American College of Obstetricians and Gynecologists' Presidential Task Force on Pregnancy and Heart Disease and Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease

Risk factors for emergency department visits and readmissions for postpartum hypertension

OBJECTIVE

Postpartum hypertension accounts for 15 to 20% of postpartum Emergency Department (ED) visits and readmissions in the United States. Postpartum readmission is a quality metric and target of quality improvement as it indicates poor control of hypertension and can portend increased morbidity. We aim to evaluate risk factors for postpartum ED visits and readmissions for hypertension.

METHODS

This was a retrospective cohort study of all birthing patients with peripartum hypertension at a single tertiary care center over a 5-year period (2017-2022). Inclusion criteria were age 18 years or above, existing diagnosis of chronic hypertension or hypertensive disease of pregnancy diagnosed during the intrapartum or postpartum course, and both delivery and ED visit or readmission at the study institution. Maternal baseline and intrapartum characteristics were chart abstracted. Primary outcome was ED visit or readmission (EDR) for postpartum hypertension. Patients who had EDR within 42 days of delivery were compared to those who underwent routine outpatient surveillance. For all analyses, p values were two-way, and the level of statistical significance was set at p < 0.05.

RESULTS

Of 16,162 patients who gave birth during the study period, 2403 (14.9%) patients met the definition of peripartum hypertension. 218 (9.1%) presented to the ED or were readmitted for hypertension. Risk factors for EDR were as follows: maternal age ≥40 years (22.9% vs 15.3%, p = 0.003), prenatal aspirin use (6.9% vs 3.9%, p = 0.039), cesarean delivery (42.7% vs 35.8%, p = 0.044), chronic hypertension (37.2% vs 31.6%, p = 0.029), preeclampsia with severe features (32.6% vs 15.6%, p < 0.001), postpartum hemorrhage (22.9% vs 12.0%, p < 0.001), and intrapartum need for intravenous anti-hypertensives (23.9% vs 3.3%, p < 0.001). Factors at discharge that increased risk of EDR included prescription of anti-hypertensives at discharge (27.5% vs 8.6%, p < 0.001) and having >50% elevated blood pressures within the 24 h prior to discharge (16.5% vs 11.9%, p = 0.046). In a multivariable logistic regression controlling for prenatal aspirin use, mode of delivery, postpartum hemorrhage, and chorioamnionitis, a higher risk of EDR remained for maternal age ≥40 years (aOR, 1.56; 95% confidence interval (CI), 1.11-2.20; p = 0.011), PO anti-hypertensives at discharge (aOR, 4.05; 95% CI, 2.86-5.73; p < 0.001), preeclampsia with severe features (aOR, 2.50; 95% CI, 1.83-3.42; p < 0.001), and history of IV anti-hypertensive exposure (aOR, 9.30; 95% CI, 6.20-13.95; p < 0.001).

CONCLUSIONS

Maternal age of 40 years and above, chronic hypertension, preeclampsia with severe features, prescription of anti-hypertensives on discharge, and elevated blood pressures leading up to discharge are associated with postpartum ED visits or readmissions for hypertension. Risk factor identification can aid in the development of predictive tools to determine high risk groups and interventions to reduce ED visits and readmissions.

Pregnancy, aortic events, and neonatal and maternal outcomes

BACKGROUND AND AIMS

This study aimed to evaluate the association between pregnancy and aortic complications and determine related maternal and neonatal outcomes.

METHODS

Records of pregnancies and neonatal deliveries from the Taiwan National Health Insurance Research Database from 2000 to 2020 were retrieved. The incidence rate ratio (IRR) was calculated to evaluate the risk factors for aortic events. Survival analysis was conducted to compare maternal and neonatal mortality with and without aortic events.

RESULTS

A total of 4 785 266 pregnancies were identified among 2 833 271 childbearing women, and 2 852 449 delivered neonates. In the vulnerable and control periods, 57 and 20 aortic events occurred, resulting in incidence rates of 1.19 and 0.42 aortic events per 100 000 pregnancies, respectively. Pregnancy was established as a risk factor for aortic events (IRR: 2.86, P < .001). The 1-year maternal mortality rate was significantly higher in pregnancies with aortic events than in those without such events (19.3% vs. 0.05%, P < .001). Neonates whose mothers experienced aortic events had a higher late mortality (6.3% vs. 0.6%, P < .001).

CONCLUSIONS

The association between pregnancy and aortic events was established in this study. The results revealed that women are at risk of aortic events from the gestational period to 1-year postpartum. Maternal mortality was significantly higher in pregnancies with aortic events than in those without. A higher late mortality and more complications were noted for neonatal deliveries with maternal aortic events. Early awareness of pregnant women at risk of aortic events-especially those with concomitant hypertensive disorders of pregnancy, contributive family histories, or aortopathy-is crucial.

Hospitalization for cardiovascular disease in the year after delivery of twin pregnancies

BACKGROUND AND AIMS

Increased cardiovascular demand in twin pregnancies, even those without hypertensive disease of pregnancy (HDP), may pose a greater risk for cardiovascular complications compared with singletons. In this study, the risk of cardiovascular disease (CVD)-related hospitalizations and mortality within the year following delivery in relation to HDP was compared between twin and singleton pregnancies.

METHODS

Using the Nationwide Readmissions Database of US hospitals from 2010 to 2020, the rates of CVD readmission in four exposure groups (twin deliveries with and without HDP and singleton deliveries with and without HDP) were estimated. Cox proportional hazard regression models were used to determine associations with singletons without HDP as the reference.

RESULTS

Of 36 million delivery hospitalizations, the rates of CVD readmission in twin and singleton pregnancies were 1105.4 and 734.1 per 100 000 delivery admissions, respectively. Compared with singletons without HDP, the adjusted hazard ratio (HR) of CVD readmission was highest for twins with HDP [HR 8.21, 95% confidence interval (CI) 7.48-9.01], followed by singletons with HDP (HR 5.89, 95% CI 5.70-6.08) and then twins without HDP (HR 1.95, 95% CI 1.75, 2.17).

CONCLUSIONS

Compared with singletons without HDP, twin pregnancies, even in the absence of HDP, are associated with increased risks for CVD complications in the first year post-partum. These findings highlight the increased strain twin pregnancies place on the maternal cardiovascular system. These findings advocate the need for appropriate pre-conception counselling for those with cardiovascular risk factors undergoing infertility treatment, which increase the risks of multi-foetal gestation, and increased post-partum surveillance in twin pregnancies.

Pregnancy-related chronic type A aortic dissection highlights the importance of thorough prenatal maternal examination

BACKGROUND

Aortic dissection occurs rarely during pregnancy but carries a significantly high vital risk for both the mother and the fetus. Early diagnosis and treatment are critical for a successful outcome.

CASE PRESENTATION

A 32-year-old pregnant woman at 31 weeks of gestation began experiencing shortness of breath, chest pain, and palpitations, which were attributed to an anxiety disorder she had been previously diagnosed with. The symptoms continued to worsen following the delivery when a chest computed tomography investigation revealed signs of chronic type A aortic dissection and an 80 mm post-dissection aneurysm of the ascending aorta. Aortic repair via composite aortic root replacement surgery (Bentall procedure) and partial aortic arch replacement was performed. The patient's postoperative evolution was notable for a series of complications.

CONCLUSIONS

Our report highlights the importance of thorough maternal examination during pregnancy. The high mortality rates associated with aortic dissection occurring in pregnant women and the possibility of missed intervention due to atypical clinical presentation warrant the need for standardized international protocols aimed at the prevention and timely diagnosis of prenatal aortic disease.

