In cardio-obstetrics, clinicians must think ‘outside the box’ on CV issues in pregnancy
CVD and cardiomyopathy are the leading causes of maternal mortality up to 1 year after pregnancy, accounting for one-quarter of maternal deaths in the U.S., according to the Pregnancy Mortality Surveillance System.
The CV risks of pregnancy, along with recent data that demonstrate an increase in pregnancy-related mortality, have brought attention to the growing cross-specialty collaboration of cardio-obstetrics. CDC data show a gradual rise in the rate of pregnancy-related mortality in the U.S., from 7.2 per 100,000 live births in 1987 to 17.2 deaths per 100,000 live births in 2015.
These data have sparked discussion in the cardiology community and beyond on strategies to reduce CV- related maternal mortality and morbidity. Some institutions have even launched dedicated cardio-obstetrics programs.
“We can attribute this to the increasing numbers of women who are at advanced maternal age who decide to get pregnant, along with the increased number of women who have comorbid preexisting conditions such as hypertension, diabetes or underlying heart disease,” Cardiology Today Editorial Board Member Laxmi S. Mehta, MD, FAHA, professor of medicine and director of preventive cardiology and women’s cardiovascular health at The Ohio State University Wexner Medical Center in Columbus, said in an interview.
Greater focus has been placed in recent years on developing a cardio-obstetrics subspecialty to care for pregnant women from prepregnancy planning to postdelivery. Although there is currently no formal training in the area, heightened interest has led to more sessions at national medical meetings, specialized clinical programs and guidelines.
“We are realizing more now than ever that we need collaboration between cardiology and maternal-fetal medicine, as mortality rates are worsening for women with cardiovascular disease who are pregnant,” Cardiology Today Next Gen Innovator Ki Park, MD, clinical assistant professor of medicine (interventional cardiology) at University of Florida in Gainesville and director of women’s cardiovascular health services at UF Health, said in an interview.
Increased awareness is needed among cardiologists and other health care professionals such as maternal-fetal medicine specialists and obstetricians who are part of a cardio-obstetrics team so that CV symptoms are not confused with routine pregnancy-associated symptoms.
“One of the issues is that the symptoms of pregnancy are very similar to that of cardiac disease,” Afshan B. Hameed, MD, clinical professor of obstetrics and gynecology and of cardiology and director of obstetrical services, patient safety and quality at University of California, Irvine, told Cardiology Today. “These women are young, and pretty much all pregnant women are going to be short of breath at some point during pregnancy, they are going to be tired, so it presents a challenge to the health care providers. That’s where the need for CV screening comes in.”
Multidisciplinary approach to pregnancy care
Training and education are key for cardiologists and other health care professionals who care for pregnant women.
“Part of it is that maternal-fetal medicine specialists are not necessarily specifically trained in cardiovascular disease, and cardiologists in general are also not specifically trained in cardio-obstetrics,” Park said. “There really hasn’t been a dedicated subspecialty in this area.”
Focus on the cardiac care of women before, during and after pregnancy is vital.
“It requires you to think differently about how to manage a common cardiovascular problem when you have to also think within the context of pregnancy physiology and how the drugs or the imaging modality might affect the fetus,” Kathryn J. Lindley, MD, director of the Center for Women’s Heart Disease and associate professor of medicine at Washington University School of Medicine in St. Louis, told Cardiology Today. “It requires you to think outside the box in terms of your diagnostic and therapeutic strategies. It is beneficial to have clinicians who have seen a lot of patients with these conditions to develop expertise and therefore can be more facile in managing these conditions.”
Cardio-obstetrics, as the name implies, requires a multidisciplinary approach across cardiology and obstetrics.
“Cardio-obstetrics, which has emerged as an important multidisciplinary field, can allow a really excellent team approach to the optimal management of cardiovascular disease during pregnancy,” Mehta said.
