Creating a Multidisciplinary Pregnancy Heart Team

Patient-Centered Adult Cardiovascular Care: A Scientific Statement From the American Heart Association

Patient-centered care is gaining widespread acceptance by the medical and lay communities and is increasingly recognized as a goal of high-quality health care delivery. Patient-centered care is based on ethical principles and aims at establishing a partnership between the health care team and patient, family member, or both in the care planning and decision-making process. Patient-centered care involves providing respectful care by tailoring management decisions to patients' beliefs, preferences, and values. A collaborative care approach can enhance patient engagement, foster shared decision-making that aligns with patient values and goals, promote more personalized and effective cardiovascular care, and potentially improve patient outcomes. The objective of this scientific statement is to inform health care professionals and stakeholders about the role and impact of patient-centered care in adult cardiovascular medicine. This scientific statement describes the background and rationale for patient-centered care in cardiovascular medicine, provides insight into patient-oriented medication management and patient-reported outcome measures, highlights opportunities and strategies to overcome challenges in patient-centered care, and outlines knowledge gaps and future directions.

Preeclamptic heart failure - perioperative concerns and management: a narrative review

Preeclampsia is an important cause of heart failure during pregnancy and the postpartum period. The aim of this review is to elucidate the pathophysiology and clinical features of preeclamptic heart failure and describe the medical and anesthetic management of these high-risk parturients. This article reviews the current evidence base regarding preeclamptic heart failure and its pathophysiology, types, and clinical features. We also describe the medical and anesthetic management of these patients during the peripartum period. Heart failure due to preeclampsia can present as either systolic or diastolic dysfunction. The management strategies of systolic heart failure include dietary salt restriction, diuresis, and cautious use of beta-blockers and vasodilators. Diuretics are the mainstay in the treatment of diastolic heart failure. In the absence of obstetric indications, vaginal delivery is the safest mode of delivery in these high-risk patients, and the use of an early labor epidural for analgesia is recommended. These patients would require increased invasive monitoring during labor and vaginal delivery. Neuraxial and general anesthesia have been used successfully for cesarean section in these patients but require crucial modifications of the standard technique. Uterotonic drugs have significant cardiovascular and pulmonary effects, and a clear understanding of these is essential during the management of these patients. Preeclamptics with heart failure require individualized peripartum care, as cardiac decompensation is an important risk factor for maternal and neonatal morbidity and mortality. These high-risk parturients benefit from timely multidisciplinary team inputs and collaborated management.

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.

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.

Female-Specific Considerations in Aortic Health and Disease

The aorta plays a central role in the modulation of blood flow to supply end organs and to optimize the workload of the left ventricle. The constant interaction of the arterial wall with protective and deleterious circulating factors, and the cumulative exposure to ventriculoarterial pulsatile load, with its associated intimal-medial changes, are important players in the complex process of vascular aging. Vascular aging is also modulated by biomolecular processes such as oxidative stress, genomic instability, and cellular senescence. Concomitantly with well-established cardiometabolic and sex-specific risk factors and environmental stressors, arterial stiffness is associated with cardiovascular disease, which remains the leading cause of morbidity and mortality in women worldwide. Sexual dimorphisms in aortic health and disease are increasingly recognized and explain-at least in part-some of the observable sex differences in cardiovascular disease, which will be explored in this review. Specifically, we will discuss how biological sex affects arterial health and vascular aging and the implications this has for development of certain cardiovascular diseases uniquely or predominantly affecting women. We will then expand on sex differences in thoracic and abdominal aortic aneurysms, with special considerations for aortopathies in pregnancy.

Mode of delivery and peripartum outcome in women with heart disease according to the ESC guidelines: an Italian multicenter study

INTRODUCTION

The European Society of Cardiology (ESC) guidelines (GL) provide indications on the mode of delivery in women with heart disease. However available data suggests that the rate of Cesarean Delivery (CD) is high and widely variable among such patients. In this study, we aimed to investigate the degree of adherence to the ESC recommendations among women delivering in four tertiary maternity services in Italy and how this affects the maternal and neonatal outcomes.

