivery. The most common complication even in women with well repaired CoA is hypertension and is seen in approximately 30%. Therefore, these patients should be under close supervision throughout pregnancy for high BP.
In very severe cases with refractory hypertension and maternal or fetal compromise during pregnancy, balloon dilatation can be considered, but, due to high risk of aortic dissection, covered stent may be required.
Women who have undergone Fontan surgery come under mWHO risk category III/IV due to unique hemodynamic abnormalities after this surgery. Even women with ideal Fontan circuit (mWHO III) are at increased risk of fertility issues, atrial arrhythmias, and worsening of functional class but may tolerate pregnancy. Occurrence of arrhythmias and thrombosis of Fontan circuit due to prothrombotic pregnancy state are major issues which can jeopardize fetal and maternal outcome. In mothers with a Fontan circulation, the offspring risk includes premature birth, small for gestational age, and fetal death in up to 50% of cases. Those with resting oxygen saturation < 85%, depressed ventricular function, moderate to severe atrio-ventricular valve regurgitation, arrhythmias, and protein losing enteropathy are at particularly high risk of maternal and fetal adverse outcomes and are best counseled against pregnancy.
Generally, vaginal delivery is possible and is preferred. Therapeutic anticoagulation should be considered since these patients are at significant risk of thromboembolism. Atrial arrhythmias need to be treated promptly and often need electrical cardioversion.
Repaired transposition of great arteries
The type of surgical correction and residual abnormalities are the major determinant of risks during pregnancy. Women with atrial switch operation (Mustard/Senning repair) often have systemic right ventricular dysfunction, tricuspid regurgitation (TR), and brady/tachyarrhythmias which often worsen during pregnancy. Failure to increase cardiac output and heart rate adequately during pregnancy may occur due to chronological incompetence and rigid conduits, baffles. Generally, pregnancy is tolerated well in those with no residual defects, normal ventricular function, and in NYHA Class I, but patients with severe right ventricular dysfunction or severe tricuspid regurgitation are advised against pregnancy. Vaginal delivery is recommended in asymptomatic patients with good ventricular function. The risk of pregnancy after arterial switch operation has not been adequately studied but is likely to be lower than after atrial switch operation.
Other congenital heart diseases
Pregnancy is well tolerated in most patients with an atrial septal defect (ASD) or a patent ductus arteriosus (PDA) as long as there is no PH. Thromboembolic complications and arrhythmias are slightly more common in patients with unrepaired ASD as compared to healthy women. The maternal and fetal outcomes are good, and no specific treatment is required. Prognosis is also good in women with corrected shunt lesions (ASD/ventricular septal defect/PDA) with no residual abnormalities.
Atrioventricular septal defects (ostium primum ASD) are best repaired before conception as arrhythmias and worsening of atrio-ventricular valve regurgitation are well described during pregnancy.
Mild to moderate pulmonary stenosis are well tolerated during pregnancy with good fetal and neonatal outcome. Severe pulmonary stenosis can result in right ventricular failure and arrhythmias and, in cases with severe symptoms, may necessitate percutaneous balloon dilatation.
Ebstein’s anomaly without cyanosis and heart failure is tolerated well during pregnancy. The incidence of arrhythmias is higher during pregnancy and may worsen the outcome. Women with right-to-left shunting through the defect in interatrial septum (patent foramen ovale/ASD present in 90% of cases) can develop progressive cyanosis during pregnancy and are at increased risk of paradoxical embolism. Women with Ebstein’s anomaly having symptoms, cyanosis, or heart failure are best treated surgically before conception.
In women with congenitally corrected transposition of great arteries, the risk depends on functional status, systemic right ventricle function, and associated tricuspid regurgitation. They are at increased risk of developing arrhythmias and heart failure (WHO risk Class III). Women with NYHA Classes III or IV, severe ventricular dysfunction, or severe tricuspid regurgitation should be counseled against pregnancy.
CHD is the most common heart disease in pregnant patients in developed countries, and this cohort is gradually increasing even in developing countries. The risk of complications during pregnancy in women with CHD largely depends on the type of underlying CHD and pre-pregnancy cardiac state. This emphasizes the importance of risk assessment and counseling prior to pregnancy. High-risk patients are best treated by a multidisciplinary team in a specialized center. Lesion-specific considerations and risk stratification should determine management decisions during pregnancy, labor, delivery, and the postnatal period in these patients. Women with severe pulmonary hypertension, Eisenmenger syndrome, severe left ventricular dysfunction, bicuspid aortic valve with aortic dilatation > 50 mm, and severe symptomatic left ventricular outflow tract obstruction should be offered termination of pregnancy if detected in time. Improvement in existing practices of assessment and management of women with CHD will result in substantial improvement in outcomes for the mother and fetus.
Did literature review and composed the first draft of the article: Saxena A
Reviewed data and worked on the subsequent revisions: Relan J
Conceptualized the study design, reviewed progress of the article at each step, and finalized the manuscript of the review article: Saxena AAvailability of data and materials
Not applicable.Financial support and sponsorship
None.Conflicts of interest
Both authors declared that there are no conflicts of interest.Consent for publication
Not applicable.Ethical approval and consent to participate
© The Author(s) 2022.
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Cite This Article
Saxena A, Relan J. Pregnancy with congenital heart disease. Vessel Plus 2022;6:15. http://dx.doi.org/10.20517/2574-1209.2021.96
Saxena A, Relan J. Pregnancy with congenital heart disease. Vessel Plus. 2022; 6: 15. http://dx.doi.org/10.20517/2574-1209.2021.96
Saxena, Anita, Jay Relan. 2022. "Pregnancy with congenital heart disease" Vessel Plus. 6: 15. http://dx.doi.org/10.20517/2574-1209.2021.96
Saxena, A.; Relan J. Pregnancy with congenital heart disease. Vessel Plus. 2022, 6, 15. http://dx.doi.org/10.20517/2574-1209.2021.96
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domain: literature