Hemodynamic Preservation Using Remimazolam in a Heart Failure Parturient Undergoing a Dilation and Curettage: A Case Report

We report a case of a parturient with severe cardiac disease requiring elective termination of pregnancy. The patient underwent successfully monitored anesthesia care using remimazolam for dilation and curettage. The patient remained hemodynamically stable and appropriately sedated while achieving optimal procedural conditions. Remimazolam is an ultrashort acting benzodiazepine that is being used with increasing frequency in short procedures requiring sedation. Patients with complex cardiac comorbidities undergoing surgical procedures may receive maximum benefit from this novel medication due to its stable hemodynamic profile and rapid metabolism.

Relationship Between Race, Predelivery Cardiology Care, and Cardiovascular Outcomes in Preeclampsia/Eclampsia Among a Commercially Insured Population

BACKGROUND

It is unknown whether predelivery cardiology care is associated with future risk of major adverse cardiovascular events (MACE) in preeclampsia/eclampsia (PrE/E). We sought to determine the cumulative incidence of MACE by race and whether predelivery cardiology care was associated with the hazard of MACE up to 1 year post-delivery for Black and White patients with PrE/E.

METHODS

Using Optum's de-identified Clinformatics Data Mart Database, we identified Black and White patients with PrE/E who had a delivery between 2008 and 2019. MACE was defined as the composite of heart failure, acute myocardial infarction, stroke, and death. Cumulative incidence functions were used to compare the incidence of MACE by race. Regression models were used to assess the hazard of MACE by cardiology care for each race. Separate hazards were calculated for the first 14 days and the remainder of the year.

RESULTS

Among 29 336 patients (83.4% White patients, 16.6% Black patients, 99.5% commercially insured, mean age: 30.9 years) with PrE/E, 11.2% received cardiology care (10.9% White patients, 13.0% Black patients). Black patients had higher incidence of MACE than White patients at 1 year post-delivery (2.7% versus 1.4%) with the majority within 14 days of delivery (Black patients: 58.7%; White patients: 67.8%). After adjusting for age and comorbidities, receipt of cardiology care was associated with a lower hazard of MACE for White patients within 14 days after delivery (hazard ratio, 0.31 [95% CI, 0.21-0.46]; P<0.001) but not Black patients (hazard ratio, 1.00 [95% CI, 0.60-1.67]; P=0.999). The effect of the interaction between race and cardiology care was significant in the first 14 days (P<0.001) but not the remainder of the year (P=0.56).

CONCLUSIONS

Among a well-insured population of patients with PrE/E, Black patients had a higher cumulative incidence of MACE up to a year post-delivery. Cardiology care was associated with a lower hazard of MACE only for White patients during the first 14 days after delivery.

Maternal Risk Conditions and Outcomes by Levels of Maternal Care

Objectives: To (1) determine associations between maternal risk conditions and severe adverse outcomes that may benefit from risk-appropriate care and (2) assess whether associations between risk conditions and outcomes vary by level of maternal care (LoMC). Methods: We used the 2017-2019 National Inpatient Sample (NIS) to calculate associations between maternal risk conditions and severe adverse outcomes. Risk conditions included severe preeclampsia, placenta accreta spectrum (PAS) conditions, and cardiac conditions. Outcomes included disseminated intravascular coagulation (DIC) with blood products transfusion or shock, pulmonary edema or acute respiratory distress syndrome (ARDS), stroke, acute renal failure, and a composite cardiac outcome. Then we used 2019 delivery hospitalization data from five states linked to hospital LoMC. We calculated associations between risk conditions and outcomes overall and stratified by LoMC and assessed for effect modification by LoMC. Results: We found positive measures of association between risk conditions and outcomes. Among patients with severe preeclampsia or PAS, the magnitudes of the associations with DIC with blood products transfusion or shock, pulmonary edema or ARDS, and acute renal failure were lower in Level III/IV compared with Collapse

Key Words

• maternal health
• maternal morbidity
• maternal severe morbidity and mortality
• pregnancy outcomes
• risk-appropriate care

Collapse

MESH Headings

• Humans
• Female
• Pregnancy
• Adult
• Pregnancy Complications/epidemiology
• Risk Factors
• Maternal Health Services/statistics & numerical data
• United States/epidemiology
• Pregnancy Outcome/epidemiology

Collapse

Grants Collapse

Affiliation(s)

Carla L DeSisto Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Alexander C Ewing Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Hafsatou Diop Division of MCH Research and Analysis, Massachusetts Department of Public Health, Boston, Massachusetts, USA
Sarah Rae Easter Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
Elizabeth Harvey Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA Division of Family Health and Wellness, Tennessee Department of Health, Nashville, Tennessee, USA
Debra J Kane Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA Iowa Department of Health and Human Services, Division of Community Access, Wellness and Prevention Branch, Bureau of Family Health, Des Moines, Iowa, USA
Miriam Naiman-Sessions Early Childhood and Family Support Division, Montana Department of Public Health and Human Services, Helena, Montana, USA
Godwin Osei-Poku Betsy Lehman Center for Patient Safety, Boston, Massachusetts, USA
Melanie Riley West Virginia Perinatal Partnership, Charleston, West Virginia, USA
Birgit Shanholtzer West Virginia Health Statistics Center, Charleston, West Virginia, USA
Audrey M Stach Division of Family Health and Wellness, Tennessee Department of Health, Nashville, Tennessee, USA
Ramya Dronamraju Maternal and Infant Health, Association of State and Territorial Health Officials, Arlington, Virginia, USA
Andrea Catalano Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Elizabeth A Clark Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Sabrina A Madni Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Lindsay S Womack Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Elena V Kuklina Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
David A Goodman Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Sarah J Kilpatrick Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
M Kathryn Menard Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA

Collapse

Patient-Reported Pregnancy Outcomes and Survival in Women with Aortic Valve and/or Aortic Root Replacement

Background: Our objective was to investigate patient-reported maternal and perinatal outcomes and survival among women undergoing aortic valve and/or aortic root replacement (AVR/ARR). Methods: This was a single-center observational study of U.S. women identified in our surgical/obstetric databases who underwent AVR/ARR between 1967 and 2019. Available, consenting patients participated in a telephone survey detailing patient-reported outcomes. The status of remaining individuals was verified through the Alabama Department of Public Health. Date of death, immediate and underlying cause of death, and death location were abstracted from death certificates. Results: Of 317 patients, 72 were confirmed living, 86 were deceased, and 159 were of unknown status. Mean age at first aortic valve replacement was 43 years. Of patients with known status (n = 158), 33% were Black, and the majority received a mechanical valve (58%). Of 57 participants completing the survey, reported complications included miscarriage (30%), preterm birth (12%), preeclampsia (14%), antepartum maternal intensive care unit admissions (6%), and congenital heart disease in the neonate (8%). Most pregnancies preceded AVR (78%). Among 86 decedents, the average age of death was 52.5 years; the average time from AVR/ARR to death was 7 years. Of those who died, a higher proportion were Black (75%) and had aortic insufficiency (72%). Conclusions: Patients who underwent aortic valve surgery report high rates of maternal and perinatal complications, and death certificate data confirm high rates of racial disparities and death within a decade of surgery. Interventions are urgently needed to improve maternal and perinatal outcomes in individuals with aortic valve disease and to eliminate preventable racial disparities.

Delivery-Related Maternal Morbidity and Mortality Among Patients With Cardiac Disease

OBJECTIVE

To assess the risk of severe maternal morbidity (SMM) and mortality among pregnant patients with cardiovascular disease (CVD).