MATERIAL AND METHODS

Retrospective multicenter cohort study including pregnant women with heart disease who gave birth between January 2014 and July 2020. Composite adverse maternal outcome (CAM) was defined by the occurrence of one or more of the following: major postpartum hemorrhage, thrombo-embolic or ischemic event, de novo arrhythmia, heart failure, endocarditis, aortic dissection, need for re-surgery, sepsis, maternal death. Composite Adverse Neonatal outcome (CAN) was defined as cord arterial pH <7.00, APGAR <7 at 5 min, admission to the intensive care unit, and neonatal death. We compared the incidence of CAM and CAN between the cases with planned delivery in accordance (group "ESC consistent") or in disagreement (group "ESC not consistent") with the ESC GL.

RESULTS

Overall, 175 women and 181 liveborn were included. A higher frequency of CAN was found when delivery was not planned accordingly to the ESC guidelines [("ESC consistent" 9/124 (7.2%) vs "ESC not consistent" 13/57 (22.8%) p = 0.002 OR 3.74 (CI 95% 1.49-9.74) , while the occurrence of CAM was comparable between the two groups. At logistic regression analysis, the gestational age at delivery was the only parameter independently associated with the occurrence of CAN (p = 0.006).

CONCLUSION

Among pregnant women with heart disease, deviating from the ESC guidelines scheduling cesarean delivery does not seem to improve maternal outcomes and it is associated with worse perinatal outcomes, mainly due to lower gestational age at birth.

Contraceptive counseling and choices in pregnancies with maternal cardiac disease

OBJECTIVE

Unplanned pregnancies in women with maternal cardiac disease (MCD) are associated with increased morbidity and mortality, but the majority of these individuals do not use highly reliable contraception on postpartum hospital discharge. Contraceptive counseling in this population outside of pregnancy is incomplete and counseling during pregnancy remains poorly characterized. Our objective was to evaluate the provision and quality of contraceptive counseling for individuals with MCD during pregnancy.

METHODS

All individuals with MCD who delivered between 2008 and 2021 at a tertiary care institution with a multidisciplinary cardio-obstetrics team were sent a 27-question survey. A subset of questions were derived from the validated Interpersonal Quality in Family Planning (IQFP) survey, which emphasizes interpersonal connection, adequate information, and decision support for the individual. Each participant received a $15 gift card for survey completion. We performed chart review for clinical and demographic details, including cardiac risk score.

RESULTS

Of 522 individuals to whom the survey was sent, 133 responded and met inclusion criteria. Overall, 67% discussed contraception with their general obstetrician, 36% with their maternal-fetal medicine (MFM) specialist, and 24% with their cardiologist. Compared to individuals with low cardiac risk scores, those with high cardiac risk scores had a nonsignificant trend toward being more likely to discuss contraception with a MFM provider (52% vs 33%, p = .08). 65% reported that their provider was 'excellent' or 'good' in all IQFP domains. Respondents valued providers who respected their autonomy and offered thorough counseling. Respondents disliked feeling pressured or uninformed about the safety of contraceptive options.

CONCLUSION

Most individuals with MCD reported excellent contraceptive counseling during pregnancy. Additional work is needed to understand barriers to and enablers for effective, patient-centered contraceptive counseling and use in this population.

Is self-advocacy universally achievable for patients? The experiences of Australian women with cardiac disease in pregnancy and postpartum

PURPOSE

Patient self-advocacy is valued and promoted; however, it may not be readily accessible to all. This analysis examines the experiences of women in Australia who had cardiac disease in pregnancy or the first year postpartum through the lenses of self-advocacy and gender, specifically seeking to elaborate on the contexts, impacts, barriers, and women's responses to the barriers to self-advocacy.

METHOD

A qualitative study design was used. Twenty-five women participated in semi-structured in-depth interviews. Data were analysed using thematic analysis.

RESULTS

Analysis of findings generated the following themes: 1) Silent dream scream, 2) Easier said than done, 3) Crazy-making, and 4) Concentric circles of advocacy. Regardless of women's personal attributes, knowledge and experience, self-advocating for their health was complex and difficult and had negative cardiac and psychological outcomes.

