Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy

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.

Maternal Cardiac Disease and Perinatal Outcomes in a Single Tertiary Care Center

OBJECTIVE

This study aims to compare the perinatal outcomes of pregnant women with heart disease and a healthy pregnant control group, as well as the maternal and newborn outcomes of pregnant women with congenital heart disease and acquired heart disease.

MATERIAL METHOD

Pregnant women with heart disease and healthy control pregnant women were included in this retrospective study. Sociodemographic data of all patients included in the study were obtained from electronic records. Perinatal outcomes of all patients were compared.

RESULTS

A total of 258 pregnant women were included in the study. While 129 pregnant women were diagnosed with heart disease, 129 patients were low-risk pregnant women. Preeclampsia (p=0.004) and cesarean section (p=0.01) rates were higher in pregnant women with heart disease compared to healthy pregnant women. Compared with healthy pregnant women, pregnant women with heart disease had a lower birth weight (p=0.003), a higher fetal growth restriction (FGR) rate (p=0.036), lower birth percentiles (p=0.002), a lower 5-minute APGAR (p=0.0001), a higher neonatal intensive care unit (NICU) admission rate (p=0.001), and a longer NICU stay rate (p=0.001). The mean gestational age at birth of pregnant women with congenital heart disease was higher than that of those with acquired heart disease (p=0.017).

CONCLUSION

It was observed that all maternal heart diseases were associated with adverse perinatal outcomes compared to healthy pregnant women. In this series, perinatal adverse outcomes of pregnant women with congenital and acquired heart disease did not differ.

Artificial intelligence-based screening for cardiomyopathy in an obstetric population: A pilot study

Background

Cardiomyopathy is a leading cause of pregnancy-related mortality and the number one cause of death in the late postpartum period. Delay in diagnosis is associated with severe adverse outcomes.

Objective

To evaluate the performance of an artificial intelligence-enhanced electrocardiogram (AI-ECG) and AI-enabled digital stethoscope to detect left ventricular systolic dysfunction in an obstetric population.

Methods

We conducted a single-arm prospective study of pregnant and postpartum women enrolled at 3 sites between October 28, 2021, and October 27, 2022. Study participants completed a standard 12-lead ECG, digital stethoscope ECG and phonocardiogram recordings, and a transthoracic echocardiogram within 24 hours. Diagnostic performance was evaluated using the area under the curve (AUC).

Results

One hundred women were included in the final analysis. The median age was 31 years (Q1: 27, Q3: 34). Thirty-eight percent identified as non-Hispanic White, 32% as non-Hispanic Black, and 21% as Hispanic. Five percent and 6% had left ventricular ejection fraction (LVEF) <45% and <50%, respectively. The AI-ECG model had near-perfect classification performance (AUC: 1.0, 100% sensitivity; 99%-100% specificity) for detection of cardiomyopathy at both LVEF categories. The AI-enabled digital stethoscope had an AUC of 0.98 (95% CI: 0.95, 1.00) and 0.97 (95% CI: 0.93, 1.00), for detection of LVEF <45% and <50%, respectively, with 100% sensitivity and 90% specificity.

Conclusion

We demonstrate an AI-ECG and AI-enabled digital stethoscope were effective for detecting cardiac dysfunction in an obstetric population. Larger studies, including an evaluation of the impact of screening on clinical outcomes, are essential next steps.

Severe maternal morbidity surveillance, temporal trends and regional variation: A population-based cohort study

OBJECTIVE

To quantify temporal trends and regional variation in severe maternal morbidity (SMM) in Sweden.

DESIGN

Cohort study.

POPULATION

Live birth and stillbirth deliveries in Sweden, 1999-2019.

METHODS

Types and subtypes of SMM were identified, based on a standard list (modified for Swedish clinical setting after considering the frequency and validity of each indicator) using diagnoses and procedure codes, among all deliveries at ≥22 weeks of gestation (including complications within 42 days of delivery). Contrasts between regions were quantified using rate ratios (RRs) and 95% confidence intervals (95% CIs). Temporal changes in SMM types and subtypes were described.

MAIN OUTCOME MEASURES

Types and subtypes of SMM.

RESULTS

There were 59 789 SMM cases among 2 212 576 deliveries, corresponding to 270.2 (95% CI 268.1-272.4) per 10 000 deliveries. Composite SMM rates increased from 236.6 per 10 000 deliveries in 1999 to 307.3 per 10 000 deliveries in 2006, before declining to 253.8 per 10 000 deliveries in 2019. Changes in composite SMM corresponded with temporal changes in severe haemorrhage rates, which increased from 94.9 per 10 000 deliveries in 1999 to 169.3 per 10 000 deliveries in 2006, before declining to 111.2 per 10 000 deliveries in 2019. Severe pre-eclampsia, eclampsia and HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome (103.8 per 10 000 deliveries), severe haemorrhage (133.7 per 10 000 deliveries), sepsis, embolism, disseminated intravascular coagulation, shock and severe mental health disorders were the most common SMM types. Rates of embolism, disseminated intravascular coagulation and shock, acute renal failure, cardiac complications, sepsis and assisted ventilation increased, whereas rates of surgical complications, severe uterine rupture and anaesthesia complications declined.

CONCLUSIONS

The observed spatiotemporal variations in composite SMM and SMM types provide substantive insights and highlight regional priorities for improving maternal health.

Political Ideology Direction of Policy Agendas and Maternal Mortality Outcomes in the U.S., 1915-2007

OBJECTIVES

The causes for persistently high and increasing maternal mortality rates in the United States have been elusive.

METHODS

We use the shift in the ideological direction of the Republican and the Democratic parties in the 1960s, to test the hypothesis that fluctuations in overall and race-specific maternal mortality rates (MMR) follow the power shifts between the parties before and after the Political Realignment (PR) of the 1960s.

RESULTS

Using time-series data analysis methods, we find that, net of trend, overall and race-specific MMRs were higher under Democratic administrations than Republican ones before the PR (1915-1965)-i.e., when the Democratic Party was a protector of the Jim Crow system. This pattern, however, changed after the PR (1966-2007), with Republican administrations underperforming Democratic ones-i.e., during the period when the Republican Party shifted toward a more economically and socially conservative agenda. The pre-post PR partisan shifts in MMRs were larger for Black (9.5%, p < . 01 ) relative to White mothers (7.4%, p < . 05 ) during the study period.

CONCLUSIONS FOR PRACTICE

These findings imply that parties and the ideological direction of their agendas substantively affect the social determinants of maternal health and produce politized health outcomes.

Use of Machine Learning for Early Detection of Maternal Cardiovascular Conditions: Retrospective Study Using Electronic Health Record Data

BACKGROUND

Cardiovascular conditions (eg, cardiac and coronary conditions, hypertensive disorders of pregnancy, and cardiomyopathies) were the leading cause of maternal mortality between 2017 and 2019. The United States has the highest maternal mortality rate of any high-income nation, disproportionately impacting those who identify as non-Hispanic Black or Hispanic. Novel clinical approaches to the detection and diagnosis of cardiovascular conditions are therefore imperative. Emerging research is demonstrating that machine learning (ML) is a promising tool for detecting patients at increased risk for hypertensive disorders during pregnancy. However, additional studies are required to determine how integrating ML and big data, such as electronic health records (EHRs), can improve the identification of obstetric patients at higher risk of cardiovascular conditions.

OBJECTIVE

This study aimed to evaluate the capability and timing of a proprietary ML algorithm, Healthy Outcomes for all Pregnancy Experiences-Cardiovascular-Risk Assessment Technology (HOPE-CAT), to detect maternal-related cardiovascular conditions and outcomes.

