Anesthetic Care of the Pregnant Patient With Cardiovascular Disease: A Scientific Statement From the American Heart Association

Maternal and neonatal outcomes in pregnant women undergoing cardiac surgery: a systematic review and meta-analysis

OBJECTIVE

Cardiac diseases that require surgical intervention present a unique challenge during pregnancy and may affect both maternal and neonatal outcomes. This systematic review and meta-analysis aimed to evaluate maternal and neonatal outcomes in pregnant females undergoing cardiac surgery.

METHODS

A comprehensive manual and electronic search was conducted in PubMed, EMBASE, Cochrane Library, and Web of Sciences databases for studies published up to 31st May 2024. Eligible studies were required to report maternal and neonatal outcomes of women who underwent cardiac surgery during pregnancy. Random-effects meta-analysis was conducted to estimate pooled maternal and neonatal mortality proportions, and the results were presented as risk ratios (RR) with 95% confidence intervals (CIs).

RESULTS

Seventeen studies met the inclusion criteria, comprising a total sample size of 196 pregnant women who underwent cardiac surgery. Cardiac surgery during pregnancy was significantly (p < 0.001) linked to increased maternal and neonatal mortality, with pooled RR of 4.9% (CI: 2.1%-7.6%) and 26.5% (CI: 19.7%-33.4%), respectively.

CONCLUSION

This study highlights the significant risks associated with cardiac surgery during pregnancy, such as increased risk of maternal and neonatal mortality and higher incidence of preterm labor. Our findings underscore the importance of specialized care and multidisciplinary management for pregnant women with cardiac conditions. Further research is warranted to identify strategies for risk mitigation and improved outcomes in this vulnerable population.

Pregnancy-Related Heart Disease in the Emergency Department

Pregnancy induces significant physiologic changes that impact the cardiovascular system, potentially exacerbating pre-existing cardiac conditions or precipitating new illnesses. Pregnant patients with cardiac emergencies pose unique challenges, as standard interventions may pose risks to the developing fetus. This article aims to enhance emergency physicians' confidence in managing pregnancy-related cardiac emergencies by providing a structured approach to initial evaluation and stabilization. We review eight common categories of pregnancy-associated cardiac illness: gestational hypertension and pre-eclampsia, cardiomyopathy, arrhythmias, valvular disease, aortopathies, congenital heart disease and pulmonary hypertension, coronary disease, and anticoagulation-related complications. For each condition, we summarize relevant pregnancy-specific pathophysiology and outline evidence-based, personalized emergency management strategies.

Standby Extracorporeal Membrane Oxygenation Use in Obstetric Patients: A Systematized Review

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) is a potentially life-saving intervention often used in critically ill patients with severe respiratory or cardiac failure unresponsive to conventional treatments. As the prevalence of high-risk obstetric patients has increased, indications for ECMO have been identified in this population, as evidenced by an increased number of cases reported in the last decade. Although the indications for ECMO are not different for pregnant patients and nonpregnant patients, given the high-risk nature of certain peripartum conditions, there has been increased interest in the use of standby ECMO or precannulation ECMO, to enable rapid deployment of venoarterial ECMO should it be necessary. The present systematized review identified 14,717 obstetric patients, of whom 1041 received ECMO and 11 were considered for or received standby ECMO. The indications, risks, and considerations related to stand-by ECMO use are described. As no consensus guidelines exist for the peripartum use of stand-by ECMO, more research is needed to establish future practice guidelines for determining suitable candidates and improving maternal outcomes.