text:
Just before Easter a head-teacher at a Midlands primary school had his registered teacher status withdrawn for five years. Not because of any offence he had committed, but for the fact that he failed to act on reports about safeguarding concerns when they were brought to his attention. In one case, a little girl died at the hands of family members. Concerns noted at school and information received about her were apparently not acted upon, nor passed on, and this may in fact have contributed to her death. Media reports suggested that teachers at the school had not been trained properly and that there were systemic failures of the school’s safeguarding system. Teachers were unclear what to report and to which agency.
Methodist safeguarding training is all about reminding people about their responsibilities to pass on concerns and be confident about reporting and referral routes. Our mantra is recognise, respond, record, report and refer. It’s a simple message but one well worth repeating at every opportunity. But does our training always help us to recognise what we see, and appreciate the significance of it?
How many of us have encountered a situation that causes us to be concerned but we don’t know why? Maybe what we see is to all intents and purposes an innocent looking scenario, but we are not convinced. This may not even be a safeguarding matter, but perhaps a financial one or something about trust. Something doesn’t look or feel quite right. At the same time we don’t want to raise the alarm, or cause a fuss, or be identified as a troublemaker in some way. This column has previously focussed on the personal cost of whistleblowing.
So it can’t be emphasised too strongly that whatever you see or hear about, and you have a worry, then in the first instance talk to the person who is your local safeguarding lead, and if you feel that you are not being heard, do contact your District Safeguarding Officer for advice.
Although reference was made to changes in procedures, it was not clear how the head-teacher reported above found his school and himself in the situation that developed. At his disciplinary hearing he was quoted as saying ‘I hold my hands up. I should have put safeguarding at the front of my thinking. I was passive’. As Methodist safeguarders, our job is to aim to put safeguarding at the front of our church life and the training we offer underpins this. But perhaps there is some scope for developing our thinking about how we look at things and appreciate their significance. If we don’t know how to look we won’t see what’s really happening.