CONCLUSION

While the women encountered significant barriers to self-advocating, they were resilient and ultimately developed strategies to be heard and to advocate on their own behalf and that of other women. Findings can be used to identify ways to support women to self-advocate and to provide adequately resourced and culturally safe environments to enable healthcare professionals to provide person-centred care.

Dilemmas in pregnancies with pulmonary hypertension: Case report from a low-resource setting

Little awareness persists of how pregnancy worsens cardiac diseases. We wish to highlight the challenges in managing pulmonary hypertension (PH) in pregnancy, within low socioeconomic environments. A 31-year-old G3P1A1 of 5 months gestation presented with worsening dyspnea and extremital edema. She had a history of heart disease with no cardiologist follow-up. She was diagnosed with type I/II PH at 4 months gestation. Her ultrasound revealed intrauterine fetal death (IUFD). She was referred for pregnancy termination. At presentation, she was tachypneic with SaO2 at 68%. After labor, she was transferred to a cardiac intensive care unit with SaO2 at 60%. Bedside echocardiography revealed a high probability of PH (pulmonary artery systolic pressure value: 109 mmHg). Unfortunately, she deteriorated and passed away a day later. Cardiac diseases in pregnancy contribute significantly to maternal mortality in Indonesia and other low socioeconomic countries. Traditional views on pregnancy and family and human rights advocate pregnancy as one of the rights, pregnancy complicated with cardiac diseases is detrimental and potentially lethal. Disparities in healthcare practices and low socioeconomic environments also contribute to such outcomes. Lack of awareness and improperly held beliefs on conception and family have led women to conceive amidst severe underlying cardiac diseases with dire outcomes.

The Role of Nurses in Fetal Cardiology Programs: An Integrative Review

BACKGROUND

Fetal cardiology programs are evolving quickly and include multiple interdisciplinary health care professionals whose roles could benefit from clear definition. Nurses provide an essential function in this field; however, descriptions or definitions of nursing practice, education and knowledge requirements, and responsibilities are limited and vary across institutions and disciplines.

PURPOSE

To conduct an integrative review summarizing the literature to determine the role of nurses in fetal cardiology programs.

METHODS

We conducted an integrative review as per Whittemore and Knafl's (2005) methodology of current literature to reveal strengths and opportunities in describing nursing practice as fetal cardiology nurses. The search strategy included five electronic databases: CINAHL, Medline, PsycINFO, Web of Science, and Google Scholar. Peer-reviewed English-language articles discussing nursing practices in fetal cardiology published between 2015 and 2022 were selected. Data extraction and analysis were completed on a final sample of 26 articles.

RESULTS

Four themes were identified on fetal cardiac nursing practice from nursing and medical perspectives: multidisciplinary key team member, psychosocial family support and counselor, coordinator or navigator, and role description.

CLINICAL IMPLICATIONS

More discussion in the literature is needed to better understand and define fetal cardiac nursing practice. Although most experts agree nurses are an important member of the interdisciplinary fetal cardiology team, their roles and educational requirements are poorly described and defined. Quality metrics and benchmarks are needed to ensure safe and effective fetal cardiology care.

Reproductive Health in Congenital Heart Disease: Preconception, Pregnancy, and Postpartum

The prevalence of congenital heart disease (CHD) in pregnancy is rising due to the improved survival of patients with CHD into childbearing age. The profound physiological changes that occur during pregnancy may worsen or unmask CHD, affecting both mother and fetus. Successful management of CHD during pregnancy requires knowledge of both the physiological changes of pregnancy and the potential complications of congenital heart lesions. Care of the CHD patient should be based on a multidisciplinary team approach beginning with preconception counseling and continuing into conception, pregnancy, and postpartum periods. This review summarizes the published data, available guidelines and recommendations for the care of CHD during pregnancy.