METHODS

This was a retrospective cohort study of U.S. delivery hospitalizations from 2010 to 2020 using weighted population estimates from the National Inpatient Sample database. The primary objective was to evaluate the risk of SMM and maternal mortality among patients with CVD at delivery hospitalization. International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes were used to identify delivery hospitalizations, CVD, and SMM events. Multivariable logistic regression analyses were performed to compare SMM and mortality risk among patients with CVD and those without CVD. Given the substantial racial and ethnic disparities in SMM, mortality, and CVD burden, secondary objectives included evaluating SMM and mortality across racial and ethnic groups and assessing the population attributable fraction within each group. Lastly, subgroup analyses of SMM by underlying CVD diagnoses (eg, congenital heart disease, chronic heart failure) were performed. Variables used in the regression models included socioeconomic and demographic maternal characteristics, maternal comorbidities, and pregnancy-specific complications.

RESULTS

Among 38,374,326 individuals with delivery hospitalizations, 203,448 (0.5%) had CVD. Patients with CVD had an increased risk of SMM (11.6 vs 0.7%, adjusted odds ratio [aOR] 12.5, 95% CI, 12.0-13.1) and maternal death (538 vs 5 per 100,000 delivery hospitalizations, aOR 44.1, 95% CI, 35.4-55.0) compared with those without CVD. Patients with chronic heart failure had the highest SMM risk (aOR 354.4, 95% CI, 301.0-417.3) among CVD categories. Black patients with CVD had a higher risk of SMM (aOR 15.9, 95% CI, 14.7-17.1) than those without CVD with an adjusted population attributable fraction of 10.5% (95% CI, 10.0-11.0%).

CONCLUSION

CVD in pregnancy is associated with increased risk of SMM and mortality, with the highest risk of SMM among patients with chronic heart failure. Although CVD affects less than 1% of the pregnant population, it contributes to nearly 1 in 10 SMM events in the United States.

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.

Pregnancy-Related Mortality Due to Cardiovascular Conditions: Maternal Mortality Review Committees in 32 U.S. States, 2017 to 2019

Background

Cardiomyopathy (CM) and other cardiovascular conditions (OCVs) are among the most frequent causes of pregnancy-related death in the United States.

Objectives

The purpose of this paper was to report demographic and clinical characteristics, preventability, contributing factors, and Maternal Mortality Review Committee (MMRC) recommendations among pregnancy-related deaths with underlying causes of CM, OCVs, and the 2 combined (cardiovascular conditions, CV).

Methods

We analyzed pregnancy-related death data from MMRCs in 32 states, occurring during 2017 to 2019, with MMRC-determined underlying causes of CVs. We describe distributions of demographic characteristics, present the most frequent contributing factor classes, and provide example MMRC prevention recommendations.

Results

Among 210 pregnancy-related deaths due to CVs, 84 (40%) were due to CM and 126 (60%) to OCVs. More than half (51.2%) of CM deaths were among non-Hispanic Black persons. Two-thirds (66%) of all CV deaths occurred among people <35 years old. Approximately 53% of CM deaths and 31% of OCV deaths occurred 43 to 365 days postpartum. Over 75% of pregnancy-related deaths due to CVs were determined by MMRCs to be preventable. The 5 most frequent contributing factor classes accounted for 50% of the total MMRC-identified contributing factors. MMRC prevention recommendations occur at multiple levels.

Conclusions

Most pregnancy-related deaths due to CM and OCV are preventable. Example MMRC recommendations provided in this report illustrate prevention opportunities that address contributing factors, including broader awareness of urgent warning signs, improved handoffs for care coordination and continuity, and expanded accessibility of community-based comprehensive and integrated care services.

A Tool to Help Nurses Provide Health Education on Adverse Pregnancy Outcomes and Cardiovascular Health

Adverse pregnancy outcomes are associated with poor short- and long-term cardiovascular health. However, patients and their health care providers may not have knowledge of this risk or of the healthful practices that can reduce this risk. Childbirth care can be a pivotal time in the patient-clinician relationship to build awareness and spur prevention planning. As part of the American Heart Association-supported program entitled Providing an Optimized and Empowered Pregnancy for You (P3OPPY), our team collaborated with a community advisory board to create a teaching handout about adverse pregnancy outcomes for incorporation into hospital-based postpartum care. This handout can be used by pregnancy and maternity care providers, including postpartum nurses, to provide health education on how adverse pregnancy outcomes can influence risk for future cardiovascular disease and what can be done for prevention.

Reach and effectiveness of a non-university cardio-obstetrics program

BACKGROUND

Current guidelines recommend multidisciplinary cardiovascular obstetric programs (CVOB) to manage complex pregnant patients with cardiovascular disease. Minimal evaluation of these programs exists, with most of these programs offered at university-based centers.

METHODS

A cohort of 113 patients managed by a CVOB team at a non-university health system (2018-2019) were compared to 338 patients seen by cardiology prior to the program (2016-2017). CVOB patients were matched with comparison patients (controls) on modified World Health Organization (mWHO) category classification, yielding a cohort of 102 CVOB and 102 controls.

RESULTS

CVOB patients were more ethnically diverse and cardiovascular risk was higher compared to controls based on mWHO ≥ II-III (57% vs 17%) and. After matching, CVOB patients had more cardiology tests during pregnancy (median of 8 tests vs 5, p < .001) and were more likely to receive telemetry care (32% vs 19%, p = .025). The median number of perinatology visits was significantly higher in the CVOB group (8 vs 2, p < .001). Length of stay was a half day longer for vaginal delivery patients in the CVOB group (median 2.66 vs 2.13, p = .006).

CONCLUSION

Implementation of a CVOB program resulted in a more diverse patient population than previously referred to cardiology. The CVOB program participants also experienced a higher level of care in terms of increased cardiovascular testing, monitoring, care from specialists, and appropriate use of medications during pregnancy.

Cardiomyopathies in Pregnancy: Trends and Clinical Outcomes in Delivery Hospitalizations in the United States (2005-2020)

BACKGROUND

Cardiomyopathy (CDM) in pregnancy is associated with maternal morbidity and mortality.

OBJECTIVES

To explore trends and clinical outcomes in CDM subtypes during delivery hospitalizations.

METHODS

We used the National Inpatient Sample database to identify delivery hospitalizations between 2005-2020 by CDM subtypes: peripartum (PPCM), dilated (DCM), hypertrophic (HCM), and restrictive (RCM). Maternal and fetal outcomes were identified using International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes. Baseline characteristics and temporal trends of CDM subtypes were analyzed. Maternal cardiovascular, pregnancy, and fetal outcomes were evaluated by CDM subtype using univariate logistic regression. The primary outcome was in-hospital mortality.

RESULTS

During 2005-2020, 37,125 out of 61,811,842 delivery hospitalizations were complicated by CDM. Among CDM-related delivery hospitalizations, the most prevalent were DCM (46%), followed by PPCM (45.6%), HCM (4.6%), and RCM (3.9%). The rates of in-hospital mortality (1.7%), adverse cardiovascular events such as acute heart failure (17%), cardiogenic shock (3.4%), and cardiac arrest (3.1%), and adverse pregnancy outcomes such as preeclampsia (14.2%) and preterm labor (11%), were highest among PPCM (all p < 0.0001). The prevalence of PPCM (49.1% to 38.5%) decreased while the prevalence of HCM (2.7% to 8.8%) and DCM (48% to 52.2%) increased over time.

CONCLUSIONS

Over a 15-year period, PPCM had higher rates of in-hospital mortality, cardiovascular events, and adverse pregnancy outcomes compared to other CDM subtypes. While the prevalence of PPCM decreased over time, the prevalence of HCM and DCM increased. Hence, further research on cardiomyopathies during pregnancy and prospective studies on this vulnerable patient cohort are urgently needed.