domain: sociology


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Properly Discharged Supervision/Evaluation
Supervisory, instructional and evaluation responsibilities which are properly carried out by managers, teachers or technologists do not constitute harassment. Performance appraisals, evaluations, discipline and appropriate enforcement of high standards which are based on objective criteria are not contrary to this policy.
Fairness for All
The college recognizes its obligation to ensure that this policy and the procedures are fair and applied fairly. The college is committed to deal quickly, fairly and effectively with harassment and discrimination. Complainants should feel free to bring their complaints forward and those against whom allegations are made should have a full and fair opportunity to respond to those allegations.
Policy Application - Who?
The policy applies to all employees and students, Board of Governors members, members of committees, societies or associations established or recognized by the college, residence staff, contractors, providers of service or research, visitors or guests and applicants for admission or employment.
All contractors providing services on College facilities on an ongoing basis are required to comply with this policy and the Ontario Human Rights Code, including co-operation in investigations. Breach of this clause may result in penalties, cancellation, or debarment if a contractor is found in violation of this policy or the Ontario Human Rights Code.
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- The college will not tolerate harassment or discrimination in its employment, educational or business dealings, whether these actions take place on its premises or during college activities off campus.
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Preventing Harassment and Discrimination - Education
- While this policy provides a resolution oriented process for resolving and, where necessary, investigating complaints, its primary purpose is to prevent harassment and discrimination taking place at Conestoga College. To this end the college is committed to ensure that each member of the college community is made aware of the policy through an ongoing program of information dissemination, education and training.
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This policy provides an opportunity to deal with harassment and discrimination issues in a timely and fair manner. All members of the college community are required to follow the policy and procedures. Nothing in the policy is intended to prevent a complainant from using an alternate procedure, such as a collective agreement, the Human Rights Code, Criminal Code or legal action.
To the extent possible, where a complaint is substantiated, the college’s objective is to restore complainants to the position they would have been in had the discrimination not occurred. A substantiated act of discrimination or harassment shall be cause for action by the college up to and including the possibility of discipline and/or discharge in the case of an employee or expulsion in the case of a student or contractual person.
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In order to protect individuals who make use of this policy or participate in proceedings as part of the complaint procedure, the college prohibits reprisal or threat of reprisal against these individuals. Any person who is found to have acted in, or threatened reprisal shall be subject to college action.
The college may, from time to time, implement a special initiative designed to relieve hardship or economic disadvantage or to assist disadvantaged persons or groups to achieve or attempt to achieve equal opportunity. The protections from discrimination and harassment defined in this policy are not infringed if such an initiative is implemented.


text:
Vivendi wants to become one of Prisa's reference partners and asks Sánchez for a lead directly. And the fact is that the French media group, which has never hidden its intentions to continue growing within the Spanish publishing group, requested on October 21 the authorization of the Minister council in order to expand its stake in the El País publisher to 29.9%, which would place it at the level of Amber Capital, the current first shareholder of the company, and whose owner is today the current president of Prisa, Joseph Oughourlian. Of course, both have different business interests within the group, and without any intention of launching a takeover bid, hence they remain at the gates of the 30% that would force them to do so. Now, for Amber the publishing business is not her goal, and for Vivendi, it is.
As ABC has learned, Vivendi's request to the Government to authorize it the purchase of 20% added to 9% which it already has (which it acquired at the beginning of this year when it bought the majority of the shareholding package that HSBC put up for sale), in practice represents an exit opportunity for shareholders who have shown their discomfort to remain in the shareholding of a company. society where the market, for months now, discounted the need for a capital increase in order to continue operating. Everything will depend on the price that Vivendi sets and the objective intentions of Prisa's current partners. The market value of that 20% does not exceed 80 million euros, a very affordable amount for the French giant, but which entails the commitment to remain in a company immersed in a restructuring plan that requires extraordinary financial efforts to remain operational. .
Thus, according to a communication sent to the National Securities Market Commission (CNMV), Vivendi does not have agreements with the rest of the partners to reach this percentage. At present, Telefónica maintains a stake very similar to that of Vivendi, also above 9%; while after the departure of the British bank, the Polanco family -historical owners of the communication group that also has Cadena Ser among its assets-, is the fourth partner in contention, with just over 7%. Finally, Banco Santander and Carso, the investment vehicle of the Mexican Carlos Slim, complete the group of significant shareholders, with each holding slightly less than 5%, according to the supervisor's records.
According to the sources consulted by this newspaper, Amber Capital has no intention of selling any share package to Vivendi, while some focus the shot on the actions of Mexicans, although they neither confirm nor deny. Both Telefónica and Santander assured ABC that do not know the conditions of the offer and, therefore, they do not make statements about speculation.

