Addressing maternal mortality: the pregnant cardiac patient

Cardiac Critical Care of the Cardio-Obstetric Patient

Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States, with an incidence that has increased from 7.2 to 32.9 fatalities per 100,000 live births in the last 3 decades. This trend underscores the potential for an increase in the volume of admissions to cardiac intensive care units (CICUs) in the peripartum period. While congestive heart failure remains at the forefront of maternal morbidity, other life-threatening conditions include myocardial infarction (MI), hypertensive emergencies, fatal arrhythmias such as ventricular fibrillation, venous thromboembolism, aortopathies, valvular dysfunction, cardiac arrest, and cardiogenic shock. The lack of standardized guidelines to facilitate management of these conditions highlights the significant gap in medical knowledge while caring for acutely ill pregnant women. Through this comprehensive review, we highlight the most common cardiac pathologies encountered in the obstetric population and their diagnosis and contemporary management in the cardiac intensive care unit.

Catheter ablation in a monochorionic diamniotic twin pregnancy: A case report and literature review

RATIONALE

Preexcitation syndrome is an uncommon congenital cardiac disorder that impairs the normal cardiac conduction system. Radiofrequency ablation is one of the most effective treatments for this condition. Nevertheless, radiofrequency ablation is rare in women with preexcitation syndrome during pregnancy.

PATIENT CONCERNS

A 33-year-old woman with monochorionic diamniotic twin pregnancy complicated by sinus arrhythmia with ventricular preexcitation at 14 weeks and 5 days of gestation, with paroxysmal palpitations and shortness of breath at 16 weeks with paroxysmal supraventricular tachycardia with preexcitation syndrome and a heart rate ranging from 180 to 225 beats per minute.

DIAGNOSES

The pregnant occurred sudden palpitations and shortness of breath in the shower. Electrocardiography revealed paroxysmal supraventricular tachycardia, and electrophysiological study revealed preexcitation syndrome (dominant accessory route of the left free wall) with atrioventricular reentrant tachycardia.

INTERVENTIONS

Radiofrequency catheter ablation was performed at 20 weeks.

OUTCOMES

Symptoms of preexcitation syndrome resolved after the radiofrequency catheter ablation, and 2 healthy infants were delivered at 36 weeks and 2 days of gestation by cesarean section.

LESSONS

Preexcitation syndrome may result in life-threatening arrhythmias such as supraventricular tachycardia during pregnancy and delivery. It might be efficiently controlled through optimal treatment by a multidisciplinary team, which would effectively minimize arrhythmia risk events during pregnancy and improve maternal-fetal outcomes. Based on the patient's individual situation, radiofrequency ablation may be a procedure in pregnant women with preexcitation syndrome.

Antiarrhythmic Drug Use in Pregnancy: Considerations and Safety Profiles

Pregnancy entails notable physiological alterations and hormonal fluctuations that affect the well-being of both the fetus and the mother. Cardiovascular events and arrhythmias are a major concern during pregnancy, especially in women with comorbidities or a history of arrhythmias. This paper provides an overview of the prevalence, therapies, and prognoses of different types of arrhythmias during pregnancy. The administration of antiarrhythmic drugs (AADs) during pregnancy demands careful consideration because of their possible effect on the mother and fetus. AADs can cross the placenta or be present in breast milk, potentially leading to adverse effects such as teratogenicity, growth restriction, or premature birth. The safety profiles of different classes of AADs are discussed. Individualized treatment approaches and close monitoring of pregnant women prescribed AADs are essential to ensure optimal maternal and fetal outcomes.

Universal Cardiovascular Disease Risk Assessment in Pregnancy: Call to Action JACC: Advances Expert Panel

The United States has the highest maternal mortality rate among developed countries, with cardiovascular disease (CVD) being one of the leading causes of maternal deaths. Diagnosing CVD during pregnancy may be challenging as symptoms of normal pregnancy overlap with those of CVD. Delays in recognition and response to the diagnosis of CVD is a missed opportunity for timely intervention to improve maternal outcomes. Implementing universal CVD risk assessment for all pregnant and postpartum patients across clinical care settings presents a pivotal opportunity to address this issue. Integrating a validated risk assessment tool into routine obstetric care, clinicians, including obstetricians, primary care, and emergency healthcare providers, can enhance awareness of cardiovascular risk and facilitate early CVD diagnosis. Consensus among stakeholders underscores the importance of screening and education on cardiovascular health strategies for pregnant and postpartum patients to reduce CVD-related maternal mortality. This comprehensive approach offers a pathway to identify at-risk individuals and intervene promptly, potentially saving lives and advancing maternal healthcare equity.