Extracorporeal membrane oxygenation: unmet needs and perspectives

Extracorporeal Membrane Oxygenation (ECMO) has become an essential lifesaving intervention for individuals with severe cardiovascular and respiratory failure. Its application is expanding across several therapeutic contexts, surpassing conventional indications. The COVID-19 pandemic has significantly stressed worldwide health systems to manage acute respiratory failure. ECMO has been employed as a vital intervention, particularly for patients with severe COVID-19-induced acute respiratory distress syndrome (ARDS). ECMO is applicable throughout pregnancy. The principal indications for ECMO in pregnant women align with those in the general population. However, pregnancy complicates issues, necessitating consideration of both mother's and infant's well-being. Patients with systemic rheumatic diseases are prone to experience life-threatening complications. While a majority of these patients respond to immunosuppressive drugs, a small percentage suffer organ failure and may benefit from ECMO as a bridge to recovery. The article addresses coagulation therapies, highlighting the necessity of precise anticoagulation to avert both bleeding and thrombosis, particularly in patients requiring extended ECMO support. Additionally, the pharmacokinetics of antibiotics in ECMO patients are summarized, including the influence of the ECMO circuit on drug metabolism. Survey-based research offers valuable insights into ECMO use, procedures, and challenges. The paper evaluates current survey-based research and ECMO guidelines, highlighting clinical practice, training, and resource availability discrepancies across ECMO centers globally. Particular focus is placed on the rehabilitation requirements of ECMO survivors, acknowledging the importance of early mobilization and post-discharge care in improving long-term outcomes and quality of life.

A practical approach to the diagnosis and initial management of acute right ventricular failure during pregnancy using point-of-care ultrasound

Acute right ventricular failure is a critical condition in pregnancy that can lead to severe maternal and fetal complications. This expert review discusses the instrumental role of point-of-care ultrasound in diagnosing and managing ARVF in pregnant patients, highlighting its benefits for immediate clinical decision-making in obstetric emergencies. The unique physiological changes during pregnancy, such as increased blood volume and cardiac output, can exacerbate underlying or latent cardiac issues, making pregnant patients particularly susceptible to acute right ventricular failure. Common causes during pregnancy include pulmonary embolism, peripartum cardiomyopathy, and congenital heart diseases, each presenting distinct challenges in diagnosis and management. The real-time capability of point-of-care ultrasound allows for the immediate assessment of right ventricular size and function, evaluation of fluid status via the inferior vena cava, and identification of potential pulmonary embolism, offering a non-invasive, rapid, and dynamic diagnostic tool right at the bedside. The expert review details specific point-of-care ultrasound techniques adapted for pregnant patients, including the parasternal long and short axis and apical 4-chamber view, essential for evaluating right heart function and guiding acute management strategies. These include fluid management, adjustment of pharmacological treatment, and immediate interventions to support cardiac function and reduce ventricular overload. Point-of-care ultrasound enhances clinical outcomes by allowing clinicians to make informed decisions quickly, reducing the time to intervention, and tailoring management strategies to individual patient needs. However, despite its apparent advantages, the adoption of point-of-care ultrasound requires specialized training and familiarity with obstetric-specific protocols. This review advocates for the integration of point-of-care ultrasound into standard obstetric care protocols, emphasizing the need for clear guidelines and structured protocols that equip healthcare providers with the skills necessary to utilize this technology effectively. Future research should aim to refine these protocols and expand the evidence base to solidify the role of point-of-care ultrasound in improving maternal and fetal outcomes in acute right ventricular failure.

CardioMEMS as an aid to the management of a pregnant patient with peripartum Cardiomyopathy: A case report

Pregnancy with history of peripartum cardiomyopathy, residual left ventricular dysfunction is associated with high maternal and neonatal morbidity and mortality. Remote monitoring of pulmonary artery pressure and vital signs have been utilized in clinical settings to manage select patients with heart failure. However, data of using these systems to aid clinical management in pregnancy remains unexplored. To our knowledge, this case report is the first to describe successful management of a 31-year-old pregnant patient with history of peripartum cardiomyopathy, severe left ventricular dysfunction and pulmonary embolism using the CardioMEMS device throughout pregnancy. CardioMEMS system provided continuous remote hemodynamic monitoring during pregnancy, aiding in the management of this high-risk patient. The device's ability to provide real-time data allowed for correlation between symptoms and hemodynamics, allowing for prompt adjustments in treatment, ensuring stability throughout the pregnancy. This patient was able to avoid hospital admissions and successfully deliver a healthy baby via vaginal delivery. This report highlights the potential benefits of utilizing CardioMEMS in clinical management of such patients.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Echocardiography for Management of Cardiovascular Disease in Pregnancy

PURPOSE OF REVIEW

Cardiovascular disease (CVD) continues to be a leading contributor to maternal mortality and morbidity. Echocardiography is an essential tool for patients with suspected and known CVD to establish symptom etiology, treatment strategy, and prognosis. We summarize the current status of conventional and novel techniques for assessment of CVD during pregnancy.

RECENT FINDINGS

Conventional techniques are still useful for evaluation of known or suspected CVD. Advanced technology using speckle tracking continues to evolve and is increasingly applied for diagnosis of subclinical disease including hypertensive disorders of pregnancy and left ventricular (LV) dysfunction. Precise recommendations on how frequently echocardiography should be performed and for whom remain in flux. However, a recently published consensus statement and new screening tool for pregnancy assessment of patients with valvular heart disease provide additional advice on using this modality. Echocardiography remains the diagnostic modality of choice for evaluation and risk stratification in pregnancy.

Vascular Ehlers-Danlos syndrome and pregnancy: A systematic review

BACKGROUND

Vascular Ehlers-Danlos syndrome (vEDS) is a hereditary connective tissue disorder associated with an elevated risk of vascular, uterine and digestive complications. Managing pregnancy in this context can be a challenge.

OBJECTIVES

To systematically review the literature data on the complications in pregnancy associated with vEDS.

SEARCH STRATEGY

We searched the Pubmed Medline and Embase databases for articles using the following terms "vascular Ehlers-Danlos syndrome" or "vEDS" AND "pregnancy".

SELECTION CRITERIA

Women with vEDS.

DATA COLLECTION AND ANALYSIS

We searched the PubMed® MEDLINE® database for publications evaluating obstetric outcomes in women with vEDS.

MAIN RESULTS

A total of 121 publications were screened, with six (accounting for 412 pregnancies) included in our review. Of the women included in this sample, 30% were infertile. The miscarriage rate was 13.8% (57/412) and 8.8% of the live births were premature. Obstetric anal sphincter injuries occurred in 11.3% (23/203) of the deliveries. The maternal mortality rate per pregnancy was 5.7%.

CONCLUSIONS

Women with vEDS present an elevated risk of uterine rupture, vascular events, digestive events and death during pregnancy. Women appear to be most at risk during the peripartum period; to avoid expulsive efforts, a caesarean section should be scheduled at 37 weeks of gestation.

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

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

Immediate Postpartum Breastfeeding following Pregnancy with Cardiac Disease

OBJECTIVE

 This study aimed to identify predictors of immediate postpartum breastfeeding among women with maternal cardiac disease (MCD).