domain: finance


text:
Dale Root has been a good mentor with community commitment
I would like to first state I am not a Shelby resident. I have no stance on matters that pertain to the town. I stand no benefit to any election in Shelby. Now that the necessary disclaimers have been made, I write this letter out of pure respect and gratitude for Shelby highway superintendent candidate Dale Root.
As many know, Dale has made his living in farming and trucking. Roughly a year ago I made the decision to buy my own tractor trailer and strike out on my own. Dale was right there to offer any help needed to establish myself amongst the trucking industry. Dale has put his reputation on the table numerous times and has vouched his confidence in me to freight brokers who generally would not give a start-up such as myself a second look.
In the 2016 election a famous catch phrase was, “Who will answer the 3 a.m. phone call?” I know Dale will! I have tested this out numerous times. A quick cargo question, a logistics inquiry, or a late-night repair tip, Dale has always been a phone call away.
I write this letter because Dale’s nature has always been to help his neighbors. He and his family have donated produce to a variety of charities and fundraisers throughout the years. Dale has gone above and beyond to mentor me when he certainly didn’t have to. For that I am grateful. I wish him the absolute best in the primary on June 25.

domain: politics


text:
Following a meeting of the IFA Farm Business Committee, National Chairman Tom Doyle has reiterated his call for the banks and other stakeholders in the agri-food sector to support farmers under cashflow pressures and help them to work towards a sustainable position during the year ahead.
He said, “With strong product prices, there is a positive outlook for farming in 2013, and it is in the interests of all involved in the agri-food sector that farmers are supported to work through this difficult time and emerge with a viable business”.
Tom Doyle continued, “While the recent improvement in the weather conditions for grass growth is very welcome, the difficulties arising from the increased costs that farmers have had to face over the last six months will not clear immediately. Across the country, the dreadful weather conditions, combined with the high costs of inputs have contributed to severe difficulties on farm, with fodder shortages and cashflow pressures”.
IFA has been in contact with all of the main banks, to repeat our call for a proactive approach to be taken with customers and to support viable customers through:
Extending working capital to farmers and the agri-supply sector to cover increased feed and other input costs;
Communicating early with customers under pressure to alleviate cash-flow difficulties;
Providing flexible and affordable restructuring options to relieve pressure on incomes; and
Taking prompt decisions on all loan applications, whether short-term cashflow alleviation, or longer-term credit.
“We have also asked the banks to work with customers who may have built up high-cost merchant credit, and asked them to support those farmers, where possible, by converting this credit into a longer-term, more sustainable, bank loan”.
He concluded, “I am urging farmers to also be proactive and to take action to deal with their cashflow problems. IFA will continue to assist farmers at local level and we are asking all stakeholders and service providers, including the banks, merchants, co-ops, Teagasc and other agri-advisory services, to provide assistance to farmers and to develop a sustainable plan to address their difficulties.”