Anesthetic Considerations for Cesarean Delivery in a Patient With Third-Degree Heart Block: A Case Report

Congenital third-degree complete heart block (CHB) detected during pregnancy is a rare condition. This report discusses a pregnant patient with an incidental finding of CHB and its implications for maternal and fetal outcomes. A 21-year-old female patient, gravida 2 para 0 (G2P0010), first registered at five weeks, two days gestation, with an incidental finding of third-degree heart block. Her baseline heart rate of 40-50 beats per minute, with no prior cardiac diagnosis. She had a history of miscarriage at six weeks' gestation. During the current pregnancy, she experienced two episodes of dizziness upon standing, each resolving within a minute without signs of hemodynamic instability. A 12-lead EKG and 24-hour Holter monitoring confirmed CHB, and echocardiography ruled out secondary causes. Cardiology and electrophysiology recommended temporary transcutaneous pacing and bedside atropine in case of instability. CHB in pregnancy is often congenital and characterized by independent ventricular activity due to atrial stimulus blockage. While typically asymptomatic, symptoms such as dizziness, hypotension, syncope, severe bradycardia, and cardiac arrest can occur. Pregnancy and labor stress, including the Valsalva maneuver, can exacerbate bradyarrhythmia, leading to adverse outcomes. Inadequate fetal perfusion and oxygenation can result in fetal bradycardia and hypoxia. Management requires a multidisciplinary approach, with echocardiograms, Holter monitoring, and, in some cases, cardiac MRI to rule out structural heart disease. Asymptomatic patients with good functional capacity may avoid permanent pacemakers, though temporary pacing is considered on a case-by-case basis. Neuraxial anesthesia is preferred for cesarean delivery in both symptomatic and asymptomatic CHB patients due to its minimal impact on myocardial function. General anesthesia should be avoided when possible. If necessary, anesthetic agents with minimal cardiac depression, such as ketamine, etomidate, rocuronium, and isoflurane, are recommended. Assisted early deliveries, such as vacuum or forceps, can help reduce the risk of Valsalva-induced bradycardia. Asymptomatic CHB cases without significant heart disease typically have favorable outcomes. However, careful cardiovascular monitoring and individualized care plans are essential to mitigate potential complications. Postpartum cardiology follow-up is necessary to assess the development of new symptoms and determine the need for a permanent pacemaker. This case highlights the importance of early diagnosis, adequate monitoring, early elective delivery, and multidisciplinary management in CHB during pregnancy. Neuraxial anesthesia and strategic labor management are key to ensuring positive maternal and fetal outcomes. Further research is needed to develop standardized guidelines for this rare condition.

Is Cardiac Surgery Safe During Pregnancy? A 40-Year Single-Institution Experience

BACKGROUND

Limited data exist to characterize maternal and fetal outcomes during pregnancy undergoing cardiac operations using cardiopulmonary bypass.

METHODS

A retrospective review was performed of all pregnant individuals who underwent cardiac surgery using cardiopulmonary bypass at a single center from 1978 to 2023. Descriptive statistical analysis was performed, with a median reported for continuous variables and incidence for dichotomous variables.

RESULTS

Twenty-nine pregnant patients with a median age of 28 years (interquartile range [IQR], 25-32 years) years underwent cardiac surgery using cardiopulmonary bypass at a median gestation of 25 weeks (IQR, 16-29 weeks). Surgery was performed in the first trimester for 3 patients (10%), second trimester for 16 (55%), and third trimester for 10 (35%). Procedures were emergent in 15 (52%) and urgent in 14 (48%). There was 1 (3%) maternal death 2 days after mechanical aortic valve thrombectomy and 5 (17%) fetal losses. Fourteen patients who underwent cardiac surgery using cardiopulmonary bypass with continuing pregnancy experienced a 29% fetal mortality rate, and 7 patients underwent delivery before surgery and experienced 14% fetal mortality. Among cases of fetal loss, surgery was performed at a median of 25 weeks (IQR, 21-26 weeks) compared with a median of 23 weeks (IQR, 20-29 weeks) in cases without fetal loss (P = .55).

CONCLUSIONS

Cardiac surgery during pregnancy was associated with low maternal mortality but significant fetal mortality. This single-institution series supports consideration of cesarean delivery before cardiopulmonary bypass procedures if the fetus is of a viable gestational age to minimize mortality.

