Cardiovascular disease and maternal mortality: perceptions in a Midwest birthing population

BACKGROUND

Missouri has one of the highest rates of maternal mortality in the United States. To date, there are currently no studies describing birthing peoples' knowledge or perceptions of contributing causes of maternal mortality. An improved understanding of population-specific knowledge can help to define how best to design targeted interventions to reduce disease-specific causes of maternal mortality.

OBJECTIVE

This study aimed to examine the knowledge and understanding of maternal mortality in a Missouri birthing population.

STUDY DESIGN

A 46-question, cross-sectional survey to assess the familiarity with local maternal mortality rates, groups affected, and causality was developed by the Missouri Perinatal Quality Collaborative and the Maternal-Child Learning and Action Network and emailed to a random sample of birthing people across Missouri. Those who identified as someone with birthing potential with a Missouri zip code and who were ≥18 years of age were eligible for inclusion. Unadjusted descriptive statistics were generated and stratified by age, race, and region.

RESULTS

Among 2196 surveys sent, 1738 people completed the survey. Of those who responded, 78.2% were aware of the risk of pregnancy-related death with 14.7% reporting that they intimately knew someone who died. When asked if a certain group is affected disproportionately more, 66.4% responded affirmatively. Black (58.7%), uninsured (61.8%), poor (71.0%), those with substance abuse disorders (57.4%), and Native American (28.8%) birthing people were identified as groups that were perceived as suffering higher rates of maternal death. When polled on etiology, severe bleeding (56.9%) was believed to be the leading cause of death, and the second stage of labor was thought to be the period of highest risk (42.3%). Beliefs about the timing of death differed by age (P=.042) but not race (P=.81) or region (P=.191).

CONCLUSION

Missouri birthing people are cognizant of the social factors associated with increased maternal mortality but are unaware of the leading causes of death, namely cardiovascular disease and mental health conditions. Future Perinatal Quality Collaborative work should focus on campaigns that raise public awareness about cardiovascular disease and mental health-related birthing risks and the importance of monitoring early warning signs after delivery.

Latency Antibiotics in Preterm Prelabor Rupture of Membranes: A Comparison of Azithromycin Regimens

BACKGROUND

Treatment with antibiotics at the time of preterm prelabor rupture of membranes (PPROM) has been shown to prolong pregnancy. Due to the recurrent shortage of erythromycin, azithromycin has been substituted in the traditional regimen; however, there are little data on optimal dosing.

OBJECTIVE

The objective of this study was to determine whether there is a difference in latency from onset of PPROM to delivery in patients who received a single dose of azithromycin compared with a 5-day course.

METHODS

This was a single-center, multisite, retrospective, IRB approved analysis of patients admitted with a diagnosis of PPROM. Patients were included if rupture occurred between 22 0/7 and 33 6/7 weeks of gestation and received either a single dose or a 5-day course of azithromycin along with a beta lactam.

RESULTS

A total of 376 patients were reviewed with 296 patients included in the final analysis. There was no statistical difference in the primary outcome of latency days in patients who received the 5-day versus the single-dose course (4 vs 5 days, P = 0.641). There was a significantly higher rate of histologic chorioamnionitis in the single-dose course of azithromycin (46.4% vs 62.6%, P = 0.006).

CONCLUSIONS AND RELEVANCE

There was no difference in latency for patients who received a 5-day course of azithromycin versus a single dose for the treatment of PPROM. A higher rate of histologic chorioamnionitis was observed in those who received the single-day course. Prospective follow-up studies are needed to confirm these findings.

Validation of a noninvasive cardiac output monitor in maternal cardiac disease: comparison of NICOM and transthoracic echocardiogram

BACKGROUND

The physiological changes to the cardiovascular system during pregnancy are considerable and are more pronounced in those with cardiac disease. In the general population, noninvasive hemodynamic monitoring is a valid alternative to pulmonary artery catheterization, which poses risk in the pregnant population. There is limited data on noninvasive cardiac output monitoring in pregnancy as an alternative to pulmonary artery catheterization.

OBJECTIVE

We sought to compare transthoracic echocardiography with a noninvasive cardiac output monitor (NICOM, Cheetah Medical) in pregnant patients with and without cardiac disease.

STUDY DESIGN

This was a prospective, open-label validation study that compared 2-dimensional transthoracic echocardiography with NICOM estimations of cardiac output in each trimester of pregnancy and the postpartum period. Participants with and without cardiac disease with a singleton gestation were included. NICOM estimations of cardiac output were derived from thoracic bioreactance and compared with 2-dimensional transthoracic echocardiography for both precision and accuracy. A mean percentage difference of ±30% between the 2 devices was considered acceptable agreement between the 2 measurement techniques.