domain: news


nanfastsmoothAngle is a function of the form y = fastsmoothAngle(x,w,type,tol) where y becomes a smoothed version of x using a moving average function of width w where NaNs in the data are ignored. This function is specifically for angles and avoids the usual problem of trying to average angles such as 10 and 350 where a normal average would be 180 but the angular average is 0 or 360.
The argument "type" determines the smooth type:
If type=1, rectangular (sliding-average or boxcar)
If type=2, triangular (2 passes of sliding-average)
If type=3, pseudo-Gaussian (3 passes of sliding-average)
The argument "tol" controls the amount of tolerance to NaNs allowed between 0and 1. A value of zero means that if the window has any NaNs in it then the output is set as NaN. A value of 1 allows any number of NaNs in the window and will still give an answer for the smoothed signal. A value of 0.5 means that there must be at least half real values in the window for the output to be valid.
The start and end of the file are treated as if there are NaNs beyond the dataset. As such the behaviour depends on the value of 'tol' as described above. With 'tol' set at 0.5 the smoothed signal will start and end at the same time as the orgional signal. However it's accuracy will be reduced and the moving average will become more and more one-sided as the beginning and end is approached.
fastsmoothAngle(Y,w,type) smooths with tol = 0.5.
fastsmoothAngle(Y,w) smooths with type = 1 and tol = 0.5
Written using Matlab 2013b but should work with older releases
This file is heavily based on the fastsmooth function by T. C. O'Haver, May, 2008.
Greg Pittam (2022). Angular Fast Smooth - NaN Tolerant (https://www.mathworks.com/matlabcentral/fileexchange/52689-angular-fast-smooth-nan-tolerant), MATLAB Central File Exchange. Retrieved .
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Father accused of killing baby to play video games
Measure M would create a city charter commission in Sacramento with 15 members out of a field of 54 candidates.
Body after body came ashore from the capsized South Korean ship, a solemn process pierced by the deafening screams and cries from the passengers' families.
The wrenching scene came after four police boats arrived in rapid succession. The first carried...


This will fuel inflation and hit consumers and businesses still grappling with the pandemic.
According to auto club AAA on Tuesday, the national average was $4.17 per gallon. Several states along each coast could soon join California's $5-and-up club.
The pump prices have been increasing for over a year and analysts are expecting further increases after President Joe Biden announced that the United States would ban imports of Russian Oil to punish Russia for its invasion of Ukraine.
Although this week's price hikes are painful, they are not the most expensive that Americans have ever paid. Inflation is also a factor. Today's dollar equivalent to the 2008 record of $4.10 per gallon is $5.24.
We look back at how we got to this point and what that means for American households.
WHEN DID PRICES START RISING?
In 2019, gasoline prices in the United States averaged $2.69 per gallon. COVID-19 caused offices and businesses to close down in 2020. A gallon of gasoline was selling for less than $1.90 by late April 2020. Since then, prices have risen as the demand for energy has rebounded. However, global production has slowed and inventories have shrunk.
WHY ARE THE PRICES SO HIGH
It all boils down to supply-demand. On average, the world consumes close to 100 million barrels per day of oil. During the pandemic, producers cut back on exploration and production and have been slow in resuming production. Some producers claim they are facing labor and parts shortages.
In afternoon trading on Tuesday, the benchmark price for U.S. crude oil was $125 per barrel, while Brent crude was higher at $130. Consumers didn't mind that crude oil was below $20 at the beginning of the pandemic.
Patrick De Haan, Petroleum Analyst at GasBuddy, says that oil companies don't set market prices. People do. They fill up their cars and set them.
WHAT IS RUSSIA'S WAR RISING?
Analysts believe that almost all the rise in gasoline prices over the past week (at 55 cents per gallon across the country, on an average) can be attributed to the anticipation that western countries will ban Russian crude oil, further reducing their already limited supplies.
"The U.S. does not need Russian oil per se," states Tom Kloza, an analyst at the Oil Price Information Service.
According to official figures, the U.S. The United States imported 245 million barrels from Russia last year. This represents 8% of all U.S. oil exports. This is less than what the United States imported from Canada and Mexico, but it was more than it took from Saudi Arabia.
WHEN WILL PRICES EASE?
Spring and summer are when fuel prices tend to rise because Americans drive more and fly more. As countries loosen COVID-19 restrictions, demand could see a rise. These trends indicate that pump prices will rise as demand continues to outstrip supply.
De Haan states, "It's going to not be a great summer for motorists."