METHODS

Retrospective data from the EHRs of a large health care system were investigated by HOPE-CAT in a virtual server environment. Deidentification of EHR data and standardization enabled HOPE-CAT to analyze data without pre-existing biases. The ML algorithm assessed risk factors selected by clinical experts in cardio-obstetrics, and the algorithm was iteratively trained using relevant literature and current standards of risk identification. After refinement of the algorithm's learned risk factors, risk profiles were generated for every patient including a designation of standard versus high risk. The profiles were individually paired with clinical outcomes pertaining to cardiovascular pregnancy conditions and complications, wherein a delta was calculated between the date of the risk profile and the actual diagnosis or intervention in the EHR.

RESULTS

In total, 604 pregnancies resulting in birth had records or diagnoses that could be compared against the risk profile; the majority of patients identified as Black (n=482, 79.8%) and aged between 21 and 34 years (n=509, 84.4%). Preeclampsia (n=547, 90.6%) was the most common condition, followed by thromboembolism (n=16, 2.7%) and acute kidney disease or failure (n=13, 2.2%). The average delta was 56.8 (SD 69.7) days between the identification of risk factors by HOPE-CAT and the first date of diagnosis or intervention of a related condition reported in the EHR. HOPE-CAT showed the strongest performance in early risk detection of myocardial infarction at a delta of 65.7 (SD 81.4) days.

CONCLUSIONS

This study provides additional evidence to support ML in obstetrical patients to enhance the early detection of cardiovascular conditions during pregnancy. ML can synthesize multiday patient presentations to enhance provider decision-making and potentially reduce maternal health disparities.

Pregnancy and Postpartum Drug Overdose Deaths in the US Before and During the COVID-19 Pandemic

Importance

Knowledge about characteristics of US pregnancy-associated decedents is needed to guide responses.

Objective

To examine individual sociodemographic characteristics and residing county's health care resources and socioeconomic factors among pregnancy-associated overdose decedents in comparison with obstetric decedents and overdose decedents who were not pregnant in the past year.

Design, Setting, and Participants

This cross-sectional, exploratory study included 1457 pregnant and postpartum overdose decedents, 4796 obstetric decedents, and 11 205 nonpregnant overdose decedents aged 10 to 44 years from 2018 to 2021. Data were analyzed August 2023.

Exposures

Decedents from the 2018-2021 Multiple Cause of Death Files linked to the 2021 Area Health Resources Files and the 2018-2021 County Health Rankings data at the county level.

Main Outcomes and Measures

Pregnancy-associated deaths were defined as deaths during pregnancy or within 1 year of pregnancy termination. This study focused on unintentional drug overdoses or drug overdoses with undetermined intent involving the most common psychotropic drugs of misuse.

Results

From 2018 to 2021, across the pregnancy-postpartum continuum, pregnancy-associated overdose mortality ratios consistently increased among women aged 10 to 44 years. Mortality ratio more than tripled among pregnant and postpartum women aged 35 to 44 years from 4.9 (95% CI, 3.0-8.0) per 100 000 mothers aged 35 to 44 years with a live birth in January to June 2018 to 15.8 (95% CI, 12.3-20.4) in July to December 2021 (average semiannual percentage changes, 15.9; 95% CI, 8.7-23.6; P < .001). Compared with pregnant obstetric decedents, pregnant overdose decedents had increased odds of being aged 10 to 34 years (75.4% vs 59.5%; range of odds ratios [ORs], 1.8 [95% CI, 1.3-2.5] for ages 10 to 24 years to 2.2 [95% CI, 1.7-2.8] for ages 25 to 34 years), being non-college graduates (72.1% vs 59.4%; range of ORs, 2.7 [95% CI, 1.7-4.3] for those with some college education to 3.9 [95% CI, 2.4-6.1] for those with less than high school education), being unmarried (88.0% vs 62.1%; OR, 4.5; 95% CI, 3.7-6.0), and dying in nonhome, non-health care settings (25.9% vs 4.5%; OR, 2.5; 95% CI, 1.8-3.6) and were associated with decreased odds of dying in health care settings (34.7% vs 77.6%; range of ORs, 0.1 [95% CI, 0.1-0.1] for those who died in hospital inpatient settings to 0.4 [95% CI, 0.3-0.6] for those who died in hospital outpatient/emergency room settings).

Conclusions and Relevance

From 2018 to 2021, the mortality ratio more than tripled among pregnant and postpartum women aged 35 to 44 years, consistent with increases in overdose mortality across US populations. Most pregnancy-associated overdose deaths occurred outside health care settings, indicating the need for strengthening community outreach and maternal medical support. To reduce pregnancy-associated overdose mortality, evidence-based interventions are urgently needed at individual, health care, local, and national levels, along with nonpunitive approaches incentivizing pregnant and postpartum women to seek substance use disorder treatments.

Cardiogenic Shock and Utilization of Mechanical Circulatory Support in Pregnancy

Maternal mortality rates are rising in the United States, a trend which is in contrast to that seen in other high-income nations. Cardiovascular disease and hypertensive disorders of pregnancy are consistently the leading causes of maternal mortality both in the United States and globally, accounting for about one-quarter to one-third of maternal and peripartum deaths. A large proportion of cardiovascular morbidity and mortality stems from acquired disease in the context of cardiovascular risk factors, which include obesity, pre-existing diabetes and hypertension, and inequities in care from maternal care deserts and structural racism. Patients may also become pregnant with preexisting structural heart disease, or acquire disease throughout pregnancy (ex: spontaneous coronary artery dissection, peripartum cardiomyopathy), and be at higher risk of pregnancy-related cardiovascular complications. While risk-stratification tools including the modified World Health Organization (mWHO) classification, Cardiac Disease in Pregnancy (CARPREG II) and Zwangerschap bij Aangeboren HARtAfwijking/Pregnancy in Women with Congenital Heart Disease (ZAHARA) have been designed to help physicians identify patients at increased risk for adverse pregnancy outcomes and who may therefore benefit from referral to a tertiary care center, the limitation of these scores is their predominant focus on patients with known preexisting heart disease. As such, identifying patients at risk for pregnancy complications presents a significant challenge, and it is often patients with high-risk cardiovascular substrates prior to or during pregnancy who are at a highest risk for adverse pregnancy outcomes including cardiogenic shock.

Pregnancy-related maternal deaths due to cardiovascular diseases in Japan from 2010 to 2019: an analysis of maternal death exploratory committee data

OBJECTIVE

Cardiovascular disease (CVD) is the leading cause of maternal deaths in high-income countries. This study aimed to assess the characteristics of maternal deaths due to CVDs and the quality of care provided to patients, and to identify elements to improve maternal care in Japan.

METHODS

This descriptive study used the maternal death registration data of the Maternal Deaths Exploratory Committee of Japan between 2010 and 2019.

RESULTS

Of 445 eligible pregnancy-related maternal deaths, 44 (9.9%) were attributed to CVD. The most frequent cause was aortic dissection (18 patients, 40.9%), followed by peripartum cardiomyopathy (8 patients, 18.2%), and pulmonary hypertension (5 patients, 11.4%). In 31.8% of cases, cardiopulmonary arrest occurred within 30 min after initial symptoms. Frequent symptoms included pain (27.3%) and respiratory symptoms (27.3%), with 61.4% having initial symptoms during the prenatal period. 63.6% of the patients had known risk factors, with age ≥35 years (38.6％), hypertensive disorder (15.9%), and obesity (15.9%) being the most common. Quality of care was assessed as suboptimal in 16 (36.4%) patients. Cardiac risk assessment was insufficient in three patients with preexisting cardiac disease, while 13 patients had symptoms and risk factors warranting intensive monitoring and evaluation.

CONCLUSION

Aortic dissection was the leading cause of maternal death due to CVDs. Obstetrics care providers need to be familiar with cardiac risk factors and clinical warning signs that may lead to impending fatal cardiac events. Timely risk assessment, patient awareness, and a multidisciplinary team approach are key to improving maternal care in Japan.