STUDY DESIGN

 This study included all gravidas with MCD who delivered at a single institution from 2012 to 2018. Charts were abstracted for maternal demographics, obstetrical outcome, cardiac diagnoses, cardiac risk stratification scores, and prepregnancy echocardiogram findings. Kruskal-Wallis and Fisher's exact tests were used to compare the breastfeeding (BF) group versus the nonbreastfeeding (NBF) group. Logistic regression was used to obtain odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

 Among 211 gravidas with MCD, 12% were not breastfeeding at the time of postpartum hospital discharge. Compared with the BF group, the NBF group had a significantly higher proportion of women with cardiomyopathy (21% NBF vs. 7% BF, OR = 3.44, 95% CI: 1.12-10.71), with modified World Health Organization (WHO) classification ≥III (33 vs. 14%, OR = 3.16, 95% CI: 1.22-8.15), and with prepregnancy ejection fraction (EF) < 50% (55 vs. 14%, OR = 7.20, 95% CI: 1.92-27.06). There were otherwise no differences between the two groups with regards to other cardiac diagnoses or cardiac risk scores.

CONCLUSION

 In women with MCD, cardiomyopathy, modified WHO class ≥III, and a prepregnancy EF < 50% were associated with NBF in the immediate postpartum period. These findings may guide providers in identifying a subset of women with MCD who can benefit from increased breastfeeding counseling and support.

KEY POINTS

· Eighty-two percent of patients with cardiac disease are breastfeeding at the time of postpartum discharge.. · Cardiomyopathy is associated with an increased odds of not breastfeeding at postpartum discharge.. · Rationale for not breastfeeding is infrequently documented in the medical record..

Cardiac physiology and pathophysiology in pregnancy

Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.

Managing hypertension in African Americans with heart failure: A guide for the primary care clinician

Hypertension is the predominant risk factor for cardiovascular disease related morbidity and mortality among Black adults in the United States. It contributes significantly to the development of heart failure and increases the risk of death following heart failure diagnosis. It is also a leading predisposing factor for hypertensive disorders of pregnancy and peripartum cardiomyopathy in Black women. As such, all stakeholders including health care providers, particularly primary care clinicians (including physicians and advanced practice providers), patients, and communities must be aware of the consequences of uncontrolled hypertension among Black adults. Appropriate treatment strategies should be identified and implemented to ensure timely and effective blood pressure management among Black individuals, particularly those with, and at risk for heart failure.

Pregnancy conditions and outcomes of Chinese women with mild, moderate and severe pulmonary arterial hypertension

Pregnancy is normally contraindicated in pulmonary arterial hypertension (PAH). Thanks to medical advances, the prognosis for pregnancy in patients with PAH has improved. The aim of our study was to investigate pregnancy conditions and outcomes in patients with mild, moderate and severe PAH. We searched PubMed, Embase, CNKI, Wanfang and Weipu databases for studies published before May 2024. Data from 29 included studies from 1898 references were pooled and analyzed. We calculated the rates for each group as well as the risk ratio (RR) and 95% confidence interval (CI) between pairwise. There was no statistical difference in maternal and neonatal survival between the mild and moderate groups. Maternal survival in the mild, moderate and severe groups was 100.0%, 99.7% and 88.8%, respectively, and neonatal survival was 100.0%, 99.7% and 96.0%, respectively. The incidence of NYHA class III-IV, pregnancy loss, intensive care unit (ICU) admission, fetal growth restriction, and neonatal asphyxia was lowest in patients with mild PAH and highest in patients with severe PAH (P < 0.001). The incidence of vaginal deliveries and term pregnancies was highest in the mild group and lowest in the severe group (P < 0.001). In conclusion, pregnant women with mild PAH can safely deliver a newborn. Given similar survival rates but greater economic and medical burdens, caution is advised in the moderate group. Pregnancy in the severe group is considered contraindicated.

Challenges and strategies regarding anaesthetic management of twin pregnancy undergoing redo aortic valve replacement

INTRODUCTION AND IMPORTANCE

Redo aortic valve replacement in twin pregnancy presents significant challenges because of the elevated risks for both maternal and fetal health. Mortality rates range from 12 % to 21 % in specialised centres, with previous cardiac surgeries further elevating the risk. Pregnancy complicates cardiac surgery, with fetal mortality rates as high as 16-33 %.

PRESENTATION OF CASE

A 31-year-old woman, 15 weeks pregnant with twins and with a history of mechanical aortic valve replacement, presented with worsening breathlessness and grade III dyspnoea. Echocardiography revealed severe valve obstruction, necessitating redo-aortic valve replacement and posterior aortic root enlargement. Despite intraoperative challenges, including ventricular fibrillation and postoperative heart block, she underwent successful surgery and pacemaker implantation, with both mother and fetuses remaining stable.

DISCUSSION

Optimal timing of surgery is crucial, considering fetal developmental vulnerability in the first trimester and maternal cardiac workload in the third trimester. Second-trimester risks are comparable to non-pregnant patients. A limited understanding of fetal-placental perfusion during bypass necessitates cautious management strategies, with emerging techniques like pulsatile perfusion showing promise. Anaesthesia selection prioritises fetal safety while monitoring fetal distress during surgery remains challenging. To achieve successful outcomes for both mother and babies in a twin pregnancy undergoing a redo aortic valve replacement, careful timing, appropriate surgical techniques, and meticulous perioperative care are essential.

CONCLUSION

A multidisciplinary approach is crucial for managing twin pregnancy following redo aortic valve surgery. Careful planning, close monitoring, and specialised surgical and anaesthetic techniques are key to minimising risks to both mother and fetus.

Remote blood pressure management for postpartum hypertension: a cost-effectiveness analysis

BACKGROUND

Recognizing the importance of close follow-up after hypertensive disorders of pregnancy, many centers have initiated programs to support postpartum remote blood pressure management.

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of remote blood pressure management to determine the scalability of these programmatic interventions.

STUDY DESIGN

This was a cost-effectiveness analysis of using remote blood pressure management vs usual care to manage postpartum hypertension. The modeled remote blood pressure management included provision of a home blood pressure monitor, guidance on warning symptoms, instructions on blood pressure self-monitoring twice daily, and clinical staff to manage population-level blood pressures as appropriate. Usual care was defined as guidance on warning symptoms and recommendations for 1 outpatient visit for blood pressure monitoring within a week after discharge. This study designed a Markov model that ran over fourteen 1-day cycles to reflect the initial 2 weeks after delivery when most emergency department visits and readmissions occur and remote blood pressure management is clinically anticipated to be most impactful. Parameter values for the base-case scenario were derived from both internal data and literature review. Quality-adjusted life-years were calculated over the first year after delivery and reflected the short-term morbidities associated with hypertensive disorders of pregnancy that, for most birthing people, resolve by 2 weeks after delivery. Sensitivity analyses were performed to assess the strength and validity of the model. The primary outcome was the incremental cost-effectiveness ratio, which was defined as the cost needed to gain 1 quality-adjusted life-year. The secondary outcome was incremental cost per readmission averted. Analyses were performed from a societal perspective.

RESULTS

In the base-case scenario, remote blood pressure management was the dominant strategy (ie, cost less, higher quality-adjusted life-years). In univariate sensitivity analyses, the most cost-effective strategy shifted to usual care when the cost of readmission fell below $2987.92 and the rate of reported severe range blood pressure with a response in remote blood pressure management was <1%. Assuming a willingness to pay of $100,000 per quality-adjusted life-year, using remote blood pressure management was cost-effective in 99.28% of simulations in a Monte Carlo analysis. Using readmissions averted as a secondary effectiveness outcome, the incremental cost per readmission averted was $145.00.

CONCLUSION

Remote blood pressure management for postpartum hypertension is cost saving and has better outcomes than usual care. Our data can be used to inform future dissemination of and support funding for remote blood pressure management programs.