In the first half of the 19thcentury, the Republic of Texas settled on a national capital that was centrally located in the republic’s territory. The community of Waterloo was then renamed “Austin” in honor of Stephen F. Austin “the Father of Texas”, and became the permanent capital of the republic.
Building booms in the 1850s and 1880s radically grew the city’s infrastructure, and the technology boom in the last twenty years has more than doubled Austin’s population.
With increased residential needs, the city has benefited from a cultural boom, as well. Museums and the arts have flourished in the last ten years. Come explore!


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Excerpt: Le cultissime "M le Maudit" de Fritz Lang est disponible depuis quelques mois en import allemand. Il ne me semble pas utile de revenir ici sur l'importance de cette œuvre au sein du cinéma mondial - même si le chroniqueur du test n'a pas daigné lui donner la note maximale. En revanche, il est important de saluer l'effort fourni par TLEFilms : car cette édition BR est absolument fabuleuse. Le travail de restauration est d'une qualité exceptionnelle.
Excerpt: Ja, genau so muss es sein, und es geht ja doch! "M - Eine Stadt sucht einen Mörder" von Fritz Lang wurde nun Bild-für-Bild restauriert (sowie auch der Ton) in dem unter anderem fehlende Bildteile wieder eingefügt wurden. Das Bild sieht nun wirklich sauber und scharf aus. An einigen Stellen hat man fast den Eindruck, dass die Szenen gestern gedreht wurden. Es sind zwei Mono-Ton Fassungen enthalten. Die 2001 Restaurierung und eine neue von 2011.
Excerpt: I feel very honoured to write the first review of the German Film-Noir classic "M(1931). Considering the age of the film, the way it was presented in terms of the concept and the suspense is amazing. Peter Lorre steals the entire show with his perfect caricatures and innocence that has to be enacted by a child abductor who is affected psychologically.
Excerpt: For an 80 year old classic this blu ray is amazing - I just cannot imagine a better print than this. Once again Masters of Cinema have hit the jackpot and with a print this good one can enjoy the sheer mastery of the film making which even by todays standards makes u sit up and take note.
Summary: M is a monumental film and seriously should be watched by all. For a film like this to be made in 1931 is just shocking. Even if the film was released today it would still be nothing like we have seen before. In our modern age of film making there has been a considerable rise in the production of films about serial killers, their complexities and particularly about pathological ones.
Summary: In an eerie propagandist fashion, the phrase "in the name of the Law" is repeated over the last two scenes of Fritz Lang's "M" as a child killer is brought to justice. If "L" represents the State and the Law, then "M" is meant to represent the Individual (who in this case is a Murderer). Lang boldly asked us way back in 1931, whose rights come first: the State or the Individual? A master of his craft, Lang leaves the question open-ended and let's the audience decide.
Summary: Fritz Lang's highly influential career as a film director began in post World War I Germany, where he was a leading figure in the German Expressionist film movement, and ended in the United States in 1953 with the production of The Big Heat, a film noir classic. Perhaps his greatest film, M (Germany, 1931) forms an historical bridge between expressionism and film noir.
Fritz Lang's (sound) masterpiece- a taut and quintessentially suspenseful story, and Lorre
29 July 2005
Summary: The first time I saw M, by Fritz Lang, I almost didn't know what to make of it. I was overwhelmed by the power of the performances, the staging of the scenes, the locations, and the power that the simple story had with such complex circumstances. Then I saw it again, and a third time, and I know that this is one of the best films ever to come out of Germany- it's a powerful statement about protecting our children (if you're looking at it as a "message" movie), but in...
Summary: Being a huge fan of German Expressionist art, I'm naturally drawn to the films of Fritz Lang. I recently was able to see the restored version of "Metropolis" on the big screen, and was delighted to see "M" on the Sundance channel - especially since it was the uncut version. M follows the trail of a child killer (Peter Lorre), sought both by the police and the members of the underworld whose businesses are being effected by the investigation.
Summary: The economy, austerity and directness of the films of Fritz Lang made him one of the most profound, and precise filmmakers... Lang, a master of the German expressionist film, shot his first talkie, a crime drama considered a landmark in the story of suspense movies... It was a shocking idea for its time, based on the real-life killer Peter Kurten, headlined as the Vampire of Düsseldorf...