Anesthetic Management of a Pregnant Patient With Mixed Aortic Valve Disease Undergoing Cesarean Section

Aortic stenosis is a condition with multiple etiologies that can remain clinically silent for years. The enhanced cardiovascular demands of pregnancy can unmask a previously undetected disease or worsen existing symptoms. Managing anesthesia in pregnant patients with cardiac valvular disease is a complex task that requires a coordinated, multidisciplinary approach. This case report presents a 28-year-old pregnant Hispanic patient with known severe aortic stenosis who was admitted to our hospital at 30 weeks of gestation for multidisciplinary management and delivery planning. Her only symptom was dyspnea, classified as NYHA class II. Upon admission, a transesophageal echocardiogram (TEE) revealed severe subvalvular aortic stenosis caused by a membrane and moderate aortic valve regurgitation with a preserved left ventricular ejection fraction.  Initially, a cesarean section was planned due to breech presentation. The procedure was scheduled for 34 weeks but postponed to 36 weeks of gestational age due to the patient's stable hemodynamic status. The anesthetic approach was a combined spinal-epidural technique that provided better hemodynamic stability and effective pain control and minimized the risk of broncho-aspiration and the maternal-fetal transfer of obstetric drugs associated with general anesthesia. Careful patient selection and continuous hemodynamic monitoring were essential to avoid complications and guarantee a successful outcome. This approach proved to be safe and effective for our patient. This case highlights the importance of a multidisciplinary team approach in managing pregnant patients with cardiac disease. It also demonstrated that combined spinal-epidural anesthesia is a safe and viable option for anesthesiologists caring for these patients.

Anesthesia management for cesarean delivery in patients with an arterial switch operation: a single center case series (2015-2023)

BACKGROUND

Arterial switch operation (ASO) for dextro-transposition of the great arteries was developed four decades ago, and women with ASO have reached childbearing age. Although over 40% of the pregnant women who received ASO gave birth via cesarean delivery, detailed information about anesthesia management has not been reported. This study aimed to evaluate anesthesia and perioperative outcomes in pregnant women with ASO undergoing cesarean delivery.

METHODS

A retrospective chart review was conducted on pregnant women with a history of ASO with a cesarean delivery at Tokyo Women's Medical University Hospital between January 1, 2015, and May 31, 2023. Obstetric and anesthetic management, as well as maternal outcomes, were analyzed.

RESULTS

A total of 12 cesarean deliveries among 10 ASO patients were identified. The median maternal age at cesarean delivery was 29 years (range: 26-38) and median gestational age was 37 weeks and 1 day (33 weeks and 6 days - 37 weeks and 6 days). Two patients developed arrhythmia (paroxysmal supraventricular tachycardia, non-sustained ventricular tachycardia, and atrial tachyarrhythmia) during pregnancy. Five patients presented with moderate to severe valvular regurgitation, three of which worsened during pregnancy. All patients received neuraxial anesthesia for the cesarean delivery. Spinal induced hypotension occurred in four cases, which was immediately treated with vasopressors. No patient developed heart failure or arrhythmias postoperatively.

CONCLUSION

Neuraxial anesthesia for cesarean delivery in pregnant women with a history of ASO resulted in favorable maternal outcomes with no postoperative cardiac complications.

Perioperative Management of Anesthesia in Patients With Cardiovascular Disease: A Review of Current Guidelines in the United States