The emergence of cardio-obstetrics has resulted in interest from not only cardiologists, but also maternal-fetal medicine and high-risk obstetrics physicians. This collaboration is occurring in physicians’ offices and hospitals, in addition to national meetings of organizations such as the American College of Cardiology, Society for Maternal-Fetal Medicine and the American Heart Association, which now offer more sessions and education focused on this area.
“I hope that, simultaneously, knowledge and general comfort with management of pregnant women with cardiovascular conditions increases throughout all cardiologists and obstetricians throughout the country,” Lindley said. “We can improve the baseline knowledge and comfort level of everyone who is taking care of these patients so everyone is more facile with managing patients, which will improve overall outcomes, but then we have more expert centers as well.”
‘Nature’s stress test’
WHO defines maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy.” Both the CDC and the American College of Obstetricians and Gynecologists (ACOG) have extended the definition of maternal mortality to 1 year.
“This is to ensure that all deaths that are truly related to pregnancy are captured and counted,” Lisa Hollier, MD, MPH, immediate past president of ACOG, said during the Louis F. Bishop Keynote delivered virtually at the cardio-obstetrics intensive during the American College of Cardiology Scientific Session in March. “Cardiomyopathy deaths are a particularly good example of the need to extend that time frame, with deaths due to this complication often happening beyond the 42 days.”
In a perspective published in Circulation: Cardiovascular Quality and Outcomes in 2019, Melinda B. Davis, MD, assistant professor of internal medicine and of obstetrics and gynecology at the University of Michigan in Ann Arbor, and Mary Norine Walsh, MD, MACC, medical director of heart failure and cardiac transplantation at St. Vincent Heart Center in Indianapolis, Indiana and past president of the ACC, compared pregnancy with “a stress test whereby subclinical cardiovascular disease may be unmasked by the hemodynamic changes.”
“During pregnancy, a woman has significant physiologic changes that affect the cardiovascular system,” Walsh, a Cardiology Today Editorial Board Member, said in an interview. “There is an increase in blood volume, heart rate and cardiac output. It is for this reason that pregnancy is frequently referred to as ‘nature’s stress test.’”
Cardiac output increases by approximately 50% during pregnancy, which can lead to physiological anemia in all women.
“Even for healthy women, that is a significant strain on their cardiac physiology,” Lindley said. “For women with underlying cardiovascular disease, that can bring out symptoms in women who were asymptomatic before they were pregnant. That can precipitate arrhythmias and heart failure events, though they were asymptomatic before going into pregnancy.”
All women experience metabolic changes during pregnancy including increases in blood glucose and lipid levels, although these changes are exaggerated in some women. This can result in gestational diabetes or preeclampsia. These disorders during pregnancy serve as red flags for increased risk for future CVD, stroke, MI and HF.
The risk for maternal morbidity and mortality is elevated in Black women. According to the CDC, pregnancy-related mortality rates in non-Hispanic Black women were 3.2 times higher than in white women (40.8 per 100,000 live births vs. 12.7 per 100,000 live births).
“Some of that [risk] may be related to suboptimal access to care, but there is emerging evidence of racial disparities leading to underrecognition of CV conditions in pregnancy and poor outcomes,” Park said.
Women with genetic disorders such as Marfan syndrome and fibromuscular dysplasia also have increased risk for coronary or aortic dissections during pregnancy.
These conditions and associated risk for mortality during pregnancy do not disappear or decrease immediately after a woman delivers. In general, deaths that occur earlier in pregnancy or shortly after delivery are associated with arrhythmias, MI, stroke or aortic dissection, whereas later deaths are attributed to conditions including HF and peripartum cardiomyopathy.
“The first year postpartum is a crucial time period,” Mehta said. “A lot of things can happen. It is not just about seeing your gynecologist at the 6-week follow-up and you’re done; women with CVD need monitoring, making sure their blood pressure is under control, making sure their heart failure hasn’t worsened, making sure they’re following that heart-healthy lifestyle.”