domain: entertainment


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1 day agoDAYTONA BEACH Fla. Go Back to See All Our Top Destinations from Orlando International MCO Airport.
If you are looking to travel to Daytona Beach within the next week you can find bus tickets as cheap as 15.
Orlando international airport to daytona beach. See all things to do. Bishops Glen Retirement Center. Prices were available within the past 7 days and starts at 120 for one-way flights and 303 for round trip for the period specified.
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Serving American Airlines Delta and Sunwingca this is a smaller airport than some others in the state. 727 miles 117 km with 75 min travel time. Best Western International Speedway.
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Distance and aircraft type by airline for flights from Orlando International Airport to Daytona Beach International Airport. I had plenty of time to wait in the AP TSA. See a list of hotels served below.
Cheap Flights from Orlando Intl. Orlando To Daytona Beach. Located only 34 miles away in Daytona Beach Daytona Beach International Airport is the closest airport to Daytona Beach Florida.
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Groome Transportation Formerly DOTS offer travelers a simple and easy way to schedule airport rides. Up to 20 cash back Daytona Beach International Airport Shuttle Service.

domain: geography


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The Slave Lodge, now part of the Iziko Musuem Collective, was first constructed in 1679 by the Dutch East India Company with the purpose of housing large numbers (in the thousands) of slaves. When Jan Van Riebeeck came to the Cape in 1652, the Groote Kerk was built as the first Christian place of worship. Church Square, just outside Groote Kerk, is the place where slaves waited for their owners to return from church.
The Slave Lodge took on many faces throughout history. Once upon a time it was known as the Cape’s largest brothel before becoming the Supreme Court in 1810 once the British arrived. Thereafter it used as government offices until 1966 before transforming into the Cultural History Musuem.
Church Square in Cape Town, however assumed the role of a car park until the 1990s after a statue of Jan Hendrik Hofmeyr was erected. He was a parliamentarian who pushed for Dutch to be recognized as equal to English in South Africa’s constitution in 1910.
When visiting the musuem today, the lower level gives the visitor insight into the history of slavery in our country before it was finally abolished in 1838. Schools can book tours with one of the museum’s educators. The upper galleries display silverware, ceramics and Egyptology from around the globe.
Slave Lodge, Adderley Street, Cape Town, 8000
Telephone: +27 21 460 8242

domain: history


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I made this feature film together with my friend Rutger Lemm, WHOM I KNOW FROM HIGH SCHOOL. BACK THEN We both loved THE SHORT stories OF ISRAELI WRITER ETGAR KERET and 15 years later we decided to make a documentary on him.
THE END RESULT IS A MIXTURE OF documentary filmmaking, fiction and animation.
IT WON AN EMMY AWARD IN THE CATEGORY ‘ARTS PROGRAMMING’, IT won TWO PRIZES AT THE MASTER OF ART-FESTIVAL IN BULGARIA AND TWO PRIZES AT THE PRIX ITALIA IN CAPRI AND ‘BEST DOCUMENTARY’ AT THE JEWISH FILM FESTIVAL IN WARSAW.
RIGHT NOW, IT'S STILL PLAYING AT FILMFESTIVALS AND IN CINEMAS OVER THE WORLD. STAY UPDATED ON OUR FACEBOOK-PAGE.

domain: artistic


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The food was fresh the staff was friendly and professional. My food was prepared in a timely manner.
Terrible service .. attitude is a shame. Slow service.. its actually ridiculous I have to write this review. Thank God their food always tastes good. But someone needs to step up in this restaurant and fix it's employees..
They need more workers. I was there on a Sunday when they opened. All the food was hot and ready but with only one person available at the counter. She had to take and fill orders! There were others there... come on people, pitch in...More
My experience at Popeye's was wonderful,the service was awesome they were polite,courteous,and very helpful.I didn't have to wait for my food long.when I got it,it was hot crispy and oh so good .I will be going back there for more meals.good job!

domain: food