Perioperative anesthesia management in cardiovascular disease (CVD) patients is an important and multifaceted process requiring careful planning, multidisciplinary coordination, and keen observance of evidence-based guidelines. Thus, owing to the increased incidence rate of perioperative complications, including postoperative and intraoperative hemodynamic instability, arrhythmias, and ischemic events, CVD patients are considered a representative group for comprehension of the broader influence of anesthesia on cardiovascular function. Anesthetic methods and agents affect hemodynamic stability and poor management might result in exacerbated complications. Therefore, the objective of this review is to evaluate and summarize the United States' guidelines on perioperative management of anesthesia in CVD patients, highlighting the best anesthesia practices, strategies for risk assessment, and evidence-based recommendations for optimizing patient outcomes and reducing perioperative complications. The research question the study seeks to answer is how the existing U.S. guidelines inform the perioperative management of anesthesia in CVD patients and what evidence-based interventions are proposed for the optimization of patient outcomes and reduction of perioperative complications. The study has reviewed guidelines developed by the American College of Cardiology (ACC) and the American Heart Association (AHA), which focus on aspects of perioperative anesthesia management, including perioperative risk assessment, hemodynamic management, and anesthetic techniques. The literature search was conducted on different online databases, including PubMed, Scopus, Web of Science, and Google Scholar, for published and peer-reviewed literature that focused on perioperative anesthesia management and guidelines in the United States. Moreover, the search strategy utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the selection and subsequent inclusion of articles for the review. The systematic review has disclosed that anesthesia is more than the observation of an unconscious patient, as the four key anesthesia components should be provided and managed with care, owing to anesthesia's potential adverse effects. While there is no universal agreement on the provision, development, and use of a general protocol, careful consideration of every type of anesthesia and the related effects on patients with CVD is important to the provision of safer and proper care.

Preemptive Use of a Left Microaxial Flow Pump in Peripartum Cardiomyopathy

Management of peripartum cardiomyopathy and cardiogenic shock often presents a significant clinical challenge. These patients are frequently best served at a specialized center with access to cardiac anesthesia, maternal-fetal medicine, and cardiac intensivists. Planning for delivery involves a plan for anesthesia and management of hemodynamic changes during the postoperative period. The use of temporary microaxial flow pumps for hemodynamic support allows for ventricular unloading and recovery without the use of catecholaminergic agents. We present a case of early left hemodynamic support with an Impella CP device (Abiomed) in the setting of cardiogenic shock during delivery.

Maternal pulmonary hypertension and cardiopulmonary outcomes during delivery hospitalization in the United States: A nationwide study from 2016-2020

BACKGROUND

Maternal pulmonary hypertension can pose substantial morbidity and mortality risks, particularly during labor and delivery. Although maternal pulmonary hypertension is conventionally considered a contraindication to pregnancy, advances in the management of pH may contribute to improving outcomes.

OBJECTIVES

In this nationwide study, we aim to characterize the prevalence of maternal pulmonary hypertension in the United States and its association with adverse cardiopulmonary outcomes during delivery hospitalizations.

STUDY DESIGN

In this cross-sectional cohort study, we analyzed delivery hospitalizations in the National Inpatient Sample from 2016 to 2020. The primary exposure was maternal pulmonary hypertension. The primary outcome was a composite of maternal cardiopulmonary morbidity events during the delivery hospitalization including: death, heart failure, intraoperative heart failure, pulmonary edema, cardiac arrest, myocardial infarction, ventricular fibrillation, respiratory failure, pneumonia, acute kidney injury, and cardiac conversion. Propensity score matching was used to estimate the association between maternal pulmonary hypertension and adverse cardiopulmonary outcomes, adjusting for sociodemographic variables and validated clinical comorbidities as covariates. Secondary outcomes included mechanical circulatory support utilization, length of stay, and total hospitalization costs.

RESULTS

Among 18,161,315 delivery hospitalizations, 4,630 patients had pulmonary hypertension, yielding a maternal pulmonary hypertension prevalence of 25 per 100,000 delivery hospitalizations with a yearly trend of increasing prevalence (odds ratio = 1.06, 95 % CI 1.01 to 1.11, P = 0.028). After propensity score matching to create well-balanced groups, 4,560 patients with pulmonary hypertension were compared to 4,560 patients without pulmonary hypertension. In this confounder-adjusted analysis, the primary composite outcome of cardiopulmonary morbidity and mortality occurred in 41.1 % of the PH group compared to 14.4 % in the no PH group (adjusted odds ratio = 4.16, 95 % CI 3.32 to 5.23, P < 0.001). Additionally, patients with PH had a higher incidence of mechanical circulatory support use (adjusted odds ratio = 9.08, 95 % CI 1.14 to 71.81, P = 0.037), longer length of stay (length of stay ratio = 2.82, 95 % CI 2.74 to 2.9, P < 0.001) and higher total hospitalization costs (total cost ratio = 1.67, 95 % CI 1.52 to 1.85, P < 0.001).