Cardio-obstetrics de novo: a state-level, evidence-based approach for addressing maternal mortality and severe maternal morbidity in Georgia

Georgia has a higher rate of severe maternal morbidity and mortality when compared with the rest of the United States. Evidence gained from the Georgia Maternal Mortality Review Committee identified areas of focus for high-yield clinical initiatives for improvement in maternal health outcomes. Cardiovascular disease, including cardiomyopathy, coronary conditions, and preeclampsia with or without eclampsia, is the most common cause of pregnancy-related death in non-Hispanic Black women in Georgia. The development of a cardio-obstetrics program is an initiative to advance health equity by decreasing cardiovascular morbidity and mortality. This report describes the following: (1) state-level advocacy for improving maternal health outcomes with funding gained through the legislative process and partnership with a governmental agency; (2) cardio-obstetrics program development based on evidence gained from the maternal mortality review process; and (3) implementation of a cardio-obstetrics service, beginning with a focused approach for capacity building and understanding barriers to care.

Postpartum care in a cardio-obstetric clinic after preterm preeclampsia: patient and healthcare provider perspectives

BACKGROUND

Despite the significant disruption and health implications of preterm preeclampsia with severe features for birthing people, little is known about how the system of postpartum care might be strengthened for affected families. Multidisciplinary cardio-obstetric clinics are emerging; however, there is limited research on patient and healthcare provider perspectives.

OBJECTIVE

To describe patient and healthcare provider perspectives of services in a cardio-obstetric clinic following preterm preeclampsia with severe features.

STUDY DESIGN

Individuals who experienced preterm preeclampsia with severe features and presented to a cardio-obstetric clinic were approached for study participation. Providers were approached if they provided postpartum care to patients with preterm preeclampsia with severe features and considered a referral to the cardio-obstetric clinic. Participants completed a remotely conducted, semistructured interview between March 2022 and April 2023. The interviews were audio-recorded, professionally transcribed, and checked for accuracy. Responses were inductively coded for content analysis around the study questions of clinical referrals, patient education, visit expectations, and care coordination in relation to ambulatory clinical services.

RESULTS

Twenty participants (n=10 patients and n=10 providers) completed interviews. Healthcare system navigation was difficult, particularly in the context of postpartum needs. When patients are informed about their diagnosis, the information could both increase anxiety and be useful for long-term healthcare planning. Language concordant care did not always occur, and both patients and providers described gaps in quality services. Within the theme of responsibility, patients described needing to be vigilant, and providers recognized the gaps in referral and care coordination systems. Comprehensible patient education provided with birthing parents' companions and enhanced systems for care coordination were areas for further improvement in providing postpartum cardio-obstetric care following preterm preeclampsia.

CONCLUSION

This qualitative study identified patients' struggles with a confusing postpartum healthcare system and captured providers' concerns about maintaining consistent care and improving access to long-term healthcare services to improve outcomes for patients at risk of cardiovascular disease.

Multidisciplinary care of peripartum heart failure: A scientific statement of the Heart Failure Association of the ESC

Heart failure is the most common cardiovascular complication during pregnancy and the postpartum period. It is associated with increased risk of maternal morbidity and mortality as well as potentially life-threatening foetal pathology. Management of heart failure in pregnancy requires expert knowledge of cardiovascular disease as well as obstetrics which underscores the importance of multidisciplinary cardio-obstetrics teams in order to optimize diagnosis, treatment and outcome. This includes counselling of women at risk before and during the course of pregnancy in order to strengthen the relationship between medical specialists and patients, as well as to allow patient-centred delivery of care and improve quality of life.

Pharmacological Management of Cardiac Arrhythmias in the Fetal and Neonatal Periods: A Scientific Statement From the American Heart Association: Endorsed by the Pediatric & Congenital Electrophysiology Society (PACES)

Disorders of the cardiac rhythm may occur in both the fetus and neonate. Because of the immature myocardium, the hemodynamic consequences of either bradyarrhythmias or tachyarrhythmias may be far more significant than in mature physiological states. Treatment options are limited in the fetus and neonate because of limited vascular access, patient size, and the significant risk/benefit ratio of any intervention. In addition, exposure of the fetus or neonate to either persistent arrhythmias or antiarrhythmic medications may have yet-to-be-determined long-term developmental consequences. This scientific statement discusses the mechanism of arrhythmias, pharmacological treatment options, and distinct aspects of pharmacokinetics for the fetus and neonate. From the available current data, subjects of apparent consistency/consensus are presented, as well as future directions for research in terms of aspects of care for which evidence has not been established.

A Complex Adult Congenital Heart Disease Case in Pregnancy: A Multidisciplinary Approach

Multidisciplinary teams decrease the likelihood of adverse pregnancy outcomes in high-risk pregnant cardiac patients. We present the case of a patient with complex congenital heart disease and a mechanical mitral valve, whose treatment included warfarin until delivery despite the discovery of placental hematomas. A multidisciplinary approach mitigated both maternal and fetal adverse pregnancy outcomes.