Maternal cardiac disease and perinatal outcomes in a single tertiary care center

OBJECTIVE

Maternal mortality in the U.S. has increased, with a substantial contribution from maternal cardiac disease. As a result of improved childhood survival, more women with congenital heart disease are reaching reproductive age leading to a growing high-risk obstetric population. We sought to determine the obstetrical and neonatal outcomes of women with maternal cardiac disease, including acquired cardiovascular disease and congenital heart disease.

METHODS

We studied a retrospective cohort study of women that delivered from 2008 to 2013 (N = 9026). Singleton pregnancies without preexisting conditions were established as the unexposed group for this study. Maternal and neonatal outcomes were compared between the unexposed group (N = 7277) and women exposed to maternal (acquired or congenital) cardiac disease (N = 139) as well as only congenital heart disease (N = 85). Statistical comparisons used univariate/multivariable logistic and linear regression analysis controlling for confounders with p < .05 and 95% confidence intervals indicating statistical significance.

RESULTS

Pregnancies complicated by maternal cardiac disease were associated with increased odds of preterm birth (<34 weeks, <37 weeks), intrauterine growth restriction (IUGR), need for assisted vaginal delivery, maternal ICU admission, and prolonged maternal hospitalization (>7 d). Neonatal outcomes including small for gestational age and Apgar score <7 at 5 min were increased in the pregnancies complicated by maternal cardiac disease. When pregnancies complicated by congenital heart disease were analyzed as a sub-group of the cohort, the results were similar. There were increased odds of preterm birth (<37 weeks), early-term delivery, need for assisted vaginal delivery, and prolonged hospitalization. Neonatal outcomes were only significant for small for gestational age.

CONCLUSION

We observed that in a select cohort of pregnancies complicated by maternal cardiac diseases (acquired or congenital), there were significant increases of adverse perinatal outcomes. Therefore, a multidisciplinary approach including maternal-fetal medicine specialists, cardiologists, obstetric anesthesia, and dedicated ancillary support is imperative for optimal care of this high-risk obstetrics population.

Peripartum Cardiogenic Shock and Mechanical Circulatory Support

Despite remarkable improvements in the past two decades, the annual cardiovascular mortality rate has remained higher for women than for men. Pregnant women represent an underinvestigated population in clinical research, and the mechanisms of long-term cardiovascular complications in women with obstetric complications remain to be elucidated. Regarding advanced heart failure during pregnancy, interventional approaches are effective but still underutilised. Percutaneous mechanical circulatory support is a valuable option for peripartum cardiogenic shock, although its use during pregnancy is still limited. Survival rates have improved in recent years, but further emphasis on the importance of early recognition and initiation of heart failure treatment in this patient group is warranted. The aims of this review are to summarise the current literature on the implementation of mechanical circulatory support in cardiogenic shock during pregnancy and delivery and to understand the role of percutaneous ventricular assist devices in the management of such conditions.

Association Between Race, Cardiology Care, and the Receipt of Guideline-Directed Medical Therapy in Peripartum Cardiomyopathy

BACKGROUND

Black patients with peripartum cardiomyopathy (PPCM) have disproportionately worse outcomes than White patients, possibly related to variable involvement of cardiovascular specialists in their clinical care. We sought to determine whether race was associated with cardiology involvement in clinical care during inpatient admission and whether cardiology involvement in care was associated with higher claims of guideline-directed medical therapy (GDMT) a week after hospital discharge.

METHODS

Using Optum's de-identified Clinformatics® Data Mart (CDM), we included Black and White patients' first hospital admission for PPCM from 2008 to 2021. Cardiology involvement in clinical care was defined as the receipt of attending care from a cardiovascular specialist during admission. GDMT included beta-blockers (BB) for all patients and triple therapy (BB, angiotensin-responsive medications, and mineralocorticoid receptor antagonists) for non-pregnant patients. Logistic regression was used to determine the associations between cardiology involvement in clinical care during admission and (1) patient race and (2) GDMT prescription, adjusting for age and comorbidities.

RESULTS

Among 668 patients (32.6% Black, 67.4% White, 93.3% commercially insured), there was no significant difference in the odds of cardiology involvement in clinical care by race (aOR: 1.41; 95%CI: 0.87-2.33, P=0.17). Inpatient cardiology care was associated with 2.75 times increased odds of having a prescription claim for GDMT (BB) for White patients (aOR: 2.75; 95%CI 1.50-5.06, P=0.001), and the estimated effect size was similar but not statistically significant for Black patients (aOR: 2.20, 95% CI, 0.84-5.71, P=0.11). The interaction between race and cardiology involvement in clinical care was not statistically significant for the receipt of BB prescription. Among 274 non-pregnant patients with PPCM (37.2% Black, 62.8% White), 5.8% received triple GDMT. Of these, none of the Black patients lacking cardiology care had triple GDMT. However, cardiology involvement in care was not significantly associated with triple GDMT for either race.

CONCLUSIONS

Among a commercially insured population within PPCM, race was not associated with cardiology involvement in clinical care during hospitalization. However, cardiology involvement in care was associated with significantly higher odds of prescription claims for BB for only White patients. Additional strategies are needed to support equitable GDMT prescription.

Substance Use in Pregnancy and its Association With Cardiovascular Events

Background

Substance use and cardiovascular (CV) events are increasing among pregnant women in the United States, but association between substance use in pregnancy and CV events remains unknown.

Objectives

The purpose of this study was to examine the association between substance use and acute CV events in pregnancy.

Methods

We identified all women with a delivery hospitalization between 2004 and 2018 in the Nationwide Inpatient Sample, stratified on the presence or absence of substance use. The primary outcome was any acute CV event, defined as the presence of: acute myocardial infarction, stroke, arrhythmia, endocarditis, acute cardiomyopathy or heart failure, or cardiac arrest. Secondary outcomes were individual acute CV events, major adverse cardiac events, and maternal mortality. The association between substance use and outcomes were examined using multivariable logistical regression.

Results

A total of 60,014,368 delivery hospitalizations occurred from 2004 to 2018, with substance use complicating 955,531 (1.6%) deliveries. Substance use was independently associated with CV events (adjusted odds ratio [aOR]: 1.61; 95% CI: 1.53-1.70; P < 0.001), major adverse cardiac events (aOR: 1.53; 95% CI: 1.46-1.61; P < 0.001), and maternal mortality (aOR: 2.65; 95% CI: 2.15-3.25; P < 0.001) during delivery hospitalization. All individual substances had an increased association with CV events; however, amphetamine/methamphetamine had the strongest association (aOR: 2.71; 95% CI: 2.35-3.12; P < 0.001). All substances other than cocaine and cannabis had a significant association with maternal death.

Conclusions

Substance use has a strong association with acute CV events and maternal mortality during hospitalization for delivery and women with substance use warrant increased surveillance for CV events during this time.

Screening for peripartum cardiomyopathies using artificial intelligence in Nigeria (SPEC-AI Nigeria): Clinical trial rationale and design

BACKGROUND

Artificial intelligence (AI), and more specifically deep learning, models have demonstrated the potential to augment physician diagnostic capabilities and improve cardiovascular health if incorporated into routine clinical practice. However, many of these tools are yet to be evaluated prospectively in the setting of a rigorous clinical trial-a critical step prior to implementing broadly in routine clinical practice.

OBJECTIVES

To describe the rationale and design of a proposed clinical trial aimed at evaluating an AI-enabled electrocardiogram (AI-ECG) for cardiomyopathy detection in an obstetric population in Nigeria.