CONCLUSIONS

Maternal pulmonary hypertension is increasing in prevalence and is strongly associated with adverse cardiopulmonary outcomes in the United States, with 41.1% of pH patients experiencing a composite outcome of cardiopulmonary morbidity and mortality during delivery hospitalization. Our findings emphasize the importance of caring for patients with maternal pulmonary hypertension in a multidisciplinary setting at high-acuity centers to ensure appropriate management of cardiopulmonary complications that arise during labor and delivery.

Obstetric anesthesia considerations in pregnancy-associated myocardial infarction: a focused review

Pregnancy-associated myocardial infarction (PAMI) is a rare but serious complication that can occur either during pregnancy or postpartum. The etiologies of PAMI are atherosclerosis, spontaneous coronary artery dissection, coronary thrombosis, coronary embolism, and coronary vasospasm. Therapy of acute PAMI depends largely on the ECG presentation, hemodynamic stability, and suspected etiology of myocardial infarction. Anesthetic management during delivery in patients with PAMI should consist of early and carefully titrated neuraxial analgesia and anesthesia, maintenance of normal sinus rhythm, preservation of afterload, and monitoring for and avoiding myocardial ischemia. To improve the care of women with PAMI, a multidisciplinary team of cardiologists, maternal fetal medicine specialists, obstetric providers, neonatologists, and anesthesiologists must work collectively to manage these complex patients.

Peripartum anesthesia management and outcomes of patients with congenital heart disease: a single-center retrospective analysis (2009-2023)

BACKGROUND

Advances in medicine have enabled more patients with congenital heart disease (CHD) to become pregnant. However, these patients face significant challenges during the peripartum period. Current peripartum anesthesia guidelines for CHD patients mainly rely on case reports and small series.

METHODS

In this retrospective study at a high-volume tertiary care center, we analyzed peripartum anesthetic approaches, postpartum hemorrhage (PPH) incidence, and maternal outcomes in CHD patients stratified by the modified World Health Organization (mWHO) classification.

RESULTS

Among 85 473 deliveries between 2009 and 2023, 409 occurred in 282 patients with CHD. Cesarean deliveries were significantly more frequent in mWHO class III, p=0.005. Labor epidural analgesia was the most common analgesic modality for vaginal deliveries (epidural rate was 71.1% with no differences between mWHO classes). Anesthesia management for cesarean deliveries varied significantly by class p<0.001. While spinal anesthesia was predominant in classes I and II, combined spinal-epidural anesthesia was more common in class III. PPH incidence was 6.4%, with no significant difference across classes, and no association was found between mWHO class severity and PPH risk (OR 0.97; 95% CI; 0.93 to 1.02, p=0.2). Higher mWHO classes correlated with significantly higher intensive care unit (ICU) admission rates, longer hospital stays, and one-year cardiac hospitalizations.

CONCLUSION

In this retrospective study on the peripartum anesthetic management and outcomes of CHD patients stratified by mWHO class, cases with greater mWHO class were more likely to deliver preterm, by cesarean delivery, with a combined spinal-epidural anesthetic and an arterial line placement for that cesarean delivery. They overall had a longer hospital stay and were more likely to be admitted to the ICU. However, the overall risk of PPH did not increase with mWHO class severity.

Obstetric anesthesia management of dilated cardiomyopathies and heart failure: a narrative review

Pregnancy in patients with dilated cardiomyopathy carries a significantly increased risk of maternal mortality or severe morbidity, and pregnancy is typically considered contraindicated for patients with severely reduced ventricular function. Nonetheless, anesthesiologists will still encounter patients with cardiomyopathy requiring delivery or termination care. This review describes how NT-ProBNP testing and echocardiography can help with early recognition of heart failure in pregnancy, and describes a suggested approach to anesthetic management of patients with cardiomyopathies or acute heart failure, including hemodynamic goals, use of vasoactive medications and mechanical support. Vaginal delivery, with effective neuraxial anesthesia is the preferred mode of delivery in most patients with cardiomyopathy, with cesarean delivery reserved for maternal or fetal indications. The Pregnancy Heart Team is vital in coordinating the multidisciplinary care necessary to safely support these patients through pregnancy.