Management of Friedreich Ataxia-Associated Cardiomyopathy in Pregnancy: A Review of the Literature

A major manifestation of Friedreich ataxia (FRDA) is cardiomyopathy, caused by mitochondrial proliferation in myocytes. Because the lifespan for patients with FRDA improves with better treatment modalities, more patients are becoming pregnant, meaning that more medical providers must know how to care for this population. This report provides a review of the literature on multidisciplinary management of pregnant patients with FRDA and cardiomyopathy from preconception through lactation. A cardio-obstetrics team, including cardiology, anesthesiology, and obstetrics, should be involved for this entire period. All patients should be counseled on pregnancy risk using elements of existing stratification systems, and contraception should be discussed, highlighting the safety of intrauterine devices. Electrocardiogram should be obtained at baseline and each trimester, looking for atrial arrhythmias and ST-segment changes, as should transthoracic echocardiogram, with a focus on left ventricular ejection fraction-which is typically normal in FRDA cardiomyopathy-and relative wall thickness and global longitudinal strain-which tend to decrease as cardiomyopathy progresses. Brain natriuretic peptide is also a helpful marker to detect adverse events. If heart failure develops, it should be treated like any other etiology of heart failure during pregnancy. Atrial arrhythmias should be treated with β blockers or electrical cardioversion and anticoagulation, as necessary. Most patients with FRDA can deliver vaginally, and neuraxial analgesia is recommended during labor because of the risks associated with general anesthesia. Breastfeeding is encouraged, even for those taking cardiac medications.

Care for the Obstetric Patient with Complex Cardiac Disease

The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.

Characteristics and outcomes of socioeconomically disadvantaged pregnant individuals with adult congenital heart disease presenting to a Cardio-Obstetrics Program

BACKGROUND

Outcomes of individuals with adult congenital heart disease who are socioeconomically disadvantaged and cared for in cardio-obstetrical programs, are lacking.

OBJECTIVE

This study aimed to describe the clinical characteristics, maternal pregnancy outcomes, and contraceptive uptake in individuals with adult congenital heart disease in an urban cardio-obstetrical program.

STUDY DESIGN

Retrospective data were collected for individuals with adult congenital heart disease seen in the Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System between 2015 and 2021 and compared using modified World Health Organization class I, II vs the modified World Health Organization class ≥II/III.

RESULTS

Over 90% of individuals with adult congenital heart disease were pregnant at the time of referral. Modified World Health Organization class I, II (n=77, 62.4% Black or Hispanic/Latina) had a total of 94 pregnancies and modified World Health Organization class ≥II/III (n=49, 49.0% Black or Hispanic/Latina) had a total of 56 pregnancies. Over 25% of individuals in each group had a body mass index ≥30 (P=.78), and very low summary socioeconomic scores. Modified World Health Organization class ≥II/III were more likely to be anticoagulated in the first trimester than modified World Health Organization class I, II (10.7% vs 0.0%, P=.002) and throughout pregnancy (14.3% vs 3.2% P=.02). Modified World Health Organization class ≥II/III were more likely to require arterial monitoring during delivery than modified World Health Organization class I, II (14.3% vs 0.0%, P=.001) or delivery under general anesthesia (8.9% vs 1.1%, P=.03) but had a comparable frequency of cesarean delivery (35.8% vs 41.3%, P=.68). There were no in-hospital maternal deaths. There was no difference in the type of contraception recommended by modified World Health Organization class, however, modified World Health Organization class ≥II/III were more likely to receive long-acting types or permanent sterilization (35.6% vs 54.6%, P=.045).

CONCLUSION

In a socioeconomically disadvantaged cohort with adult congenital heart disease from a historically marginalized community, those with modified World Health Organization class ≥II/III had more complex antepartum and intrapartum needs but similar maternal and obstetrical outcomes as modified World Health Organization class I, II. The multidisciplinary approach offered by a cardio-obstetrics program may contribute to successful outcomes in this high-risk cohort, and these data are hypothesis-generating.

Interventional Cardiac Procedures and Pregnancy

As the average maternal age advances with increasing concurrent cardiovascular disease risk factors, more women are entering pregnancy with or at risk for various cardiovascular conditions. Although rare, pregnant patients may require various cardiac interventions in the catheterization laboratory. An understanding of indications for intervention in pregnant patients with conditions such as myocardial infarction, severe valvular disease, and cardiogenic shock is critical to optimizing both fetal and maternal outcomes. This document highlights the most common cardiovascular conditions that may be encountered during pregnancy that may require intervention and highlights indications for intervention and periprocedural considerations to facilitate favorable maternal and fetal outcomes.

Maternal deaths due to indirect causes: Report from a tertiary care center of a developing country

Objective

To assess the causes of indirect maternal deaths.

Setting

The Department of Obstetrics & Gynecology, of a tertiary referral center in Karachi, Pakistan, from January 2018 to December 2020. Maternal deaths were categorized according to World Health Organization guidelines into direct and indirect deaths.

Result

The total maternal deaths during the study period were 96, with 26 (27%) due to indirect causes. The mean age in the indirect group was 27 (range: 20-35) years, with only eight (31%) registered (attending for three of more antenatal visits). The mean gestational age was 33 (range: 22-39) weeks. Cesarean section was the main mode of delivery, in 13 (50%). Perinatal mortality was 68%. Cardiac and hepatic diseases (each six deaths, 23%) were the main causes of indirect maternal deaths. The majority of women (20; 76%) died during the postpartum period. Delays in seeking medical help, referral, and appropriate treatment were observed in 10, 9, and 7 cases, respectively.