DESIGN

The protocol will enroll 1,000 pregnant and postpartum women who reside in Nigeria in a prospective randomized clinical trial. Nigeria has the highest reported incidence of peripartum cardiomyopathy worldwide. Women aged 18 and older, seen for routine obstetric care at 6 sites (2 Northern and 4 Southern) in Nigeria will be included. Participants will be randomized to the study intervention or control arm in a 1:1 fashion. This study aims to enroll participants representative of the general obstetric population at each site. The primary outcome is a new diagnosis of cardiomyopathy, defined as left ventricular ejection fraction (LVEF) < 50% during pregnancy or within 12 months postpartum. Secondary outcomes will include the detection of impaired left ventricular function (at different LVEF cut-offs), and exploratory outcomes will include the effectiveness of AI-ECG tools for cardiomyopathy detection, new diagnosis of cardiovascular disease, and the development of composite adverse maternal cardiovascular outcomes.

SUMMARY

This clinical trial focuses on the emerging field of cardio-obstetrics and will serve as foundational data for the use of AI-ECG tools in an obstetric population in Nigeria. This study will gather essential data regarding the utility of the AI-ECG for cardiomyopathy detection in a predominantly Black population of women and pave the way for clinical implementation of these models in routine practice.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT05438576.

Timing and Preventability of Cardiovascular-Related Maternal Death

OBJECTIVE

To describe the clinical profile, management, and potential preventability of maternal cardiovascular deaths.

METHODS

We conducted a retrospective, descriptive study of all maternal deaths resulting from a cardiovascular disease during pregnancy or up to 1 year after the end of pregnancy in France from 2007 to 2015. Deaths were identified through the nationwide permanent enhanced maternal mortality surveillance system (ENCMM [Enquête Nationale Confidentielle sur les Morts Maternelles]). Women were classified into four groups based on the assessment of the national experts committee: those who died of a cardiac condition and those who died of a vascular condition and, within these two groups, whether the condition was known before the acute event. Maternal characteristics, clinical features and components of suboptimal care, and preventability factors, which were assessed with a standard evaluation form, were described among those four groups.

RESULTS

During the 9-year period, 103 women died of cardiac or vascular disease, which corresponds to a maternal mortality ratio from these conditions of 1.4 per 100,000 live births (95% CI 1.1-1.7). Analyses were conducted on 93 maternal deaths resulting from cardiac (n=70) and vascular (n=23) disease with available data from confidential inquiry. More than two thirds of these deaths occurred in women with no known pre-existing cardiac or vascular condition. Among the 70 deaths resulting from a cardiac condition, 60.7% were preventable, and the main preventability factor was a lack of multidisciplinary prepregnancy and prenatal care for women with a known cardiac disease. For those with no known pre-existing cardiac condition, preventability factors were related mostly to inadequate prehospital care of the acute event, in particular an underestimation of the severity and inadequate investigation of the dyspnea. Among the 23 women who died of a vascular disease, three had previously known conditions. For women with no previously known vascular condition, 47.4% of deaths were preventable, and preventability factors were related mostly to wrong or delayed diagnosis and management of acute intense chest or abdominal pain in a pregnant woman.

CONCLUSION

Most maternal deaths attributable to cardiac or vascular diseases were potentially preventable. The preventability factors varied according to the cardiac or vascular site and whether the condition was known before pregnancy. A more granular understanding of the cause and related risk factors for maternal mortality is crucial to identify relevant opportunities for improving care and training health care professionals.

Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity

Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.

Alliance for Innovation on Maternal Health: Consensus Bundle on Cardiac Conditions in Obstetric Care

Cardiac conditions are the leading cause of pregnancy-related deaths and disproportionately affect non-Hispanic Black people. Multidisciplinary maternal mortality review committees have found that most people who died from cardiac conditions during pregnancy or postpartum were not diagnosed with a cardiovascular disease before death and that more than 80% of all pregnancy-related deaths, regardless of cause, were preventable. In addition, other obstetric complications, such as preeclampsia and gestational diabetes, are associated with future cardiovascular disease risk. Those with cardiac risk factors and those with congenital and acquired heart disease require specialized care during pregnancy and postpartum to minimize risk of preventable morbidity and mortality. This bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people with cardiac conditions and to respond to cardio-obstetric emergencies. This bundle is one of several core patient safety bundles developed by the Alliance for Innovation on Maternal Health that provide condition- or event-specific clinical practices for implementation in appropriate care settings. The Cardiac Conditions in Obstetric Care bundle is organized into five domains: 1) Readiness , 2) Recognition and Prevention , 3) Response , 4) Reporting and Systems Learning , and 5) Respectful Care . This bundle is the first by the Alliance to be developed with the fifth domain of Respectful Care . The Respectful Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into elements in each domain.

Focused cardiac ultrasound in pregnancy

Cardiac disease in pregnancy is an important cause of maternal morbidity and mortality. In many high-income countries, acquired cardiac disease is now the largest cause of maternal mortality. Given its prevalence in low- and middle-income countries (LMICs), rheumatic heart disease is the most common cause of cardiac disease in pregnancy worldwide and is associated with poor maternal outcome. The diagnosis of cardiac disease in pregnancy is often delayed resulting in excess maternal morbidity and mortality. Maternal mortality review committees have suggested that prompt recognition and treatment of heart disease in pregnancy may improve maternal outcome. Given the similarities between symptoms of normal pregnancy and those of cardiac disease, the clinical diagnosis of heart disease in pregnancy is challenging with echocardiography being the primary diagnostic modality. Focused cardiac ultrasound (FOCUS) at the point of care provides supplemental data to the history and physical examination and has been demonstrated to permit early diagnosis and improvement in the management of cardiac disease in emergency medicine, intensive care, and anesthesia. It has also been demonstrated to be useful in surveillance for rheumatic heart disease in LMICs. The use of FOCUS may allow earlier and more accurate diagnosis of cardiac disease in pregnancy with the potential to decrease morbidity and mortality in both developed and developing countries.

The landscape of disparities in obstetric neurocritical care and a path forward

Health disparities in the obstetric population affect maternal morbidity and mortality. In the past years, there has been no significant improvement in disparities in care in the obstetric population. Patients who are pregnant are known to have a higher risk of pregnancy-associated neurologic conditions such as stroke and intracerebral hemorrhage. They can also experience concomitant neurocritical care disease states such as status epilepticus and traumatic brain injury. Studies exploring the disparities of care among pregnant patients who are neurotically ill are lacking. We aim to provide the landscape of disparities of care among the obstetric neurocritically-ill population and provide potential actionable opportunities to address these disparities in care.

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.

Cardiovascular Risk Assessment as a Quality Measure in the Pregnancy and Postpartum Period

Background

Cardiovascular disease (CVD) is the leading cause of maternal mortality in the United States, accounting for over one-third of all pregnancy-related deaths. Contributing factors such as lack of recognition and delayed diagnosis of CVD are primarily due to the overlap of signs and symptoms of a normal pregnancy with those of CVD.

Objectives

This study aimed to demonstrate the feasibility of introducing CVD risk assessment into clinical practice using the California Maternal Quality Care Collaborative algorithm to detect CVD during pregnancy and postpartum periods.

Methods

We implemented the CVD risk assessment algorithm into electronic health records at 3 large hospital networks serving over 14,000 patients at 23 sites. We determined the percentage of pregnant and/or postpartum patients who were screened for CVD risk and the follow-up rate for patients in whom the tool recommended a follow-up assessment. Rates were stratified according to clinical site characteristics. We obtained clinician feedback regarding the feasibility and acceptability of the tool.

Results

The rate of patients screened for CVD risk in the 3 hospital networks was 57.1%, 71.5%, and 98.7%. For those with a positive screen, follow-up rates were 65.8%, 72.5%, and 55.9% in the 3 networks. The rates of screening and follow-up varied based on the clinic size and specialty. Clinician-identified barriers were busy clinics, competing priorities, and the type of clinical practice.