Anesthetic management for cesarean section in two parturient with ascending aortic aneurysm: a case-based discussion

BACKGROUND

The anesthetic management of parturients with ascending aortic aneurysm for cesarean section can be particularly challenging, primarily because of increased risk for aortic dissection or aneurysm rupture.

CASE PRESENTATION

We present some aspects of the anesthetic management of two parturients with ascending aortic aneurysm for cesarean sections; amongst, the use of remifentanil with its effects on patient and newborn. We emphasize the importance of a cardio-obstetric team in the context of preoperative planning of such patients. Also, we reviewed some literature on the anesthetic management with its effect on peri-operative hemodynamic stability.

CONCLUSION

Maintaining hemodynamic stability is paramount in the prevention of the rupture or dissection of ascending aortic aneurysm during labor of parturient.

Using part of the initial analgesic dose as the epidural test dose did not delay the onset of labor analgesia: a randomized controlled clinical trial

BACKGROUND

Epidural test dose for labor analgesia is controversial and varies widely in clinical practice. It is currently unclear whether using a portion of the initial dose for analgesia as the test dose delays the onset time of analgesia, compared to the traditional test dose.

METHODS

One hundred and twenty-six parturients who chose epidural analgesia during labor were randomly assigned to two groups. The first dose in group L was 3 ml 1.5% lidocaine, and in the RF group was 10 ml 0.1% ropivacaine combined with 2 μg/ml fentanyl. After 3 min of observation, both groups received 8 ml 0.1% ropivacaine combined with 2 μg/ml fentanyl. The onset time of analgesia, motor and sensory blockade level, numerical pain rating scale, patient satisfaction score, and side effects were recorded.

RESULTS

The onset time of analgesia in group RF was similar to that in group L (group RF vs group L, 7.0 [5.0-9.0] minutes vs 8.0 [5.0-11.0] minutes, p = 0.197). The incidence of foot numbness (group RF vs group L, 34.9% vs 57.1%, p = 0.020) and foot warming (group RF vs group L, 15.9% vs 47.6%, p < 0.001) in group RF was significantly lower than that in group L. There was no difference between the two groups on other outcomes.

CONCLUSIONS

Compared with 1.5% lidocaine 3 ml, 0.1% ropivacaine 10 ml combined with 2 μg/ml fentanyl as an epidural test dose did not delay the onset of labor analgesia, and the side effects were slightly reduced.

CLINICAL TRIAL REGISTRATION

http://www.chictr.org.cn (ChiCTR2100043071).

Recommendations for the Management of High-Risk Cardiac Delivery: ACC Cardiovascular Disease in Women Committee Panel

Maternal mortality is a major public health crisis in the United States. Cardiovascular disease (CVD) is a leading cause of maternal mortality and morbidity. Labor and delivery is a vulnerable time for pregnant individuals with CVD but there is significant heterogeneity in the management of labor and delivery in high-risk patients due in part to paucity of high-quality randomized data. The authors have convened a multidisciplinary panel of cardio-obstetrics experts including cardiologists, obstetricians and maternal fetal medicine physicians, critical care physicians, and anesthesiologists to provide a practical approach to the management of labor and delivery in high-risk individuals with CVD. This expert panel will review key elements of management from mode, timing, and location of delivery to use of invasive monitoring, cardiac devices, and mechanical circulatory support.

Changes in rate-pressure product associated with pregnancy

BACKGROUND

In nonpregnant individuals, the rate-pressure product, the product of heart rate and systolic blood pressure, is used as a noninvasive surrogate of myocardial O2 consumption during cardiac stress testing. Pregnancy is considered a physiological cardiovascular stress test. Evidence describing the impact of pregnancy on myocardial O2 demand, as assessed by the rate-pressure product, is limited.

OBJECTIVE

This study aimed to describe changes in the rate-pressure product for each pregnancy trimester, during labor and delivery, and the postpartum period among low-risk pregnancies.