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

The pregnancy-related mortality rate in the United States is excessively high. The American Heart Association is dedicated to fighting heart disease and recognizes that cardiovascular disease, preexisting or acquired during pregnancy, is the leading cause of maternal mortality in the United States. Comprehensive scientific statements from cardiology and obstetrics experts guide the treatment of cardio-obstetric patients before, during, and after pregnancy. This scientific statement aims to highlight the role of specialized cardio-obstetric anesthesiology care, presenting a systematic approach to the care of these patients from the anesthesiology perspective. The anesthesiologist is a critical part of the pregnancy heart team as the perioperative physician who is trained to prevent or promptly recognize and treat patients with peripartum cardiovascular decompensation. Maternal morbidity is attenuated with expert anesthesiology peripartum care, which includes the management of neuraxial anesthesia, inotrope and vasopressor support, transthoracic echocardiography, optimization of delivery location, and consideration of advanced critical care and mechanical support when needed. Standardizing the anesthesiology approach to patients with high peripartum cardiovascular risk and ensuring that cardio-obstetrics patients have access to the appropriate care team, facilities, and advanced cardiovascular therapies will contribute to improving peripartum morbidity and mortality.

Outcomes of pregnant women hospitalized with unrepaired congenital heart disease: Insights from a multidisciplinary center in Vietnam

Background

In developing countries, fewer women have access to multidisciplinary congenital heart disease and reproductive programs staffed by experts. We report pregnancy outcomes of a multidisciplinary healthcare strategy utilizing an in-hospital teamwork approach in Vietnam.

Methods

This retrospective cohort study included pregnant women with unrepaired congenital heart disease managed at a referral cardiovascular center.

Results

Undiagnosed congenital heart disease before pregnancy, a lack of pre-pregnancy cardiology counseling, and modified World Health Organization class III/IV were common. Under the multispecialty healthcare strategy, although the rate of maternal death was 8.2% in the modified World Health Organization class IV group, no deaths occurred in any other group. Fetal/neonatal complications occurred in 54% of pregnancies, and 49.4% of neonates survived. Poor pregnancy outcomes were associated with admission during the first/seconde trimester for fetus/neonates, third trimester for mother, modified World Health Organization class III/IV, cyanosis, and heart failure.

Conclusion

The outcomes of pregnant women with unrepaired congenital heart disease were poor but seemed to improve with a multidisciplinary in-hospital healthcare teamwork strategy.

The role of the pregnancy heart team in clinical practice

Significant maternal and fetal morbidity and mortality risk has been shown to be associated with cardiovascular disease in pregnancy. Several determinants, such as the increasing number of females with corrected congenital heart disease in reproductive age, a more advanced maternal age associated with cardiovascular risk factors, and a greater prevalence of preexisting comorbidities related to cardiac disorders such as cancer and COVID-19), lead to a higher incidence of cardiac complications in pregnancy in the last few decades. However, adopting a multidisciplinary strategy may influence maternal and neonatal outcomes. This review aims at assessing the role of the Pregnancy Heart Team, which should ensure careful pre-pregnancy counseling, pregnancy monitoring, and delivery planning for both congenital and other cardiac or metabolic disorders, addressing several emerging aspects in the multidisciplinary team-based approach.

Optimizing postpartum contraception for high-risk obstetric patients

PURPOSE OF REVIEW

This review will focus on those who are at greatest risk of maternal and neonatal morbidity from a subsequent unplanned or short interval pregnancy and the interventions to increase contraceptive uptake in the postpartum period.

RECENT FINDINGS

Populations at highest risk of maternal or neonatal morbidity - those with a history of preterm birth or those with complex medical conditions - are also those at the highest risk for unintended pregnancies attributed to low-efficacy contraceptive failure/ noncontraceptive use, and many are discharged from birth hospitalization without understanding the importance of birth spacing related to their high-risk pregnancies. Current innovative strategies to improve postpartum contraception access and uptake among high-risk populations include utilizing the antenatal period to initiate contraception counseling, developing multidisciplinary teams, and incorporating multimedia-based educational tools. However, ongoing challenges that continue to pose barriers to contraception access include racial and economic disparities and the restructuring of obstetric care during the COVID-19 pandemic.