Conclusions

This innovative population-based approach for universal CVD risk assessment during pregnancy is feasible and may be a helpful strategy to decrease CVD-related maternal morbidity and mortality.

Predictors and Hospital Outcomes in Pregnant Patients Undergoing Extracorporeal Membrane Oxygenation: A Nationwide Study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is increasingly used in patients with severe cardiorespiratory collapse. Although prior large database reviews of ECMO use in the peripartum population exist, they do not stratify by ECMO indication nor do they include obstetric conditions such as preeclampsia. Our objective was to characterize the incidence, indication-associated mortality, and factors associated with mortality in pregnant patients who underwent ECMO.

METHODS

We examined the United States National Inpatient Sample database to identify hospitalizations for pregnancy from January 1, 2010 to December 31, 2016. We identified pregnant patients who underwent ECMO using International Classification of Diseases ninth and tenth revisions codes. The primary outcome was in-hospital all-cause mortality across pregnant patients who underwent ECMO for any indication. We evaluated the indication for ECMO, incidence, prevalence of risk factors, comorbidities and conditions, and their association with in-hospital mortality.

RESULTS

Fifty-nine of 5'346,517 pregnant patients underwent ECMO during our study period (incidence, 1.1; 95% confidence interval [CI], 0.84-1.4 per 100,000 hospitalizations). Indications for ECMO support included respiratory failure (79.7%), cardiogenic shock (64.4%), or circulatory arrest (25.4%). Most patients (57.6%) had more than 1 indication. The overall in-hospital mortality rate was 30.5%. Mortality was 29.8% in patients with respiratory failure, 39.5% with cardiogenic shock, 46.7% with cardiac arrest, and 42.4% in those with combined diagnoses. Cardiogenic shock was associated with a significantly higher mortality rate and adjusted odds ratio 5.0 (95% CI, 1.25-27.0). Most patients (62.7%) had one or more comorbidities.

CONCLUSIONS

The frequency of ECMO use across the pregnant population was low over this time period, with a mortality rate of 1 in 3 patients. Mortality was greatest in patients with cardiogenic shock. Further work is needed to understand how best to improve ECMO outcomes in pregnant patients.

Point of care maternal ultrasound in obstetrics

Ultrasound is the hallmark imaging modality traditionally used by obstetricians for fetal diagnosis and surveillance. The COVID-19 pandemic highlighted the role of point of care ultrasound for expeditious assessment of the maternal cardiopulmonary status. The familiarity of obstetricians with ultrasound, coupled with the availability of ultrasound equipment without the need to transport the patient, make point of care ultrasound particularly valuable in the labor and delivery unit. The rising contribution of cardiopulmonary disorders to maternal morbidity and mortality carves out many potential applications for point of care ultrasound during labor and delivery. Obstetricians have access to the technology and the skills to obtain the basic views required to assess for the presence of pulmonary edema, ventricular dysfunction, or intra-abdominal free fluid. Point of care ultrasound can be used routinely for the evaluation of pulmonary complaints or in the assessment of hypotension and may play an essential role in the diagnosis and management of life-threatening emergencies such as shock, an amniotic fluid embolism, or cardiac arrest. We reviewed the currently established point of care ultrasound protocols for the evaluation of cardiopulmonary complaints through the lens of the obstetrician. We call on educators and academic leaders to incorporate maternal point of care ultrasound teachings into existing curricula. Point of care ultrasound is of enormous value for providers with limited access to diagnostic imaging or subspecialty providers. With the growing complexity of the obstetrical population, acquiring the clinical skills to meet these evolving needs is a requisite step in the ongoing efforts to reduce maternal morbidity and mortality.

Maternal Outcomes in Women with Peripartum Cardiomyopathy versus Age and Race-Matched Peers in an Urban US Community

Peripartum cardiomyopathy (PPCM) is idiopathic systolic congestive heart failure around pregnancy. Comparisons with matched controls are lacking. We investigated maternal characteristics and outcomes up to 12 months in a cohort admitted to Montefiore Health System in Bronx, New York 1999−2015 (n = 53 cases and n = 92 age and race-matched controls, >80% Black or Hispanic/Latina). Compared to peers, women with PPCM had more chronic hypertension (24.5% vs. 8.8%, p = 0.001), prior gestational hypertension (20.8% vs. 5.4%, p = 0.001), prior preeclampsia (17.0% vs. 3.3%, p = 0.001), familial dilated cardiomyopathy (5.7% vs. 0.0%, p = 0.04), smoking (15.1% vs. 2.2%, p = 0.001), lower summary socioeconomic scores (−4.12 (IQR −6.81, −2.13) vs. −1.62 (IQR −4.20, −0.74), p < 0.001), public insurance (67.9% vs. 29.3% p = 0.001), and frequent depressive symptoms. Women with PPCM were often admitted antepartum (34.0% vs. 18.5%, p = 0.001) and underwent Cesarean section (65.4% vs. 30.4%, p = 0.001), but had less preterm labor (27.3% vs. 51.1%, p = 0.001). Women were rarely treated with bromocriptine (3.8%), frequently underwent left ventricular assist device placement (9.4% and n = 2 with menorrhagia requiring transfusion and progesterone) or heart transplantation (3.8%), but there were no in-hospital deaths. In sum, women with PPCM had worse socioeconomic disadvantage and baseline health than matched peers. Programs addressing social determinants of health may be important for women at high risk of PPCM.

Association of Neighborhood Income with Clinical Outcomes Among Pregnant Patients with Cardiac Disease

Cardiovascular disease is the leading cause of pregnancy mortality. Socioeconomic and racial disparities in pregnancy are well established. Despite this, little is known about the impact of social determinants of health in pregnant patients with heart disease. This study aims to determine whether pregnant patients with heart disease living in lower income neighborhoods and managed at cardio-obstetrics programs have higher rates of cardiac events or preterm deliveries compared with those living in higher income neighborhoods. This is a retrospective cohort study of 206 patients between 2010 and 2020 at a quaternary care hospital in Northern California. The exposure was household income level based on neighborhood defined by the US Census data. Patients in lower income neighborhoods (N = 103) were 45% Hispanic, 34% White, and 14% Asian versus upper income neighborhoods (N = 103), which were 48% White, 31% Asian, and 12% Hispanic (p < 0.001). There was no significant difference in the rates of intrapartum cardiac events (10% vs. 4%; p = 0.16), postpartum cardiac events (14% vs. 17%; p = 0.7), and preterm delivery (24% vs. 17%; p = 0.23). The rates of antepartum hospitalization were higher for lower income neighborhoods (42% vs 22%; p = 0.004). While there is no significant difference in cardiac events and preterm delivery rates between patients from low versus high income neighborhoods, patients from lower income neighborhoods have higher antepartum hospitalization rates. Earlier identification of clinical deterioration provided by a cardio-obstetrics team may contribute to increased hospitalizations, which might mitigate socioeconomic disparities in outcomes for these pregnant patients with heart disease.

Arrhythmias and Heart Failure in Pregnancy: A Dialogue on Multidisciplinary Collaboration

The prevalence of CVD in pregnant people is estimated to be around 1 to 4%, and it is imperative that clinicians that care for obstetric patients can promptly and accurately diagnose and manage common cardiovascular conditions as well as understand when to promptly refer to a high-risk obstetrics team for a multidisciplinary approach for managing more complex patients. In pregnant patients with CVD, arrhythmias and heart failure (HF) are the most common complications that arise. The difficulty in the management of these patients arises from variable degrees of severity of both arrhythmia and heart failure presentation. For example, arrhythmia-based complications in pregnancy can range from isolated premature ventricular contractions to life-threatening arrhythmias such as sustained ventricular tachycardia. HF also has variable manifestations in pregnant patients ranging from mild left ventricular impairment to patients with advanced heart failure with acute decompensated HF. In high-risk patients, a collaboration between the general obstetrics, maternal-fetal medicine, and cardiovascular teams (which may include cardio-obstetrics, electrophysiology, adult congenital, or advanced HF)—physicians, nurses and allied professionals—can provide the multidisciplinary approach necessary to properly risk-stratify these women and provide appropriate management to improve outcomes.