STUDY DESIGN

This was a retrospective cohort study that assessed uncomplicated pregnancies delivered vaginally at term. We collected rate-pressure product (heart rate × systolic blood pressure) values preconception, during pregnancy for each trimester (at ≤13 weeks + 6/7 days, at 14 weeks + 0/7 days through 27 weeks + 6/7 days, and at ≥28 weeks + 0/7 days), during the labor and delivery encounter (hospital admission until complete cervical dilation, complete cervical dilation until placental delivery, and after placental delivery until hospital discharge), and during the outpatient postpartum visit at 2 to 6 weeks after delivery. We calculated the percentage change at each time point from the preconception rate-pressure product (delta rate-pressure product). We used a mixed-linear model to analyze differences in the mean delta rate-pressure product over time and the influence of prepregnancy age, prepregnancy body mass index, and neuraxial anesthesia status during labor and delivery on these estimates.

RESULTS

Our cohort comprised 316 patients. The mean rate-pressure product increased significantly from preconception starting at the third trimester of pregnancy and during labor and delivery (P≤.05). The mean delta rate-pressure product peaked at 12% and 38% in the third trimester and during labor and delivery, respectively. Prepregnancy body mass index was inversely correlated with the mean delta rate-pressure product changes (estimate, -0.308; 95% confidence interval, -0.536 to -0.80; P=.008). In contrast, neither the prepregnancy age, nor neuraxial anesthesia status during labor had a significant influence on this parameter.

CONCLUSION

This study validates the transient but significant increase in the rate-pressure product, a clinical estimate of myocardial O2 demand, during uncomplicated pregnancies delivered vaginally at term. Pregnant individuals with lower prepregnancy body mass index experienced a sharper increase in this parameter. Patients who receive neuraxial anesthesia during labor and delivery experience similar changes in the rate-pressure product as those who did not.

Development and implementation of a pregnancy heart team at a Southeastern United States tertiary hospital: a qualitative study

BACKGROUND

The United States has seen a significant rise in maternal mortality and morbidity associated with cardiovascular disease over the past 4 decades. Contributing factors may include an increasing number of parturients with comorbid conditions, a higher rate of pregnancy among women of advanced maternal age, and more patients with congenital heart disease who survive into childbearing age and experiencing pregnancy. In response, national medical organizations have recommended the creation of multidisciplinary obstetric-cardiac teams, also known as pregnancy heart teams, to provide comprehensive preconception counseling and coordinated pregnancy management that extend through the postpartum period.

OBJECTIVE

We sought to describe the development and implementation of a pregnancy heart team for parturients with cardiac disease at a southeastern United States tertiary hospital.

STUDY DESIGN

This was a qualitative study that was conducted among healthcare team members involved during the pregnancy heart team formation. Semi-structured interviews were conducted between April and May 2022, professionally transcribed, and the responses were thematically coded for categories and themes using constructs from The Consolidated Framework for Implementation Research.

RESULTS

Themes identified included intentional collaboration to improve outpatient and inpatient coordination through earlier awareness of patients who meet the criteria and via documented care planning. The pregnancy heart team united clinicians around best practices and coordination to promote the success and safety of pregnancies and not only to minimize maternal health risks. Developing longitudinal care plans was critical among the pathway team to build on collective expertise and to provide clarity for those on shift to reduce hesitancy and achieve timely, vetted practices without additional consults. Establishing a proactive approach of specialists offering their perspectives was viewed as positively contributing to a culture of speaking up. Barriers to the successful development and sustainability of the pregnancy heart team included unmet administrative needs and clinician turnover within a context of shortages in staffing and high workload.

CONCLUSION

This study described the process of developing and implementing a pregnancy heart team at 1 institution, thereby offering insights for future multidisciplinary care for maternal cardiac patients. Establishing pregnancy heart teams can enhance quality care for high-risk patients, foster learning and collaboration among physician and nursing specialties, and improve coordination to manage complex maternal cardiac cases.

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.