SUMMARY

Preventing an unintended short interval pregnancy by providing contraception in the postpartum period is one of the most modifiable risk factors for those at highest risk of subsequent maternal or neonatal morbidity and therefore should be prioritized by clinicians, hospitals, and insurance coverage.

Eliminating Disparities in Cardiovascular Disease for Black Women

Black women are disproportionately affected by cardiovascular disease with an excess burden of cardiovascular morbidity and mortality. In addition, the racialized structure of the United States shapes cardiovascular disease research and health care delivery for Black women. Given the indisputable evidence of the disparities in health care delivery, research, and cardiovascular outcomes, there is an urgent need to develop and implement effective and sustainable solutions to advance cardiovascular health equity for Black women while considering their ethnic diversity, regions of origin, and acculturation. Innovative and culturally tailored strategies that consider the differential impact of social determinants of health and the unique challenges that shape their health-seeking behaviors should be implemented. A patient-centered framework that involves collaboration among clinicians, health care systems, professional societies, and government agencies is required to improve cardiovascular outcomes for Black women. The time is "now" to achieve health equity for all Black women.

Timing of Delivery in Women with Cardiac Disease

OBJECTIVE

Guidelines do not exist to determine timing of delivery for women with cardiovascular disease (CVD) in pregnancy. The neonatal benefit of a term delivery as compared with an early term delivery is well described. We sought to examine maternal outcomes in women with CVD who delivered in the early term period (37^0/7 through 38^6/7 weeks) compared with those who delivered later.

STUDY DESIGN

This is a prospective cohort study examining cardiac and obstetric outcomes in women with CVD delivering between September 2011 and December 2016. The associations between gestational age at delivery and maternal, fetal, and obstetric characteristics were evaluated.

RESULTS

Two-hundred twenty-five women with CVD were included, 83 (37%) delivered in the early term period and 142 (63%) delivered at term. While the early term group had significantly higher rates of any hypertension during pregnancy (18.1 vs. 7%, p = 0.01) and intrauterine growth restriction (22.9 vs. 2.8%, p < 0.001), there was no difference in high-risk cardiac or obstetric characteristics. No difference in composite cardiac morbidity was found (4.8 vs. 3.5%, p = 0.24). Women in the early term group were more likely to undergo cesarean delivery than women in the term group (43.4 vs. 24.7%, p = 0.004).

CONCLUSION

There is no maternal benefit of an early term delivery in otherwise healthy women with CVD. Given the known fetal consequences of early term delivery, this study offers support to existing literature suggesting term delivery in these women.

KEY POINTS

· Question of delivery timing in women with cardiac disease.. · No difference in cardiac morbidity, term versus early term.. · Term delivery in women with asymptomatic cardiac disease..

Improving the heart team: An interdisciplinary team and integrated practice unit

Heart Team emerged as an important tool in the cardiovascular care, improving the efficiency of decision-making process. In addition to the benefits in patient care, it symbolizes a new culture and mindset. However, beyond the clinical condition, in low/middle-income countries other concerns arise regarding patient's background and these demands are, usually, as challenging as the medical treatment. New models have been proposed face these demands and to assure a holistic care by Integrated Practice Units. Optimization and reorganization of already existing resources and promotion of interdisciplinary and holistic care may be an effective manner to improve outcomes despite socioeconomic barriers.

Longitudinal blood pressure patterns of women with hypertensive disorders of pregnancy: preconception through postpartum

OBJECTIVE

To investigate the longitudinal blood pressure (BP) pattern of women with hypertensive disorders of pregnancy (HDP) preconception through the postpartum day (PPD) 42.

STUDY DESIGN

A retrospective study of women (≥15 years old) diagnosed with an HDP antenatally or postpartum, who were enrolled prospectively in a postpartum remote BP monitoring program between 3/2017 and 5/2020. BPs were collected from 47-time points: preconception, each trimester, delivery day, and 42 days postpartum. Analysis was conducted utilizing a mixed-effects longitudinal model.

MAIN OUTCOME MEASURES

Primary outcome was the longitudinal BP patterns. Secondary outcomes were the timing of BP stabilization (BPs < 140/90 mmHg for ≥48 h) and resolution (stabilized without antihypertensive medication use).