Association of Race and Ethnicity and Social Factors With Postpartum Primary Care or Cardiology Follow-Up Visits Among Individuals With Preeclampsia

BACKGROUND

Preeclampsia is associated with increased cardiovascular morbidity and death. Primary care or cardiology follow-up, in complement to routine postpartum obstetric care, provides an essential opportunity to address cardiovascular risk. Prior studies investigating racial differences in the recommended postpartum follow-up have incompletely assessed the influence of social factors. We hypothesized that racial and ethnic differences in follow-up with a primary care provider or cardiologist would be modified by income and education.

METHODS AND RESULTS

We identified adult individuals with preeclampsia (September 2014 to September 2019) in a national administrative database. We compared occurrence of a postpartum visit with a primary care provider or cardiologist within 1 year after delivery by race and ethnicity using multivariable logistic regression models. We examined whether education or income modified the association between race and ethnicity and the likelihood of follow-up. Of 18 050 individuals with preeclampsia (aged 31.8±5.7 years), Black individuals (11.7%) had lower odds of primary care provider or cardiology follow-up within 1 year after delivery compared with White individuals (adjusted odds ratio, 0.77 [95% CI, 0.70-0.85]) as did Hispanic individuals (14.8%; adjusted odds ratio, 0.79 [95% CI, 0.73-0.87]). Black and Hispanic individuals with higher educational attainment were more likely to have follow-up than those with lower educational attainment (P for interaction=0.033) as did those in higher income brackets (P for interaction=0.006).

CONCLUSIONS

We identified racial and ethnic differences in primary care or cardiology follow-up in the year postpartum among individuals diagnosed with preeclampsia, a disparity that may be modified by social factors. Enhanced system-level interventions are needed to reduce barriers to follow-up care.

Cardiovascular Disease in Pregnancy: Clinical Outcomes and Cost-Associated Burdens From a National Cohort at Delivery

Background

Cardiovascular disease (CVD) in pregnancy is a leading cause of maternal morbidity and mortality in the United States, with an increasing prevalence.

Objectives

This study aimed to examine risk factors for adverse maternal cardiac, maternal obstetric, and neonatal outcomes as well as costs for pregnant people with CVD at delivery.

Methods

Using the National Inpatient Sample 2010-2019 and the Internal Classification of Diseases diagnosis codes, all pregnant people admitted for their delivery hospitalization were included. CVD diagnoses included congenital heart disease, cardiomyopathy, ischemic heart disease, arrhythmias, and valvular disease. Multivariable regressions were used to analyze major adverse cardiovascular events (MACE), maternal and fetal complications, length of stay, and resource utilization.

Results

Of the 33,639,831 birth hospitalizations included, 132,532 (0.39%) had CVD. These patients experienced more frequent MACE (8.5% vs 0.4%, P < 0.001), obstetric (24.1% vs 16.6%, P < 0.001), and neonatal complications (16.1% vs 9.5%, P < 0.001), and maternal mortality (0.16% vs 0.01%, P < 0.001). Factors associated with MACE included cardiomyopathy (adjusted OR [aOR]: 49.9, 95% CI: 45.2-55.1), congenital heart disease (aOR: 13.8, 95% CI: 12.0-15.9), Black race (aOR: 1.04, 95% CI: 1.00-1.08), low income (aOR: 1.06, 95% CI: 1.02-1.11), and governmental insurance (aOR: 1.03, 95% CI: 1.00-1.07). On adjusted analysis, CVD was associated with higher odds of maternal mortality (aOR: 9.28, 95% CI: 6.35-13.56), stillbirth (aOR: 1.66, 95% CI: 1.49-1.85), preterm birth (aOR: 1.33, 1.27-1.39), and congenital anomalies (aOR: 1.84, 95% CI: 1.69-1.99). CVD was also associated with an increase of $2,598 (95% CI: $2,419-2,777) per patient during admission for delivery.

Conclusions

CVD in pregnancy is associated with higher rates of adverse outcomes. Our study highlights the association of key clinical and demographic factors with CVD during pregnancy to emphasize those at highest risk for complications.

Hypertrophic cardiomyopathy in pregnancy: Nationwide analysis of patients characteristics and outcomes

INTRODUCTION

Hypertrophic cardiomyopathy (HCM) poses unique challenges in the management of pregnant patients due to the complex interplay of physiological changes of pregnancy. Despite its relatively low prevalence among pregnant women, HCM can significantly impact maternal and fetal outcomes. This study aims to enhance understanding of pregnant patients with HCM and the associated outcomes through a nationwide analysis of patient characteristics and outcomes.

METHODS

A retrospective analysis was conducted using data obtained from the Agency for Healthcare Research in Quality (AHRQ) Nationwide Inpatient Sample (NIS) database from January 2016 to December 2020. 3,599,855 pregnant patients without HCM and 187 pregnant patients with HCM were identified using International Classification of Disease (ICD) codes, and baseline characteristics, medical comorbidities, and outcomes were compared between the two groups.

RESULTS

Significant differences were observed in baseline characteristics, including age distribution, racial composition, and prevalence of systemic organ disease, between pregnant women with and without HCM. Women with HCM had higher odds of experiencing maternal complications, such as acute heart failure and peripartum cardiomyopathy, as well as higher rates of fetal distress and obstetric interventions, including preterm delivery and caesarean section.

CONCLUSION

Comprehensive cardiovascular assessment and risk stratification are essential in pregnant women with HCM to optimize maternal and fetal outcomes. Moreover, disparities in baseline characteristics and outcomes among black pregnant women with HCM highlight the need for a multifactorial approach to addressing pregnancy-related complications.

Machine learning: a new era for cardiovascular pregnancy physiology and cardio-obstetrics research

The maternal cardiovascular system undergoes functional and structural adaptations during pregnancy and postpartum to support increased metabolic demands of offspring and placental growth, labor, and delivery, as well as recovery from childbirth. Thus, pregnancy imposes physiological stress upon the maternal cardiovascular system, and in the absence of an appropriate response it imparts potential risks for cardiovascular complications and adverse outcomes. The proportion of pregnancy-related maternal deaths from cardiovascular events has been steadily increasing, contributing to high rates of maternal mortality. Despite advances in cardiovascular physiology research, there is still no comprehensive understanding of maternal cardiovascular adaptations in healthy pregnancies. Furthermore, current approaches for the prognosis of cardiovascular complications during pregnancy are limited. Machine learning (ML) offers new and effective tools for investigating mechanisms involved in pregnancy-related cardiovascular complications as well as the development of potential therapies. The main goal of this review is to summarize existing research that uses ML to understand mechanisms of cardiovascular physiology during pregnancy and develop prediction models for clinical application in pregnant patients. We also provide an overview of ML platforms that can be used to comprehensively understand cardiovascular adaptations to pregnancy and discuss the interpretability of ML outcomes, the consequences of model bias, and the importance of ethical consideration in ML use.

Primary Care After Pregnancy Survey: Patient Preferences, Health Concerns, and Anticipated Barriers

Despite recommendations for ongoing care after pregnancy, many individuals do not see a primary care clinician within the first postpartum year, missing a critical window to engage reproductive-age individuals in primary care. We administered an anonymous, cross-sectional, trilingual survey at a large urban safety-net hospital to assess postpartum individuals' preferences, health concerns, and anticipated barriers to primary care during the year after pregnancy. While 90% of respondents preferred a visit within one year, most individuals - including those with complicated pregnancies - did not recall a primary care recommendation from their pregnancy care team. Respondents reported a variety of primary care-amenable health concerns, and many social and logistical barriers to care. Preference for virtual care increased if self-monitoring tools were hypothetically available, indicating virtual visits may improve primary care access.

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.