Conclusion

Indirect maternal deaths are an important cause of maternal mortality.

Wolff-Parkinson-White Syndrome and Peripartum Cardiomyopathy

Wolff-Parkinson-White (WPW) is a rare congenital arrhythmia that could result in peripartum cardiomyopathy. This condition could be managed by medical treatments or ablation treatments. In this report, we presented a 14-year-old pregnant girl with initial signs of syncope and palpitation, who was later diagnosed with WPW-induced peripartum cardiomyopathy. The baby was successfully delivered at 32 weeks gestational age, and the patient received a beta-blocker as the main treatment strategy. We recommend that a proper cardiology and gynecology care is critical in providing the best prognosis.

Cardiac and obstetric outcomes in pregnant women with heart disease: appraisal of the 2018 mWHO classification

OBJECTIVE

To appraise the application of the 2018 European Society of Cardiology-adapted modified WHO (mWHO) classification to pregnant women with heart disease managed at our maternal-fetal medicine referral centre and to assess whether the lack of a multidisciplinary Pregnancy Heart team has influenced their outcomes.

METHODS

A retrospective cohort study including all pregnancies with heart disease managed at our centre between June 2011 and December 2020. Cardiac conditions were categorised in five classes according to the mWHO classification. An additional class, named X, was created for conditions not included in this classification. Outcomes were compared among all classes and factors potentially associated to cardiac complications were assessed.

RESULTS

We identified 162 women with 197 pregnancies, for a prevalence of 0.7%. Thirty-eight (19.3%) gestations were included in class X. Caesarean section was performed in 64.9% pregnancies in class X, a rate similar to that of class II, II-III, and III/IV, and mostly for obstetric indications; in turn, it was more commonly performed for cardiology reasons in class II-III and III/IV. Cardiac complications occurred in 10.7%, with class X and II pregnancies showing the highest number of events (n=30.8% and 34.6%, respectively). Multiple gestation and urgent caesarean section associated with a 5-fold and 6.5-fold increase in complication rates.

CONCLUSIONS

Even in a maternal-fetal medicine referral centre, the lack of a multidisciplinary team approach to women with heart disease may negatively impact their outcomes.

Implementing a Cardiovascular Screening Tool for High-Risk Pregnant Women in a Hospital Setting

OBJECTIVE

To implement a cardiovascular screening tool in a hospital unit for high-risk pregnant women to determine if additional testing and specialty consultation were indicated.

DESIGN

Quality improvement project.

SETTING

High-risk obstetrics unit of a U.S. Midwest 127-bed specialty hospital.

PARTICIPANTS

Women ages 19 years and older who were admitted to the high-risk obstetric care unit during February and March of 2020; staff registered nurses assigned to the women completed the screening tool upon women's admission to the unit.

INTERVENTION

Nursing implementation of a cardiovascular screening tool in women hospitalized on a high-risk unit. The Iowa Model of Evidence-Based Care was used for implementation to recruit staff, guide the intervention of the screening tool, and collect and analyze the data.

RESULTS

In a 2-month period of time, the cardiovascular screening tool was completed for 31 women. Four of the 31 women screened positive, indicating the need for clinicians to consider further testing and/or specialty consultation. The intervention identified pregnant women requiring additional interventions including testing and/or specialty consultation, which may not have occurred without the screening triggering such need.

CONCLUSION

Further research is needed to validate if routine screening of pregnant women using a cardiovascular screening tool will improve long-term outcomes for pregnant women.

Fetal Supraventricular Tachycardia: What the Adult Cardiologist Needs to Know

Fetal supraventricular tachycardia management is challenging, with consequences for both the fetus and the mother. If left untreated, fetal hydrops may ensue, at which point delivery and treatment of the arrhythmia is preferred. However, if the fetus is not at term nor near-term, significant doses of antiarrhythmics may be needed to achieve adequate transplacental bioavailability. Although digoxin has classically been the mainstay of treatment, the use of flecainide or sotalol as monotherapy or in combination with digoxin is being studied. Interdisciplinary team management and shared decision-making between the physician and patient are key to achieving successful outcomes. Adult cardiologists, particularly inpatient consultation services or through burgeoning cardio-obstetrics programs, may, in some practice settings, be asked to evaluate or comanage pregnant women with fetal arrhythmia.

Cardiovascular Testing and Imaging in Pregnant Women

Cardiovascular disease is a major contributor to maternal morbidity and mortality and frequently preventable. Women with known cardiovascular disease should undergo cardiac evaluation before pregnancy. Many women with pregnancy-associated cardiac complications are not previously known to have cardiac disease. Women at high risk or who have signs or symptoms suggestive of heart failure, angina, or arrhythmias should undergo prompt evaluation. This article describes various diagnostic imaging modalities that can be used in pregnancy, including indications, strengths, and limitations.