With increasing rates of maternal mortality in the U.S., states including California have conducted maternal mortality reviews to assess how to combat the issue. According to California’s review, which Hameed worked on, maternal deaths in the state increased from 7.7 deaths per 100,000 live births in 1999 to 16.9 deaths per 100,000 live births in 2006. Black women were approximately four times more likely to die than women in other racial/ethnic groups.
“These were women who came in with symptoms of cardiac disease, but we never thought of that,” Hameed said. “They presented once, twice or sometimes three times to seek care before they eventually died. The saddest part of this review is that almost half of their cardiac conditions were diagnosed at autopsy. Either we didn’t consider a cardiac diagnosis while the patient was alive, or it was too late to help when the diagnosis was ultimately entertained.”
In response to these trends, California launched a project to identify deaths related to pregnancy, in addition to causation and contributing factors. This resulted in a 55% decline in maternal mortality in California from 2006 to 2013 despite continued increases nationwide.
Although these data predominantly focus on California, findings from this review are generalizable to other parts of the U.S., Hameed said.
Training and guidance
Although there is growing interest in cardio-obstetrics, there currently is no formal Accreditation Council for Graduate Medical Education (ACGME) fellowship program. Several centers throughout the U.S. have formalized clinical programs in conjunction with their academic training programs. With these programs, fellows can participate in formalized training pathways, or visiting fellows can do a year rotation at a specific institution.
“It would be great to have a formal curriculum both in the cardiology fellowship and the maternal-fetal medicine specialty where there is training for the future cardiologists and [maternal-fetal medicine] specialists in this area,” Hameed said.
Others note the potential of specialty centers for training.
“Perhaps the right thing to do is to adjust our criteria to make sure that all of our fellows are being well trained in the basics, and then further expand the number of specialty centers such that a fellow could obtain the training they need to become an expert in their local training center as a subspecialized general cardiology or heart failure pathway,” Lindley said.
The newly created ACC CardioObstetrics Work Group aims to expand education in this area. One of its initiatives is to survey cardiologists on knowledge of cardio-obstetrics and use those data to provide more educational opportunities including seminars, webinars and CME programs.
“We are hoping that through our work within this ACC work group that we can use the data we are collecting to promote educational initiatives in cardio-obstetrics for both providers and trainees,” Park, who is co-chair of the work group, told Cardiology Today. “For instance, trying to require that fellows at least have X amount of lectures during the year on cardio-obstetric topics. Or, if they work in a program with a cardio-obstetrics program, rotate in that clinic for at least 1 month.”
More guidance is now available to aid risk stratification and care for women with cardiac-related complications during pregnancy. The CARPREG II study, published in the Journal of the American College of Cardiology in May 2018, outlined specific predictors of maternal cardiac complications in women with CVD that can be used as a risk stratification index. Predictors include patient history, physical exam, specific lesions, imaging, delivery of care and variables such as other maternal comorbidities, medications and fertility therapy.
Guidelines and recommendations are also available. ACOG in May 2019 released practice bulletin No. 212, which outlines the risks for CVD and its management in pregnancy. This bulletin also focuses on the development of a pregnancy heart team and the importance of long-term CV follow-up, especially after complicated pregnancies.
In May, the AHA published a scientific statement in Circulation emphasizing the importance of managing CVD and risks for cardiac conditions before, during and after pregnancy to improve outcomes for both mother and baby.
“It is important to have a statement out there like this to recognize that cardiovascular disease is the No. 1 cause of maternal mortality,” Mehta, who was chair of the AHA scientific statement writing group, said in an interview.
Cardio-obstetrics has also gained traction outside the hospital — on social media.
At an ACOG meeting in 2018, Walsh introduced the idea of using the Twitter hashtag #CardioObstetrics to create an online community around this discipline.
“#CardioObstetrics has encouraged communication among the clinicians caring for pregnant women with or at risk for cardiovascular disease,” Walsh told Cardiology Today. “In the communities of cardiology, maternal-fetal medicine, OB-GYN and anesthesiology, we all have access to different scientific publications and meeting content and having a hashtag has allowed for collaboration and sharing of science.”