A rare case with double trouble: Peripartum cardiomyopathy and preeclampsia together with placental abruption resulting in both cardiac and kidney failure

Peripartum cardiomyopathy and hypertensive disorders of pregnancy are not very uncommon in routine practice, but when associated with abruptio placentae and significant hypotension, survival of both child and mother becomes challenging. We report a case of a 20-year-old primigravida who presented in the gynecology emergency unit of our hospital with an ejection fraction of < 20%, severe preeclampsia with abruptio placentae leading to fetal demise, and renal failure in the immediate postoperative period. Challenges faced during decision making regarding the mode of delivery and grave concerns during intraoperative and postoperative periods are discussed. In this case, prompt termination of pregnancy, various point-of-care sonographic measurements, and post-operative emergency dialysis played vital roles in the complete recovery of this patient with a failing heart and grossly jeopardized hemodynamics. Hence, multidisciplinary team-based management is crucial for managing such cases to prevent maternal mortality and morbidity.

Unique features of dyslipidemia in women across a lifetime and a tailored approach to management

Purpose of Review

Cardiovascular disease is a leading cause of death worldwide. Dyslipidemia is a critical modifiable risk factor for the prevention of cardiovascular disease. Dyslipidemia affects a large population of women and is especially pervasive within racial/ethnic minorities.

Recent Findings

Dyslipidemia in pregnancy leads to worse outcomes for patients and creates increased cardiovascular risk for women at an older age. However, women remain underscreened and undertreated compared to men. Females also comprise a small portion of clinical trial participants for lipid lowering agents with increased disease prevalence compared to trial representation. However, recent lipid trials have shown different efficacies of therapies such as ezetimibe, inclisiran, and bempedoic acid with a greater relative benefit for women.

Summary

Pathophysiology of dyslipidemia varies between men and women and across a woman's lifetime. While increased lipid levels or lipid imbalances are more common in postmenopausal women over age 50, conditions such as PCOS and FH produce higher cardiovascular risk for young women.Best practices for management of women with dyslipidemia include early screening with lifestyle intervention and pharmacotherapy with statin and non-statin agents to achieve guideline directed LDL-C thresholds.

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.

Gender Matters: A Multidimensional Approach to Optimizing Cardiovascular Health in Women

Cardiovascular diseases remain a leading cause of mortality among women, yet they are often underestimated and insufficiently addressed. This narrative review delves into the gender disparities in cardiovascular health, underscoring the critical importance of recognizing and addressing the unique challenges women face. The article explores the pathophysiological differences between men and women, highlighting the role of hormonal factors, such as estrogen and menopause, in conferring cardioprotection or increasing risk. It examines the complexities of diagnosis and assessment, including differences in symptom presentation, diagnostic accuracy, and the challenges of interpreting non-invasive testing in women. The review also highlights the need for tailored risk assessment and prevention strategies, incorporating sex-specific conditions and pregnancy-related factors. It emphasizes the importance of lifestyle modifications and interventions, as well as the potential benefits of personalized treatment approaches, considering gender-specific variations in medication responses and cardiac interventions. Furthermore, the article sheds light on the impact of psychosocial and sociocultural factors, such as gender norms, mental health considerations, and access to healthcare, on women's cardiovascular health. It also addresses the significant gaps and challenges in research, including the historical underrepresentation of women in clinical trials and the lack of sex- and gender-sensitive studies. Finally, the review advocates for a multidisciplinary approach, involving patient-centered care, shared decision-making, and collaboration among policymakers, stakeholders, and healthcare systems. This comprehensive strategy aims to enhance awareness, prevention, diagnosis, and treatment of cardiovascular disease in women, ultimately improving health outcomes and reducing the burden of this often overlooked epidemic.

Cardiac evaluation in pregnant patients with dyspnea and palpitations

BACKGROUND

Symptoms of underlying cardiac disease in pregnancy can often be mistaken for common complaints because of normal physiological changes in pregnancy. Echocardiographic evaluation of patients with symptoms of palpitations and dyspnea can detect structural changes and identify high-risk features.

OBJECTIVE

This study aimed to examine transthoracic echocardiograms of perinatal individuals completed for palpitations or dyspnea to determine the frequency of identifying structural changes.

STUDY DESIGN

This was a retrospective cohort study of all perinatal individuals with a transthoracic echocardiogram at a single academic center between October 1, 2017, and May 1, 2022. The indication for the echocardiogram, demographics, and clinical characteristics were recorded. Transthoracic echocardiograms with any abnormal findings noted in the transthoracic echocardiogram report were reviewed and categorized into findings of congenital heart disease, valvular disease, pericardial effusion, evidence of ischemia or wall motion abnormalities, abnormal diastolic or systolic function, and other.

RESULTS

Of 539 transthoracic echocardiograms completed on 478 individuals who were pregnant or in the 12-week postpartum period, 96 (17.8%) had an indication of palpitations, and 32 (5.9%) had an indication of dyspnea. Abnormal findings were seen in 21.9% of patients with palpitations and in 34.4% of patients with dyspnea. In patients with palpitations who had abnormal findings, 33.3% had congenital heart disease; 33.3% had mild valvular disease, including mitral valve prolapse; 19.0% had a pericardial effusion; and 14.3% had evidence of ischemia or wall motion defects. Abnormal transthoracic echocardiogram findings in the dyspnea cohort included ischemia or wall motion defects (27.3%), mild valvular disease or mitral valve prolapse (36.4%), and abnormal systolic or diastolic function (36.4%).

CONCLUSION

Many of the transthoracic echocardiograms completed for patients with dyspnea or palpitations identified no structural abnormality; however, in 1 of 3 to 1 of 4 patients, underlying structural heart disease was identified. Although some of these abnormalities were unlikely to change delivery plans, such as mild valvular disease or small effusions, other abnormalities, such as ischemia, congenital abnormalities, and abnormal systolic or diastolic function, were likely to have implications for pregnancy and postpartum management.

Redesigning Care for the Management of Postpartum Hypertension: How Can Ob-Gyns and Primary Care Physicians Partner in Caring for Patients after a Hypertensive Pregnancy?

The standard care model in the postpartum period is ripe for disruption and attention. Hypertensive disorders of pregnancy (HDPs) can continue to be a challenge for the postpartum person in the immediate postpartum period and is a harbinger of future health risks. The current care approach is inadequate to address the needs of these women. We propose a model for a multidisciplinary clinic and collaboration between internal medicine specialists and obstetric specialists to shepherd patients through this high-risk time and provide a bridge for lifelong care to mitigate the risks of a HDP. KEY POINTS: · HDPs are increasing in prevalence.. · The postpartum period can be more complex for women with HDPs.. · A multidisciplinary clinic could fill the postpartum care gap for women with HDP..

Beneath the Sword of Damocles: Moral Obligations of Physicians in a Post-Dobbs Landscape

Since the U.S. Supreme Court's decision in Dobbs vs. Jackson Women's Health Organization, a growing web of state laws restricts access to abortion. Here we consider how, ethically, doctors should respond when terminating a pregnancy is clinically indicated but state law imposes restrictions on doing so. We offer a typology of cases in which the dilemma emerges and a brief sketch of the current state of legal prohibitions against providing such care. We examine the issue from the standpoints of conscience, professional ethics, and civil disobedience and conclude that it is almost always morally permissible and praiseworthy to break the law and that, in a subset of cases, it is morally obligatory to do so. We further argue that health care institutions that employ or credential physicians to provide reproductive health care have an ethical duty to provide a basic suite of practical supports for them as they work to ethically resolve the dilemmas before them.