Management of Ischemic Heart Disease in Pregnancy

PURPOSE OF REVIEW

Cardiovascular disease is an escalating cause of maternal morbidity and mortality. Women are at risk for acute myocardial infarction (MI), and more are living with risk factors for ischemic heart disease (IHD). The purpose of this review is to describe the evaluation and management of women at risk for and diagnosed with IHD in pregnancy.

RECENT FINDINGS

Pregnancy can provoke MI which has been estimated as occurring in 1.5-10/100, 000 deliveries or 1/12,400 hospitalizations, with a high inpatient mortality rate of approximately 5-7%. An invasive strategy may or may not be preferred, but fetal radiation exposure is less of a concern in comparison to maternal mortality. Common medications used to treat IHD may be continued successfully during pregnancy and lactation, including aspirin, which has an emerging role in pregnancy to prevent preeclampsia, preterm labor, and maternal mortality. Hemodynamics can be modulated during pregnancy, labor, and postpartum to mitigate risk for acute decompensation in women with IHD. Cardiologists can successfully manage IHD in pregnancy with obstetric partners and should engage women in a lifetime of cardiovascular care.

Maternal Heart Failure

Heart failure (HF) remains the most common major cardiovascular complication arising in pregnancy and the postpartum period. Mothers who develop HF have been shown to experience an increased risk of death as well as a variety of adverse cardiac and obstetric outcomes. Recent studies have demonstrated that the risk to neonates is significant, with increased risks in perinatal morbidity and mortality, low Apgar scores, and prolonged neonatal intensive care unit stays. Information on the causal factors of HF can be used to predict risk and understand timing of onset, mortality, and morbidity. A variety of modifiable, nonmodifiable, and obstetric risk factors as well as comorbidities are known to increase a patient's likelihood of developing HF, and there are additional elements that are known to portend a poorer prognosis beyond the HF diagnosis. Multidisciplinary cardio‐obstetric teams are becoming more prominent, and their existence will both benefit patients through direct care and increased awareness and educate clinicians and trainees on this patient population. Detection, access to care, insurance barriers to extended postpartum follow‐up, and timely patient counseling are all areas where care for these women can be improved. Further data on maternal and fetal outcomes are necessary, with the formation of State Maternal Perinatal Quality Collaboratives paving the way for such advances.

Canadian Cardiovascular Society: Clinical Practice Update on Cardiovascular Management of the Pregnant Patient

The number of women of childbearing age with cardiovascular disease (CVD) is growing due to increased survival of children with congenital heart disease (CHD). More women are also becoming pregnant at an older age, which is associated with increased co-morbidities including hypertension, diabetes and acquired CVD. Over the last decade the field of cardio-obstetrics has significantly advanced with the development of multidisciplinary cardio-obstetric programs (COPs) to address the increasing burden of CVD in pregnancy. With the introduction of formal COPs, pregnancy outcomes in women with heart disease have improved. COPs provide preconception counseling, antenatal and postpartum cardiac surveillance, labor and delivery planning. Pre-pregnancy counseling by a COP should be offered to women with suspected CVD who are of child bearing age. In those women who present while pregnant, counseling should be performed by a COP as early as possible in pregnancy. The purpose of counseling is to reduce the risk of pregnancy to the mother and fetus whenever possible. This is done through accurate maternal and fetal risk stratification, optimizing cardiac lesions, reviewing safety of medications in pregnancy, and making a detailed plan for the pregnancy, labor and delivery. This Clinical Practice Update highlights the COP approach to pre-pregnancy counseling, risk stratification, and management of commonly encountered cardiac conditions through pregnancy. We highlight "red flags" that should trigger a more timely assessment by a COP. We also describe the approach to some of the cardiac emergencies that the care provider may encounter in a pregnant woman.

Pregnancy-associated arterial dissections: a nationwide cohort study

AIMS

Pregnancy is a known risk factor for arterial dissection, which can result in significant morbidity and mortality in the peripartum period. However, little is known about the risk factors, timing, distribution, and outcomes of arterial dissections associated with pregnancy.

METHODS AND RESULTS

We included all women ≥12 years of age with hospitalizations associated with pregnancy and/or delivery in the Nationwide Readmissions Database between 2010 and 2015. The primary outcome was any dissection during pregnancy, delivery, or the postpartum period (42-days post-delivery). Secondary outcomes included timing of dissection, location of dissection, and in-hospital mortality. Among 18 151  897 pregnant patients, 993 (0.005%) patients were diagnosed with a pregnancy-related dissection. Risk factors included older age (32.8 vs. 28.0 years), multiple gestation (3.6% vs. 1.9%), gestational diabetes (14.3% vs. 0.2%), gestational hypertension (6.0% vs. 0.6%), and pre-eclampsia/eclampsia (2.7% vs. 0.4%), in addition to traditional cardiovascular risk factors. Of the 993 patients with dissection, 150 (15.1%) dissections occurred in the antepartum period, 232 (23.4%) were diagnosed during the admission for delivery, and 611 (61.5%) were diagnosed in the postpartum period. The most common locations for dissections were coronary (38.2%), vertebral (22.9%), aortic (19.8%), and carotid (19.5%). In-hospital mortality was 3.7% among pregnant patients with a dissection vs. <0.001% in patients without a dissection. Deaths were isolated to patients with an aortic (8.6%), coronary (4.2%), or supra-aortic (<2.5%) dissection.