If one follows the #CardioObstetrics hashtag on Twitter, they will see studies that have been published, questions about a patient they are caring for and calls to action from other users.
“The social media community for cardio-obstetrics elevates the whole field,” Park said. “Having the hashtag is really important for the awareness of the whole field in general and particularly in connecting those of us who are really active in this area.”
Importance of team-based care
Cardiologists play an important role in the care of pregnant women even before they become pregnant. Prepregnancy counseling with a cardiologist and an obstetrician can help inform women of their risks associated with pregnancy, aid in modification of medications and educate women on potential fetal complications. This involvement can span throughout a woman’s pregnancy journey.
“It is helpful to have a cardiologist with a trained eye to assess for volume overload, to assess moms in the hospital after they have delivered a baby to evaluate for signs of volume overload and heart failure, and to see them quickly after they are discharged home from the hospital to help counsel moms on signs and symptoms of cardiovascular complications,” Lindley said. “Through this, we can hopefully help moms recognize if they are having complications so they can present back to the hospital, and we can help identify those complications early and treat them before they lead to more serious complications.”
A team-based approach can further improve care for these women. This team might include a cardiologist, an obstetrician, a maternal-fetal medicine specialist, nurses, pharmacists and anesthesiologists, among others.
“There are many facets to providing optimal cardiovascular care for the mother as well as ensuring the health of the baby,” Park said. “You really cannot do that as one provider; you need folks in very specific areas and different areas of expertise who can comment on all of those components.”
All health care professionals involved in the care of a pregnant woman must keep in mind the importance of screening for any potential CV symptoms, which includes asking women about their pregnancy history and any complications related to childbearing.
“One of the things that needs to be highlighted is that for any childbearing woman who comes to the emergency department — for example, for any cardiac complaint — one of the first questions should be if they were pregnant in the preceding year,” Hameed said. “If they had a baby in the last year and they are coming in with cardiac complaints, a cardiac diagnosis should be entertained.”
- ACOG. Pregnancy and Heart Disease. Available at: www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/05/pregnancy-and-heart-disease. Accessed June 9, 2020.
- California Maternal Quality Care Collaborative.CA-PAMR (Maternal Mortality Review). Available at: www.cmqcc.org/research/ca-pamr-maternal-mortality-review. Accessed June 8, 2020.
- CDC. Pregnancy Mortality Surveillance System. Available at: https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm. Accessed June 9, 2020.
- CDC. Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths. Available at: www.cdc.gov/media/releases/2019/p0905-racial-ethnic-disparities-pregnancy-deaths.html. Accessed June 8, 2020.
- Davis MB, et al. Circ Cardiovasc Qual Outcomes. 2019;doi:10.1161/CIRCOUTCOMES.118.005417.
- Hollier L. Louis F. Bishop Keynote. Presented at: American College of Cardiology Scientific Session; March 28-30, 2020 (virtual meeting).
- Mehta LS, et al. Circulation. 2020;doi:10.1161/CIR.0000000000000772.
- Silversides CK, et al. J Am Coll Cardiol. 2018;doi:10.1016/j.jacc.2018.02.076.
- WHO. Maternal mortality ratio (per 100,000 live births). Available at: www.who.int/healthinfo/statistics/indmaternalmortality/en/. Accessed June 9, 2020.
- For more information:
- Afshan B. Hameed, MD, can be reached at firstname.lastname@example.org; Twitter: @afshanhmdmd.
- Kathryn J. Lindley, MD, can be reached at email@example.com; Twitter: @drklindley.
- Laxmi S. Mehta, MD, FAHA, can be reached at firstname.lastname@example.org; Twitter: @drlaxmimehta.
- Ki Park, MD, can be reached at email@example.com; Twitter: @cardioPCImom.
- Mary Norine Walsh, MD, MACC, can be reached at firstname.lastname@example.org; Twitter: @minnowwalsh.