RESULTS

Our final analysis included 897 of the 964 eligible women. The peak systolic and diastolic BPs were on PPDs 3, 4, 5, and 5, 6, 7, respectively. Systolic BP fell below the preconception level after PPD15; diastolic BP reached its plateau after PPD17 and remained above the preconception level till PPD42 (p < .001). Postpartum BP peaked with the highest percentage of BP spikes on PPDs 4-7. The median survival times to BP stabilization and resolution were PPDs 11 (95% CI: 10-12) and 23 (95% CI: 21-25), respectively. By PPD42, 91.0% and 74.1% of women achieved BP stabilization and resolution, respectively.

CONCLUSION

This study data could be used to develop evidence-based recommendations for women with an HDP. Diastolic BPs remaining significantly higher than the preconception level indicates the long-term risk of cardiovascular disease. In our cohort, 26% of women had unresolved hypertension by PPD42, which reinforces the necessity to ensure long-term follow-up.

A reproductive and sexual health promotion program for women with heart diseases: A protocol for mixed methods study

BACKGROUND

Nowadays, for various reasons, the prevalence of heart diseases has increased in women during reproductive age. These diseases can lead to serious reproductive and sexual-related complications in the affected women. This study will conduct to develop a reproductive health promotion program for women with heart diseases.

MATERIALS AND METHODS

This is an exploratory sequential mixed methods study that will be conducted in four phases. The first phase is a qualitative research that is done using content analysis method and semi-structured individual interviews. The experiences of women with heart disease and health providers' team in educational hospitals, health centers, and private offices of physicians about reproductive health need will be explored. Purposive sampling will be continued until data saturation is reached and the conventional content analysis method will be used. In the second phase, the studies published from 2000 to 2020 will be reviewed by the matrix method and then will be analyzed by using thematic analysis. Integrating the results of these two stages, the draft of the program will be designed. In the third phase, the validation of the program will be checked by using the two-round modified Delphi method. In the fourth phase, the program will be implemented by the health system and its process will be monitored.

CONCLUSION

A life cycle reproductive health program for women with heart disease can help improve their preconception health, fertility planning, and sexual health and promote the well-being of these women in the long run.

The Importance of Cardiovascular Risk Assessment and Pregnancy Heart Team in the Management of Cardiovascular Disease in Pregnancy

Pregnancy-related maternal morbidity and mortality is increasing because of complications from cardiovascular disease. Pregnancy results in physiologic changes that can adversely impact the cardiovascular system and lead to adverse pregnancy outcomes. A multidisciplinary pregnancy heart team is essential to safely navigate women with heart disease through pregnancy. This role of the pregnancy heart team is to offer preconception counseling, determine pregnancy risks and educate women about those risks, develop a comprehensive antenatal and delivery plan, and ensure appropriate postpartum follow-up. These steps are important to improve cardiovascular outcomes in pregnancy.

Cardiovascular adverse events in pregnancy: A global perspective

Pregnant women with heart disease are vulnerable to many adverse cardiovascular events (AE). AEs during and after pregnancy continue to be important causes of maternal mortality and morbidity worldwide, with huge variations in burden in different countries and regions. These AEs are classified as having direct or indirect causes, depending on whether they are directly caused by pregnancy or due to some pre-existing disease and/or non-obstetric cause, respectively. The risks continue throughout pregnancy and even after childbirth. Apart from immediate complications during pregnancy, there is increasing evidence of a significant link between several events and the risk of cardiovascular disease (CVD) later in life. A significant number of pregnancy-related deaths caused by cardiovascular disease are preventable. This prevention can be realized through increasing awareness of cardiovascular AE in pregnancy, coupled with the application of strategies for prevention and treatment. Knowledge of the risks associated with CVD and pregnancy is of extreme importance in that regard. We discuss the global distribution of cardiovascular maternal mortality, adverse events during and after pregnancy, their predictors and risk stratification. In addition, we enumerate possible solutions, particularly the role of cardio-obstetric clinics.