CONCLUSION

Arterial dissections occurred in 5.5/100 000 hospitalized pregnant or postpartum women, most frequently in the postpartum period, and were associated with high mortality risk. The coronary arteries were most commonly involved. Pregnancy-related dissections were associated with traditional risk factors, as well as pregnancy-specific conditions.

Impact of type of maternal cardiovascular disease on pregnancy outcomes among women managed in a multidisciplinary cardio-obstetrics program

BACKGROUND

Maternal cardiovascular disease complicates up to 4% of pregnancies in the United States. Knowledge regarding the impact of the cardiovascular disease category is limited.

OBJECTIVE

The purpose of this study was to compare the maternal and neonatal outcomes among women with different types of cardiovascular diseases managed in a multidisciplinary program.

STUDY DESIGN

This was a retrospective cohort study of patients with documented structural or functional cardiovascular disease who received care in a multidisciplinary program with maternal-fetal medicine and cardiology specialists at a single institution between March 2010 and November 2019. Women were categorized as having congenital heart disease, acquired heart disease, arrhythmias and channelopathies, or aortopathies. Women were excluded from the pregnancy outcome analysis if they never became pregnant or delivered at a different institution. The outcomes were analyzed according to the disease category using univariate techniques.

RESULTS

A total of 232 women with 253 pregnancies met the inclusion criteria for pregnancy outcome analysis. Of these, 77 (30.4%) had congenital heart disease, 63 (24.9%) had acquired heart disease, 94 (37.2%) had arrhythmias or channelopathies, and 19 (7.5%) had aortopathies. Obesity and hypertension were more common among women with acquired heart disease, and women with acquired heart disease and arrhythmias had higher Cardiac Disease in Pregnancy II scores. Most of the pregnancies had good maternal and neonatal outcomes. Preeclampsia occurred more commonly in women with acquired heart disease (27% among those with acquired heart disease vs 10.4% among those with congenital heart disease, 13.8% among those with arrhythmias or channelopathies, and 0% among those with aortopathies; P=.009). Indicated preterm birth was highest among women with acquired heart disease (15.9%). Significant postpartum arrhythmias occurred in 2.4% of women. Preconception counseling was underutilized.

CONCLUSION

Most women with preexisting cardiovascular disease experienced good pregnancy and neonatal outcomes when managed in a specialized, multidisciplinary program. Women with acquired heart disease were at highest risk for pregnancy complications such as preeclampsia and preterm birth.

Are Essential Women's Healthcare Services Fully Covered? A Comparative Analysis of Policy Documents in Shanghai and New York City from 1978-2017

This study aimed to analyze the changes in the 10 major categories of women's healthcare services (WHSs) in Shanghai (SH) and New York City (NYC) from 1978 to 2017, and examine the relationship between these changes and maternal mortality ratio (MMR). Content analysis of available public policy documents concerning women's health was conducted. Two indicators were designed to represent the delivery of WHSs: The essential women's healthcare service coverage rate (ESCR) and the assessable essential healthcare service coverage rate (AESCR). Spearman correlation was used to analyze the relationship between the two indicators and MMR. In SH, the ESCR increased from 10% to 90%, AESCR increased from 0% to 90%, and MMR decreased from 24.0/100,000 to 1.01/100,000. In NYC, the ESCR increased from 0% to 80%, the AESCR increased from 0% to 60%, and the MMR decreased from 24.7/100,000 to 21.4/100,000. The MMR significantly decreased as both indicators increased (p < 0.01). Major advances have been made in women's healthcare in both cities, with SH having a better improvement effect. A common shortcoming for both was the lack of menopausal health service provision. The promotion of women's health still needs to receive continuous attention from governments of SH and NYC. The experiences of the two cities showed that placing WHSs among policy priorities is effective in improving service status.

Patent Ductus Arteriosus in Pregnancy: Cardio-Obstetrics Management in a Late Presentation

•

Congenital heart disease may be first diagnosed during pregnancy.

•

PDA with significant left-to-right shunting can cause peripartum cardiac decompensation.

•

Multidisciplinary management of congenital heart disease in pregnancy is recommended.

Catecholaminergic polymorphic ventricular tachycardia in pregnancy: a case report

Introduction

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a genetic disorder that can cause fatal tachyarrhythmias brought on by physical or emotional stress. There is little reported in the literature regarding management of CPVT in pregnancy much less during labor.