Screening for Cardiovascular Disease in Pregnancy: Is There a Need?

Maternal mortality in the United States has been on the rise. Every year, about 700 women die from pregnancy-related complications. Cardiovascular disease (CVD) accounts for a large majority of pregnancy-related deaths driven by the lack of recognition and delays in diagnosis due to the overlap of normal pregnancy symptoms with those of CVD. Risk factors for CVD including race, advanced maternal age, hypertension, diabetes, obesity, socioeconomic status, and geographic region play an important role in CVD-related deaths. Several risk assessment models are available to stratify women with a known diagnosis of CVD. However, most women who die from CVD during pregnancy or the postpartum period do not have a prior diagnosis of CVD, and cardiomyopathy is an important contributor. The California Maternal Quality Care Collaborative (CMQCC) developed an algorithm to screen all pregnant and postpartum women to allow stratification into low or high risk for CVD. The algorithm has been validated in diverse patient populations. We propose universal CVD screening for all women in the antepartum and postpartum period to identify women at risk and to provide education and awareness for both patients and healthcare providers. This screening tool would work to reduce the increasing rates of severe maternal mortality and morbidity while having a significant impact on healthcare costs in the United States.

Heart Failure Subtypes and Cardiomyopathies in Women

Heart failure affects over 2.6 million women and 3.4 million men in the United States with known sex differences in epidemiology, management, response to treatment, and outcomes across a wide spectrum of cardiomyopathies that include peripartum cardiomyopathy, hypertrophic cardiomyopathy, stress cardiomyopathy, cardiac amyloidosis, and sarcoidosis. Some of these sex-specific considerations are driven by the cellular effects of sex hormones on the renin-angiotensin-aldosterone system, endothelial response to injury, vascular aging, and left ventricular remodeling. Other sex differences are perpetuated by implicit bias leading to undertreatment and underrepresentation in clinical trials. The goal of this narrative review is to comprehensively examine the existing literature over the last decade regarding sex differences in various heart failure syndromes from pathophysiological insights to clinical practice.

Maternal health expert feedback on the attributes of a predictive analytics tool to improve pregnancy-related cardiovascular and mental health outcomes in the United States

Identify pregnancy-related challenges and opportunities to improve maternal health care in the United States and understand the potential role of predictive analytics tool(s) in bridging the existing gaps, specifically, in CVD (cardiovascular disease) and depression. Experts in maternal health care, research, patient advocacy, CVD, psychiatry, and technology were interviewed during February and March of 2020. Additionally, published literature was reviewed to assess existing data, insights, and best practices that might help develop effective predictive analytics tool(s). The majority (78%) of the 18 experts interviewed were women. The feedback revealed several insights, including multiple barriers to diagnosis and treatment of pregnancy-related CVD and depression. In experts' collective opinion, predictive analytics could play an important role in maternal health care and in limiting pregnancy-related CVD and depression, but it must be grounded in quality data and integrate with existing health management systems. A holistic approach to maternal health that factors in racial-ethnic, regional, and socioeconomic disparities is needed that starts with preconception counseling and continues through 1 year postpartum. Predictive analytics tool(s) that are based on diverse and high-quality data could bridge some of the existing gaps in maternal health care and potentially help limit pregnancy-related CVD and depression.

Heart rate as an early predictor of severe cardiomyopathy and increased mortality in peripartum cardiomyopathy

Background

Delays in diagnosis of peripartum cardiomyopathy (PPCM) are common and are associated with worse outcomes; however, few studies have addressed methods for improving early detection.

Hypothesis

We hypothesized that easily accessible data (heart rate [HR] and electrocardiograms [ECGs]) could identify women with more severe PPCM and at increased risk of adverse outcomes.

Methods

Clinical data, including HR and ECG, from patients diagnosed with PPCM between January 1998 and July 2016 at our institution were collected and analyzed. Linear and logistic regression were used to analyze the relationship between HR at diagnosis and the left ventricular ejection fraction (LVEF) at diagnosis. Outcomes included overall mortality, recovery status, and major adverse cardiac events.

Results

Among 82 patients meeting inclusion criteria, the overall mean LVEF at diagnosis was 26 ± 11.1%. Sinus tachycardia (HR > 100) was present in a total of 50 patients (60.9%) at the time of diagnosis. In linear regression, HR significantly predicted lower LVEF (F = 30.00, p < .0001). With age‐adjusted logistic regression, elevated HR at diagnosis was associated with a fivefold higher risk of overall mortality when initial HR was >110 beats per minute (adjusted odds ratio 5.35, confidence interval 1.23–23.28), p = .025).

Conclusion

In this study, sinus tachycardia in women with PPCM was associated with lower LVEF at the time of diagnosis. Tachycardia in the peripartum period should raise concern for cardiomyopathy and may be an early indicator of adverse prognosis.

Predictors of maternal and neonatal complications in women with severe valvular heart disease during pregnancy in Tunisia: a retrospective cohort study

Background

Severe valvular heart disease, especially stenosis, is a contraindication for conception according to the World Health Organization. This is still encountered in countries with a high rheumatic fever prevalence. The objective of this study was to determine predictors of maternal cardiac, obstetric and neonatal complications in pregnant women with severe valve disease.

Methods

This is an observational retrospective cohort study of all pregnant women with severe heart valvulopathy who gave birth between 2010 and 2017.

Results

We included 60 pregnancies in 54 women. Cardiac complications occurred during 37 pregnancies (61%). In multivariate analysis, parity (aOR =2.41, 95% CI[1.12–5.16]), revelation of valvulopathy during pregnancy (aOR = 6.34; 95% CI[1.26–31.77]), severe mitral stenosis (aOR = 6.98, 95% CI[1.14–41.05],) and systolic pulmonary arterial pressure (aOR =1.08, 95% CI[1.01–1.14]) were associated with cardiac complications. Obstetrical complications were noted during 19 pregnancies (31.8%). These complications were associated with nulliparity (aOR = 5.22; 95% CI[1.15–23.6]), multiple valve disease (aOR = 5.26, 95% CI[1.19–23.2]), systolic pulmonary arterial pressure (aOR =1.04, 95% CI[1.002–1.09]), and treatment with vitamin K antagonists (aOR = 8.71, 95% CI[1.98–38.2]). Neonatal complications were noted in 39.3% of newborns (n = 61) and these were associated with occurrence of obstetric complications (aOR = 16.47, 95% CI[3.2–84.3]) and revelation of valvulopathy during pregnancy (aOR = 7.33, 95% CI[1.4–36.1]).

Conclusions

Revelation of valvular heart disease during pregnancy is a predictor of not only cardiac but also neonatal complications. Valvular heart disease screening during pre-conceptional counseling is thus crucial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04259-6.

Detecting cardiomyopathies in pregnancy and the postpartum period with an electrocardiogram-based deep learning model

Aims

Cardiovascular disease is a major threat to maternal health, with cardiomyopathy being among the most common acquired cardiovascular diseases during pregnancy and the postpartum period. The aim of our study was to evaluate the effectiveness of an electrocardiogram (ECG)-based deep learning model in identifying cardiomyopathy during pregnancy and the postpartum period.

