Pregnancy and Heart Disease Guidelines Target Maternal Mortality

Most women who die of cardiovascular disease during pregnancy or the postpartum period were not aware that they had cardiac conditions.

Recently released guidelines for cardiovascular care of pregnant women have the potential to achieve significant reductions in maternal morbidity and mortality. The guidelines, which are detailed in a practice bulletin from the American College of Obstetricians and Gynecologists (ACOG), feature 27 recommendations.

Women face several cardiovascular disease risks during and after pregnancy, including heart rhythm abnormalities, heart valve conditions such as scarring, congestive heart failure, and exacerbation of congenital heart defects. From 2011 to 2014, cardiovascular disease was the leading cause of maternal mortality, according to the Texas Department of State Health Services.

"Cardiovascular disease is a major problem in obstetrics-gynecology," James Martin, MD, chair of the ACOG Pregnancy and Heart Disease Task Force, said during a May 3 conference call highlighting the new guidelines.

Cardiovascular care is critically important during and after pregnancy, he said. "The risk for cardiovascular disease can accelerate during pregnancy, and it can persist postpartum."

Care after delivery represents a major opportunity to reduce maternal morbidity and mortality, Martin said.

"There is a great need to follow-up with these patients and be very careful with postpartum care. As many as 40% of pregnant women do not return for postpartum care. That is a very sad statistic and reflects some of the need to change our payment models, so physicians and patients realize the importance of coming back for continuing care. If these patients have cardiovascular disease, it is likely to become worse during their lifetime."

Detection improvement needed
 

Screening for cardiovascular disease is another opportunity to reduce maternal morbidity and mortality, Pregnancy and Heart Disease Task Force executive member Afshan Hameed, MD, said during the conference call.

"The vast majority of mothers who die from cardiovascular disease either had undiagnosed cardiovascular conditions or had new onset of cardiomyopathy after their pregnancy. These are women who presented multiple times to healthcare providers for symptoms of shortness of breath, fatigue, or cough that were either dismissed or misdiagnosed," she said.

There is an urgent need to identify cardiovascular disease during and after pregnancy, Hameed said.

"We recommend screening all pregnant women and postpartum women to assess their individual risk for cardiovascular disease. This would allow for early diagnosis and treatment. … The overwhelming majority of women who die of cardiovascular disease during pregnancy or during the postpartum period were not aware that they had cardiovascular disease."

Team approach to care
 

Care teams should be assembled for women who are at risk of cardiovascular disease during and after pregnancy, Janet Wei, MD, said during the conference call. "A pregnancy heart team is multidisciplinary, with a minimum requirement of an obstetrics provider, a cardiologist, and—in moderate to high-risk patients—a maternal fetal specialist, and an anesthesiologist."

Pregnancy heart teams take a broad approach to care, said Wei, who is liaison for the American College of Cardiology on the Pregnancy and Heart Disease Task Force.

"The pregnancy heart team should have a comprehensive plan established for the pregnancy, delivery, and postpartum period. The plan should include the review of cardiac medication safety for the mother and the fetus, and the risk to the fetus from congenital and genetic conditions."

Top recommendations
 

The first 10 ACOG recommendations drawn from consensus and expert opinion feature advisories for maternal health as well as fetal and neonate care.

1. Knowledge: Clinicians should be familiar with signs and symptoms of cardiovascular disease.

2. Assessment: Ideally, a cardiologist should evaluate women with cardiovascular disease before pregnancy or as early as possible during the pregnancy for diagnosis, assessment of the effect pregnancy will have on cardiovascular conditions, risks to the woman and fetus, and treatment of underlying cardiac conditions.

3. Patient management: Women with cardiovascular disease risk should be managed through pregnancy and the postpartum period by a pregnancy heart team.

4. Patient engagement: Women with cardiovascular disease should be advised that pregnancy can contribute to a decline in cardiac status, risk of maternal mortality or morbidity, and fetal risks such as preterm birth.

5. Individualized care: To support the mother's decision making, the care team should take a personalized approach that accounts for maternal and fetal hazards linked to specific cardiac disorders and the patient's pregnancy plans.

6. Assessment tool: The California Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum toolkit should be used to assess all pregnant women for cardiovascular disease.

7. Ongoing evaluation: A pregnancy heart team should conduct ongoing evaluation of all pregnant and postpartum women with known or suspected cardiovascular disease.

8. Testing protocols: For women with cardiovascular disease and symptoms such as shortness of breath, chest pain, or palpitations, testing of cardiac status during pregnancy and the postpartum period is warranted.

9. ECG testing: Pregnant and postpartum women with known or suspected congenital heart disease, valvular and aortic disease, cardiomyopathies, and a history of cardiotoxic chemotherapy should have echocardiogram examination.

10. Fetal testing: For women with congenital heart disease, there should be fetal echocardiography. Conversely, when congenital heart disease is found in a fetus or neonate, screening for parental congenital heart disease could be warranted.