RESULTS

A total of 58 subjects were enrolled; 36 did not have cardiac disease and 22 had cardiac disease. Heart rate measurements between the 2 devices were strongly correlated in both groups, whereas stroke volume and cardiac output measurements showed weak correlation. When comparing the techniques, the NICOM device overestimated cardiac output in the control group in all trimesters and the postpartum period (mean percentage differences were 50.3%, 52.7%, 48.1%, and 51.0% in the first, second, and third trimesters and the postpartum period, respectively). In the group with cardiac disease, the mean percentage differences were 31.9%, 29.7%, 19.6%, and 35.2% for the respective timepoints.

CONCLUSION

The NICOM device consistently overestimated cardiac output when compared with 2-dimensional transthoracic echocardiography at all timepoints in the control group and in the first trimester and postpartum period for the cardiovascular disease group. The physiological changes of pregnancy, specifically the mean chest circumference and total body water, may alter the accuracy of the cardiac output measurement by the NICOM device as they are currently estimated. Although NICOM has been validated for use in the critical care setting, there is insufficient data to support its use in pregnancy.

Contraception for the Cardiac Patient: a Cardiologist’s Primer

Purpose of review

Cardiovascular disease (CVD) is the number one cause of maternal mortality in the USA. There are many cardiac conditions which pose significant risk to maternal health, and these women should be offered options to avoid unwanted pregnancies. Individualized contraceptive counseling focusing on woman’s desire for future pregnancy, comorbid conditions, and desire for hormone or non-hormonal (contraceptive) options is paramount to avoid adverse or unwanted side effects. The purpose of this review is to give general guidance on prescribing both hormonal and non-hormonal contraceptives for providers caring for women with heart disease.

Recent findings

Specific recommendation for the use of either non-hormonal or hormonal contraception requires knowledge of the types of contraceptive options available, cost, failure rates, and contraindications to use. Newer progestin-only options have become available and should be considered first-line therapy for women with cardiovascular disease.

Summary

The physiologic burden of pregnancy on the cardiovascular system can cause significant maternal morbidity and mortality for women with underlying CVD. These women should be offered safe and effective options for birth control, and both cardiology and obstetrical providers alike should possess fundamental knowledge of appropriate options.

Cardiovascular Medications in Pregnancy: A Primer

Cardiovascular disease and cardiovascular disease-related disorders remain among the most common causes of maternal morbidity and mortality in the United States. Due to increased rates of obesity, delayed childbearing, and improvements in medical technology, greater numbers of women are entering pregnancy with preexisting medical comorbidities. Use of cardiovascular medications in pregnancy continues to increase, and medical management of cardiovascular conditions in pregnancy will become increasingly common. Obstetricians and cardiologists must familiarize themselves with the pharmacokinetics of the most commonly used cardiovascular medications in pregnancy and how these medications respond to the physiologic changes related to pregnancy, embryogenesis, and lactation.

Improving Cardiovascular Workforce Competencies in Cardio-Obstetrics: Current Challenges and Future Directions

Maternal mortality in the United States is the highest among all developed nations, partly because of the increased prevalence of cardiovascular disease in pregnancy and beyond. There is growing recognition that specialists involved in caring for obstetric patients with cardiovascular disease need training in the new discipline of cardio-obstetrics. Training can include integrated formal cardio-obstetrics curricula in general cardiovascular disease training programs, and developing and disseminating joint cardiac and obstetric societal guidelines. Other efforts to help strengthen the cardio-obstetric field include increased collaborations and advocacy efforts between stakeholder organizations, development of US-based registries, and widespread establishment of multidisciplinary pregnancy heart teams. In this review, we present the current challenges in creating a cardio-obstetrics community, present the growing need for education and training of cardiovascular disease practitioners skilled in the care of obstetric patients, and identify potential solutions and future efforts to improve cardiovascular care of this high-risk patient population.

Creating a maternal cardiac center of excellence: a call to action

In contrast to most industrialized countries, maternal mortality in the USA is rising. Cardiovascular disease, both acquired heart disease (e.g. coronary disease, arrhythmias, and heart failure), as well as congenital heart disease survivors, are all potentially important factors in explaining this worrisome trend. Increase in acquired cardiac disease is likely attributable to greater rates of obesity, diabetes, hypertension, and an increase in the incidence of advanced maternal age, while congenital heart disease in pregnancy is increasing due to advances in pediatric cardiovascular surgery. Despite the growing cardiovascular risk of pregnant women, most obstetricians and cardiologists have limited experience in caring for women with heart disease. Accordingly, management is largely guided by expert opinion likely to vary greatly across centers. To address these challenges, a multidisciplinary approach to care that includes both cardiologists and obstetricians could leverage the knowledge of both specialties and support streamlined communication between the patient and her providers. Our experience highlights the necessary components and essential infrastructure for building a center of excellence in treating pregnant women with heart disease.Condensation: A guide for creating a center of excellence for prenatal care for women with cardiovascular disease.The problem: Cardiac disease is the leading cause of maternal mortality, and pregnancies affected by cardiac disease continue to rise, both congenital and acquired.The solution: Maternal fetal medicine, obstetricians, and cardiologists can join together in tertiary facilities to create Maternal Cardiac Centers of Excellence to provide multidisciplinary, structured care for these high-risk patients.