Case presentation

A gravida 2, para 1 presented to our high-risk clinic at 15 weeks gestation with known CPVT. The Caucasian female patient had been diagnosed after experiencing a cardiac arrest following a motor vehicle accident and found to have a pathogenic cardiac ryanodine receptor mutation. An implantable cardioverter defibrillator was placed at that time. Her pregnancy was uncomplicated, and she was medically managed with metoprolol, flecainide, and verapamil. Her labor course and successful vaginal delivery were uncomplicated and involved a multidisciplinary team comprising specialists in electrophysiology, maternal fetal medicine, anesthesiology, general obstetrics, lactation, and neonatology.

Conclusions

CPVT is likely underdiagnosed and, given that cardiovascular disease is a leading cause of death in pregnancy, it is important to bring further awareness to the diagnosis and management of this inherited arrhythmia syndrome in pregnancy.

Cardiomyopathies in Pregnancy: Etiologies and Management Strategies

The cardiomyopathies are a diverse group of disorders characterized by structural abnormalities of heart muscle, many of which have a genetic component. They are associated with substantial morbidity and mortality in pregnancy. We review the distinct forms of cardiomyopathy (dilated, hypertrophic, and functional) which can be seen during pregnancy, discuss complications associated with each distinct group such as heart failure, arrhythmias, and transmission to offspring, and address management strategies for stable and unstable patients.

Introduction to Building the Cardio-Obstetric Team

The pregnant cardiac patient has become a national focus in the United States during the 21st century. Maternal mortality in the United States is on the rise, cardiac disease in pregnancy has been identified as the number one indirect cause and has driven the increase in maternal death rate greatly. This may be explained by the increasing number of women with congenital heart disease reaching reproductive age and a higher prevalence of chronic medical diseases. A triad solution includes cardiovascular screening, patient education and a multidisciplinary team. The Cardio Obstetric team is described here.

Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions

The rising trend in pregnancy-related deaths during the past 2 decades in the United States stands out among other high-income countries where pregnancy-related deaths are declining. Cardiomyopathy and other cardiovascular conditions, hemorrhage, and other chronic medical conditions are all important causes of death. Unintentional death from violence, overdose, and self-harm are emerging causes that require medical and public health attention. Significant racial/ethnic inequities exist in pregnancy care with non-Hispanic black women incurring 3 to 4 times higher rates of pregnancy-related death than non-Hispanic white women. Varied terminology and lack of standardized methods for identifying maternal deaths in the United States have resulted in nuanced data collection and interpretation challenges. State maternal mortality review committees are important mechanisms for capturing and interpreting data on cause, timing, and preventability of maternal deaths. Importantly, a thorough standardized review of each maternal death leads to recommendations to prevent future pregnancy-associated deaths. Key interventions to improve maternal health outcomes include 1) integrating multidisciplinary care for women with high-risk comorbidities during preconception care, pregnancy, postpartum, and beyond; 2) addressing structural racism and the social determinants of health; 3) implementing hospital-wide safety bundles with team training and simulation; 4) providing patient education on early warning signs for medical complications of pregnancy; and 5) regionalizing maternal levels of care so that women with risk factors are supported when delivering at facilities with specialized care teams.

The Real Maternal Risks in a Pregnancy: A Structured Review to Enhance Maternal Understanding and Education

This review sought to use high-level published data sources for system knowledge translation, collaborative enhanced maternal education and understanding, and prospective maternal quality and safety care planning. The goal was to answer the following question: What are the short- and long-term maternal risks ("near misses," adverse events, severe morbidity and mortality) associated with pregnancy and childbirth? A structured analysis of the literature (systematic review, meta-analysis, observational case-control cohort), focusing on publications between 2016 and April 2019, was undertaken using the following key word search strategy: maternal, morbidity, mortality, co-morbidities (BMI, fertility, hypertension, cardiac, chronic renal disease, diabetes, mental health, stroke), preconception, antepartum, intrapartum, postpartum, "near miss," and adverse events. Only large cohort database sources with control comparison studies were accepted for inclusion because maternal mortality events are rare. Systematic review and meta-analysis were not undertaken because of the wide clinical scope and the goal of creating an education algorithm tool. For this educational tool, the results were presented in a counselling format that included a control group of common maternal morbidity from a regional maternity cohort (2017) of 54 000 births and published risk estimates for pre-conception, pregnancy-associated comorbidity, pregnancy-onset conditions, long-term maternal health associations, and maternal mortality scenarios. Because issues related to maternal comorbidities are increasing in prevalence, personalized pre-conception education on maternal pregnancy risk estimates needs to be encouraged and available to promote greater understanding. This maternal morbidity and mortality evaluation tool allows for patient-provider review and recognition of the possible leading factors associated with an increased risk of maternal morbidity: pre-conception risks (maternal age >45 years; pre-existing cardiac or hypertensive conditions) and pregnancy-obstetrical risks (gestational hypertension, preeclampsia, eclampsia; caesarean delivery, whether preterm or term; operative vaginal delivery; maternal sepsis; placenta accreta spectrum; and antepartum or postpartum hemorrhage).