Methods and results

We used an ECG-based deep learning model to detect cardiomyopathy in a cohort of women who were pregnant or in the postpartum period seen at Mayo Clinic. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. We compared the diagnostic probabilities of the deep learning model with natriuretic peptides and a multivariable model consisting of demographic and clinical parameters. The study cohort included 1807 women; 7%, 10%, and 13% had left ventricular ejection fraction (LVEF) of 35% or less, <45%, and <50%, respectively. The ECG-based deep learning model identified cardiomyopathy with AUCs of 0.92 (LVEF ≤ 35%), 0.89 (LVEF < 45%), and 0.87 (LVEF < 50%). For LVEF of 35% or less, AUC was higher in Black (0.95) and Hispanic (0.98) women compared to White (0.91). Natriuretic peptides and the multivariable model had AUCs of 0.85 to 0.86 and 0.72, respectively.

Conclusions

An ECG-based deep learning model effectively identifies cardiomyopathy during pregnancy and the postpartum period and outperforms natriuretic peptides and traditional clinical parameters with the potential to become a powerful initial screening tool for cardiomyopathy in the obstetric care setting.

Postpartum Respiratory Depression

Postpartum respiratory depression is a complex, multifactorial issue that encompasses a patient's baseline preexisting conditions, certain pregnancy-specific conditions or complications, as well as the iatrogenic element of various medications given in the peripartum period. In this review, we discuss many of these factors including obesity, sleep-disordered breathing, chronic lung disease, neuromuscular disorders, opioids, preeclampsia, peripartum cardiomyopathy, postpartum hemorrhage, amniotic fluid embolism, sepsis, acute respiratory distress syndrome (ARDS), and medications such as analgesics, sedatives, anesthetics, and magnesium. Current recommendations for screening, treatment, and prevention are also discussed.

Cardiovascular Disease in Pregnancy

Cardiovascular disease remains a major contributor to rising maternal morbidity and mortality. Both the pregnant woman and fetus are exposed to many potential complications as a result of the physiologic changes of pregnancy. These changes can exacerbate existing cardiac disease, as well as lead to the development of de novo issues during gestation, delivery, and the postnatal period. For women with preexisting cardiac disease, including congenital malformations, valvular disease, coronary artery disease, and aortopathies, it is crucial that they receive multidisciplinary evaluation, counseling, and optimization before conception, as well as close monitoring and medication management during pregnancy. Close monitoring is also essential for patients who develop cardiovascular complications such as preeclampsia, cardiomyopathy, congestive heart failure, coronary events, and arrhythmias during pregnancy. In addition, concerning disparities in maternal morbidity and mortality exist across many dimensions, in part because of the lack of uniformity of care in different treatment settings. Establishment of multidisciplinary cardio-obstetric teams including representatives from cardiology, anesthesia, obstetrics, maternal-fetal medicine, and specialized nursing has proven instrumental to delivering evidence-based and equitable care to high-risk patients. Multidisciplinary teams should work to guide these patients through the preconception, antepartum, delivery, and postpartum phases to ensure appropriate care for weeks to years after pregnancy.

Trends, causes and solutions of maternal mortality in Jinan, China: the epidemiology of the MMR in 1991-2020

BACKGROUND

China was one of the few countries to achieve the Millennium Development Goals 5. China had taken many effective measures to reduce maternal mortality ratio (MMR) and has achieved encouraging progress. These measures were worth sharing for other countries to reduce the MMR, but the introduction of these measures from the national perspective was too grand, and the measures implemented in a city and the results achieved were more valuable. However, there were few studies on the prevalence and trends of prolonged maternal mortality in a city. In this study, we mainly introduced the prevalence of the MMR in Jinan,China from 1991 to 2020, analyzed the causes of trends and put forward some solutions to the difficulty existing in the process of reducing the MMR,hoping to serve as a model for some developing cities to reduce MMR.

METHODS

We collected maternal mortality data from paper records, electronic files and network platforms. The time trend of MMR was tested by Cochran-Armitage Test (CAT). We divided the study period into three stages with 10 years as a stage and the Chi-square test or Fisher's exact test was used to test the difference in MMR of different periods.

RESULTS

From 1991 to 2020, We counted 1,804,162 live births and 323 maternal deaths, and the MMR was 17.93 per 100,000 live births. The MMR declined from 44.06 per 100,000 live births in 1991 to 5.94 per 100,000 live births in 2020, with a total decline of 86.52% and an annual decline of 2.89%. The MMR declined by 88.54% in rural areas, with an average annual decline 2.95%, faster than that in urban areas (82.06, 2.73%). From 1991 to 2020, the top five causes of maternal deaths were obstetric haemorrhage (4.55 per 100,000 live births), amniotic fluid embolism (3.27 per 100,000 live births), pregnancy-induced hypertension (2.61 per 100,000 live births), heart disease (2.33 per 100,000 live births) and other medical complications (2.05 per 100,000 live births). Postpartum hemorrhage, amniotic fluid embolism, pregnancy-induced hypertension showed a downward trend (P < 0.05) and other medical complications showed an upward trend (P < 0.05).

CONCLUSIONS

Subsidy for hospitalized delivery of rural women, free prenatal check-ups for pregnant women and rapid referral system between hospitals have contributed to reducing MMR in Jinan. However, it was still necessary to strengthen the treatment of obstetric hemorrhage by ensuring blood supply, reduce the MMR due to medical complications by improving the skills of obstetricians to deal with medical diseases, and reduce the MMR by strengthening the allocation of emergency equipment in county hospitals and the skills training of doctors.

Pre-pregnancy Obesity and the Risk of Peripartum Cardiomyopathy

OBJECTIVE

The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy.

STUDY DESIGN

This population-based study used linked birth record and maternal hospital discharge data from live births in California during 2007 to 2012 (n = 2,548,380). All women who had a diagnosis of peripartum cardiomyopathy during the childbirth hospitalization or who were diagnosed with peripartum cardiomyopathy during a postpartum hospital readmission within 5 months of birth were identified as cases. Pre-pregnancy body mass index (BMI, kg/m²) was classified as normal weight (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9), and obesity class 3 (≥40). Because of small numbers, we excluded women with underweight BMI, and in some analyses, we combined obesity classes into one group. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) expressing associations between BMI and peripartum cardiomyopathy, adjusted for maternal age, race/ethnicity, education, health care payer, parity, plurality, and comorbidities.

RESULTS

The overall prevalence of peripartum cardiomyopathy during hospital admissions was 1.3 per 10,000 live births (n = 320). Unadjusted ORs were 1.32 (95% CI: 1.01-1.74) for women with overweight BMI and 2.03 (95% CI: 1.57-2.62) for women with obesity, compared with women with normal pre-pregnancy BMI. Adjusted ORs were 1.26 (95% CI: 0.95-1.66) for overweight women and 1.38 (95% CI: 1.04-1.84) for women with obesity. The ORs suggested a dose-response relationship with increasing levels of obesity, but the 95% CIs for the specific classes of obesity included 1.00.

CONCLUSION

Pre-pregnancy obesity was associated with an increased risk of peripartum cardiomyopathy. These findings underscore the importance of BMI during pregnancy. There is a need to recognize the increased risk of peripartum cardiomyopathy in women with high BMI, especially in the late postpartum period.

KEY POINTS

· Pre-pregnancy obesity affects maternal health.. · Effects may extend to peripartum cardiomyopathy.. · The risk includes peripartum cardiomyopathy that emerges postpartum..

Cardiovascular Deaths in Pregnancy: Growing Concerns and Preventive Strategies

There has been an increase in maternal deaths from cardiovascular disease in many countries. In high-income countries, cardiovascular deaths secondary to cardiomyopathies, ischemic heart disease, sudden arrhythmic deaths, aortic dissection, and valve disease are responsible for up to one-third of all pregnancy-related maternal deaths. In low- and middle-income countries, rheumatic heart disease is a much more common cause of cardiac death during pregnancy. Although deaths occur in women with known heart conditions or cardiovascular risk factors such as hypertension, many women present for the first time in pregnancy with unrecognised heart disease or with de novo cardiovascular conditions such as preeclampsia, peripartum cardiomyopathy, spontaneous coronary artery dissection. Not only has maternal cardiovascular mortality increased, but serious cardiac morbidity, or "near misses," during pregnancy also have increased in frequency. Although maternal morbidity and mortality are often preventable, many health professionals remain unaware of the impact of cardiovascular disease in this population, and the lack of awareness contributes to inappropriate care and preventable deaths. In this review, we discuss the maternal mortality from cardiovascular causes in both high- and low- and middle-income countries and strategies to improve outcomes.

Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016‒2017

Objectives. To better understand racial and ethnic disparities in US maternal mortality. Methods. We analyzed 2016-2017 vital statistics mortality data with cause-of-death literals (actual words written on the death certificate) added. We created a subset of confirmed maternal deaths that had pregnancy mentions in the cause-of-death literals. Primary cause of death was identified and recoded using cause-of-death literals. We examined racial and ethnic disparities both overall and by primary cause. Results. The maternal mortality rate for non-Hispanic Black women was 3.55 times that for non-Hispanic White women. Leading causes of maternal death for non-Hispanic Black women were eclampsia and preeclampsia and postpartum cardiomyopathy with rates 5 times those for non-Hispanic White women. Non-Hispanic Black maternal mortality rates from obstetric embolism and obstetric hemorrhage were 2.3 to 2.6 times those for non-Hispanic White women. Together, these 4 causes accounted for 59% of the non-Hispanic Black‒non-Hispanic White maternal mortality disparity. Conclusions. The prominence of cardiovascular-related conditions among the leading causes of confirmed maternal death, particularly for non-Hispanic Black women, necessitates increased vigilance for cardiovascular problems during the pregnant and postpartum period. Many of these deaths are preventable.

Delivering Coordinated Cardio-Obstetric Care from Preconception through Postpartum

Coordinated preconception through postpartum cardio-obstetrics care is necessary to optimize both maternal and fetal health. Maternal mortality in the United States is increasing, largely driven by increasing cardiovascular (CV) disease burden during pregnancy and needs to be addressed emergently. Both for women with congenital and acquired heart disease, CV complications during pregnancy are associated with increased future risk of CV disease. Comprehensive cardio-obstetrics care is a powerful way of ensuring that women's CV risks before and during pregnancy are appropriately identified and treated and that they remain engaged in CV care long term to prevent future CV complications.

Obstetric Anesthesia and Heart Disease: Practical Clinical Considerations

Maternal morbidity and mortality as a result of cardiac disease is increasing in the United States. Safe management of pregnancy in women with heart disease requires appropriate anesthetic, cardiac, and obstetric care. The anesthesiologist should risk stratify pregnant patients based upon cardiac disease etiology and severity in order to determine the appropriate type of hospital and location within the hospital for delivery and anesthetic management. Increased intrapartum hemodynamic monitoring may be necessary and neuraxial analgesia and anesthesia is typically appropriate. The anesthesiologist should anticipate obstetric and cardiac emergencies such as emergency cesarean delivery, postpartum hemorrhage, and peripartum arrhythmias. This clinical review answers practical questions for the obstetric anesthesiologist and the nonsubspecialist anesthesiologist who regularly practices obstetric anesthesiology.

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.

Causes contributing to the excess maternal mortality risk for women 35 and over, United States, 2016-2017

To better understand age-related disparities in US maternal mortality, we analyzed 2016-2017 vital statistics mortality data with cause-of-death literal text (actual words written on the death certificate) added. We created a subset of confirmed maternal deaths which had pregnancy mentions in the cause-of-death literals. Primary cause of death was identified and recoded using cause-of-death literals. Age-related disparities were examined both overall and by primary cause. Compared to women <35, the 2016-2017 US maternal mortality rate was twice as high for women aged 35-39, four times higher for women aged 40-44, and 11 times higher for women aged 45-54 years. Obstetric hemorrhage was the leading cause of death for women aged 35+ with rates 4 times higher than for women <35, followed by postpartum cardiomyopathy with a 3-fold greater risk. Obstetric embolism, eclampsia/preeclampsia, and Other complications of obstetric surgery and procedures each had a two-fold greater risk of death for women aged 35+. Together these 5 causes of death accounted for 70.9% of the elevated maternal mortality risk for women aged 35+. The excess maternal mortality risk for women aged 35+ was focused among a few causes of death and much of this excess mortality is preventable. Early detection and treatment, as well as continued care during the postpartum year is critical to preventing these deaths. The Alliance for Innovation on Maternal Health has promulgated patient safety bundles with specific interventions that health care systems can adopt in an effort to prevent these deaths.

Pregnancy-related death disparities in non-Hispanic Black women

While the rate of pregnancy-related death steadily increases in the United States, this tragic outcome is disproportionately devastating US-born non-Hispanic Black women at a rate that is three to four times that of their White and non-Black Hispanic counterparts. These disparities persist despite controlling for variables such as socioeconomic status, education levels, and geographical location. Pregnancy-related deaths in Black women are largely cardiovascular in etiology, and while these complications also occur in women of other ethnic backgrounds, they often are more severe and more deadly in Black women. This population often lacks adequate prenatal care likely because they face personal and structural barriers. Reversal of barriers during the prenatal period, the implementation of medical protocols during delivery, and the assurance of close follow-up during the postpartum year are vital in improving outcomes. This article will detail seven specific concerns within perinatal care and pregnancy-related death, and offer potential solutions to addressing them. Pregnancy-related death in Black women is not as an isolated event, but rather is one adverse outcome that exists on a broad spectrum of adverse outcomes. Now is the time to reckon with the reality that our nation’s Black women are dying at a disproportionate rate compared to women of other ethnicities due to pregnancy-related complications and suffering lifelong consequences even if they escape this fatal outcome. This is a call to action to understand this deeply devastating, multi-factorial issue so we may strive to eliminate this highly preventable and tragic event altogether.

Long-Term Cardiovascular Outcomes After Pregnancy in Women With Heart Disease

Background

Women with heart disease are at risk for pregnancy complications, but their long‐term cardiovascular outcomes after pregnancy are not known.

Methods and Results

We examined long‐term cardiovascular outcomes after pregnancy in 1014 consecutive women with heart disease and a matched group of 2028 women without heart disease. The primary outcome was a composite of mortality, heart failure, atrial fibrillation, stroke, myocardial infarction, or arrhythmia. Secondary outcomes included cardiac procedures and new hypertension or diabetes mellitus. We compared the rates of these outcomes between women with and without heart disease and adjusted for maternal and pregnancy characteristics. We also determined if pregnancy risk prediction tools (CARPREG [Canadian Cardiac Disease in Pregnancy] and World Health Organization) could stratify long‐term risks. At 20‐year follow‐up, a primary outcome occurred in 33.1% of women with heart disease, compared with 2.1% of women without heart disease. Thirty‐one percent of women with heart disease required a cardiac procedure. The primary outcome (adjusted hazard ratio, 19.6; 95% CI, 13.8–29.0; P<0.0001) and new hypertension or diabetes mellitus (adjusted hazard ratio, 1.6; 95% CI, 1.4–2.0; P<0.0001) were more frequent in women with heart disease compared with those without. Pregnancy risk prediction tools further stratified the late cardiovascular risks in women with heart disease, a primary outcome occurring in up to 54% of women in the highest pregnancy risk category.

Conclusions

Following pregnancy, women with heart disease are at high risk for adverse long‐term cardiovascular outcomes. Current pregnancy risk prediction tools can identify women at highest risk for long‐term cardiovascular events.

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.

Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 1/5

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.