Anesthesia for Pregnant Women with Pulmonary Hypertension

Despite advances in the therapy for pulmonary hypertension over the past decades, the prognosis of pregnant patients with pulmonary hypertension remains poor, with high maternal mortality. This poses a particular challenge for the mother and her medical team. In the present review, the authors have updated the classification and definition of pulmonary hypertension, summarized the current knowledge with regard to perioperative management and anesthesia considerations for these patients, and stressed the importance of a "pregnancy heart team" to improve long-term outcomes of pregnant women with pulmonary hypertension.

Adherence to clinical practice guidelines for South Australian pregnant women with cardiac conditions between 2003 and 2013

Background

For pregnant women with a known cardiac condition or those who develop cardiac disease during pregnancy, there is an increased risk of complications during pregnancy, to both mother and foetus. To reduce this risk, best practice guidelines have been developed and available in South Australia for several years. Measuring clinical practice against the guideline recommendations verifies real-life practice and an essential part of any clinical practice quality improvement project by identifying gaps. This study is the first report on adherence to statewide perinatal guidelines for these women in South Australia.

Objectives

Design

A retrospective cross-sectional observational design that analysed data from medical records.

Setting

Three SA Health public metropolitan, university-affiliated teaching hospitals with an obstetric service within a ten-year timeframe (2003–2013).

Participants

271 admissions of women who were categorised as ‘pre-existent’ or ‘newly acquired’ cardiac condition during their pregnancy.

Outcome measures

Adherence to guidelines was measured using a purposefully designed scoring system across the three sites. The researcher chose a minimum acceptable score of 17 applicable to the ‘newly acquired’ group and 35 for the ‘pre-existent’ group.

Results

Overall adherence to the perinatal guidelines for the combined groups (n = 271) reported a mean score of 16.3, SD ± 6.7, with a median score of 17. Women in the ‘newly acquired’ group scored less compared to women in the ‘pre-existent’ group (Estimate -2.3, CI -3.9,-0.7). Variance in adherence was observed across the three hospitals (P value <0.0001). The most significant predictor of adherence to guidelines was pre-pregnancy cardiac consultation which increased the likelihood of preconception care by Odds ratio 18.5 (95%, CI 2, 168). Similarly, compliance with mental health screening was associated with improved adherence to antenatal assessments (OR: 11.3(95% CI 4.7, 27.3).

Conclusion

There was overall suboptimal adherence to the statewide guidelines for women with cardiac conditions in pregnancy. The variance in the level of adherence across the three hospitals correlated with the exposure to higher acuity cases, and that appropriate up- referral to a higher acuity hospital was intrinsically linked to better adherence. Recommendations include preconception counselling, and to ensure that all health practitioners have the skills, sufficient training and time to complete a comprehensive initial antenatal assessment

Trial registration

ACTRN12617000417381

ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease

Maternal heart disease has emerged as a major threat to safe motherhood and women's long-term cardiovascular health. In the United States, disease and dysfunction of the heart and vascular system as "cardiovascular disease" is now the leading cause of death in pregnant women and women in the postpartum period () accounting for 4.23 deaths per 100,000 live births, a rate almost twice that of the United Kingdom (). The most recent data indicate that cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths (). Of further concern are the disparities in cardiovascular disease outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women. Contributing factors include barriers to prepregnancy cardiovascular disease assessment, missed opportunities to identify cardiovascular disease risk factors during prenatal care, gaps in high-risk intrapartum care, and delays in recognition of cardiovascular disease symptoms during the puerperium. The purpose of this document is to 1) describe the prevalence and effect of heart disease among pregnant and postpartum women; 2) provide guidance for early antepartum and postpartum risk factor identification and modification; 3) outline common cardiovascular disorders that cause morbidity and mortality during pregnancy and the puerperium; 4) describe recommendations for care for pregnant and postpartum women with preexisting or new-onset acquired heart disease; and 5) present a comprehensive interpregnancy care plan for women with heart disease.

Creating a Multidisciplinary Pregnancy Heart Team

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of maternal death and cases of cardiovascular death are often associated with failure to provide timely risk-appropriate care. This review outlines considerations for creation of a team focused on the care of women with CVD during pregnancy and beyond.

RECENT FINDINGS

Improved outcomes for women with complex medical or obstetric conditions managed by a multidisciplinary care team inspired national guidelines advising the creation of a Pregnancy Heart Team for women with CVD in pregnancy. The recommendations from the European Society of Cardiology provide general guidance for risk-appropriate care without elaborating on the details of these specialized care teams. A Pregnancy Heart Team led by providers from cardiology, maternal-fetal medicine, obstetrics, obstetric anesthesia, pharmacy, and nursing support a holistic approach to patient care while facilitating opportunities for cross-disciplinary education. This team should focus on frequent antepartum risk stratification, multidisciplinary delivery planning, and comprehensive preconception and postpartum care. Available evidence suggests that a consistent and integrated approach to care for women with CVD in pregnancy has the potential to decrease severe maternal morbidity and mortality. The cost-effectiveness of this approach and the impact of this comprehensive care model on a woman's long-term cardiovascular health warrant future study.