The Role of the Electrocardiogram in Pregnant Individuals with Chronic Hypertension

OBJECTIVE

The American College of Obstetricians and Gynecologists suggests that an electrocardiogram is an acceptable first-line test. We sought to examine whether an electrocardiogram is a sufficient screening tool to identify echocardiogram-diagnosed left ventricular hypertrophy. We also sought to determine risk factors associated with left ventricular hypertrophy.

STUDY DESIGN

This was a retrospective cohort study of pregnant individuals with chronic hypertension who delivered at 20 weeks' gestation or greater at a tertiary care center. Analyses were limited to individuals who had both electrocardiogram and echocardiogram during pregnancy. Left ventricular hypertrophy was diagnosed using the American Society of Echocardiography guidelines. Maternal demographics and electrocardiogram results were compared between individuals with left ventricular hypertrophy and those without left ventricular hypertrophy. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of the electrocardiogram to identify left ventricular hypertrophy were also calculated. Adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) were calculated, controlling for covariates.

RESULTS

Of 172 individuals, 60 (34.9%) had left ventricular hypertrophy. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of the electrocardiogram to identify echocardiogram-diagnosed left ventricular hypertrophy was 18.3% (95% CI: 9.5-30.4), 91.1% (95% CI: 84.2-95.6), 2.05 (95% CI: 0.93-4.56), and 0.90 (95% CI: 0.78-1.02), respectively. Compared with individuals without left ventricular hypertrophy, those with left ventricular hypertrophy were more likely to have hypertension of 4 years' duration or longer (aOR = 4.01; 95% CI: 1.71-9.42), unknown duration of hypertension (aOR = 4.66; 95% CI: 1.28-17.04), and higher body mass index (aOR = 1.04; 95% CI: 1.01-1.07). After adjusting for covariates, left ventricular hypertrophy by electrocardiogram was not associated with actual left ventricular hypertrophy (aOR = 2.59; 95% CI: 0.94-7.10).

CONCLUSION

Electrocardiogram was not a sufficient test for identifying left ventricular hypertrophy in pregnant individuals with chronic hypertension. We suggest an echocardiogram evaluation for all individuals with chronic hypertension.

KEY POINTS

· The first-line test for cardiac evaluation is an electrocardiogram.. · In our cohort, the rate of left ventricular hypertrophy was 35%.. · The electrocardiogram was not sensitive to detect left ventricular hypertrophy..

Infective Endocarditis in Pregnancy: A Contemporary Cohort

OBJECTIVE

Pregnancy-related infective endocarditis (IE) caries a high risk of morbidity and mortality. With increasing intravenous drug abuse (IVDA) amid the opioid epidemic, the risk factor profile may be shifting. In this case series, we aimed to describe risk factors and outcomes for peripartum IE in a contemporary cohort.

STUDY DESIGN

We identified patients with IE diagnosed during pregnancy or up to 6 weeks' postpartum from 2015 through 2018 at a single tertiary care center. We abstracted detailed medical history and clinical outcome measures from the electronic medical record. The diagnosis of IE was supported by the modified Duke Criteria.

RESULTS

Nine patients had peripartum IE: eight (89%) with a history of IVDA, one with an indwelling central venous catheter (11%), and one with prior IE (11%). None had preexisting congenital or valvular heart disease. Six (67%) had comorbid hepatitis C. Eight cases (89%) had gram-positive cocci with vegetations involving the tricuspid valve (56%) and both mitral and tricuspid valves (22%). Major complications included shock (33%), mechanical ventilation (44%), septic emboli (67%), and noncardiac abscesses (33%). Two patients underwent valve surgery, and there were two cases of postpartum maternal mortality (22%), one from septic shock and one from intracerebral hemorrhage. While four patients (44%) delivered preterm (average gestational age 35 weeks), most delivered vaginally (89%) with only one requiring an emergent caesarean section. There was no fetal mortality, although three newborns (43%) required admission to the neonatal intensive care unit. Two patients were initiated on medication-assisted treatment for opioid use disorder. Consultants included infectious disease, cardiology, cardiac surgery, maternal-fetal medicine, and psychiatry.

CONCLUSION

These findings confirm that IVDA is a growing risk factor for pregnancy-related IE. Peripartum IE carries a high risk of complications, including maternal mortality, and warrants management with a multidisciplinary care team at a tertiary center.

KEY POINTS

· Intravenous drug use was the most common risk factor for IE in pregnancy.. · IE in pregnancy carries a high morbidity and mortality with complications including septic emboli, septic shock, and need for mechanical ventilation.. · A multidisciplinary team approach can assure the best possible maternal and fetal outcomes..

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Obstetrical and neonatal outcomes in patients with surgically repaired heart disease

BACKGROUND

Congenital and acquired heart disease complicate 1% to 4% of pregnancies in the United States. Beyond the risks of the underlying maternal congenital heart disease, cardiac surgery and its sequelae, such as surgical scarring resulting in higher rates of arrhythmias and implanted valves altering anticoagulation status, have potential implications that could affect gestation and delivery.

OBJECTIVE

This study aimed to investigate whether history of maternal cardiac surgery is associated with adverse obstetrical or neonatal outcomes compared with patients without a history of cardiac disease or surgery, considered "healthy controls."

STUDY DESIGN

This is a secondary analysis of retrospective cohort studies performed at a tertiary care facility in the United States comparing obstetrical outcomes in patients with a history of open cardiac surgery who delivered from January 2007 to December 2018 with healthy controls, who delivered from April 2020 to July 2020. There were 74 pregnancies in 61 patients with a history of open cardiac surgery that were compared with pregnancies in healthy controls. Of the 74 pregnancies, 65 were successfully matched based on gestational age to controls at a 1:3 (case-to-control) ratio. The remainder of cases were matched at a 1:2 or 1:1 ratio; therefore, a total of 219 control pregnancies were included in the analysis. Our primary outcome was the incidence of hypertensive disorders of pregnancy, as well as cesarean delivery, in patients with a history of open cardiac surgery compared with healthy controls. Our secondary outcome was the incidence of low-birthweight neonates in patients with a history of open cardiac surgery compared with healthy controls.

RESULTS

Patients with a history of cardiac surgery were not more likely to have any hypertensive disorder diagnosed than healthy controls. Patients with a history of cardiac surgery were more likely to have an operative delivery (P<.0001) but equally likely to have a cesarean delivery (P=.528) compared with healthy controls. Birthweight was not statistically different of 2655±808 g in neonates born to patients with a history of cardiac surgery vs 2844±830 g born to healthy controls (P=.092).

CONCLUSION

Patients with a history of cardiac surgery may not be at higher risk of hypertensive disorder diagnosis during pregnancy. Similarly, most patients with a history of cardiac surgery are also likely not at higher risk of cesarean delivery or low-birthweight neonates.

Peripartum Pharmacotherapy: A Pharmacist's Guide

Complications throughout the peripartum period may be caused by preexisting conditions or pregnancy-induced conditions and may alter pharmacotherapy management. Pharmacotherapy management during late pregnancy and delivery requires careful consideration due to changing hormones, hemodynamic status, and pharmacokinetics, and concerns for potential maternal and/or fetal morbidity. Increased maternal and fetal monitoring are often required and may lead to therapy changes. Pharmacists, as key members of the interprofessional team, can contribute essential perspective to the management of postpartum pharmacotherapy through assessment and recommendation of appropriate and judicious use of medications.

[Maternal mortality due to cardiovascular diseases in France 2016-2018]

Between 2016 and 2018, cardiovascular diseases were responsible for 41 deaths, making it the leading cause of maternal death within 42 days postpartum in France. The maternal mortality ratio (MMR) for cardiovascular disease is 1.8 per 100,000 NV, a non-significant increase compared with the 2013-2015 triennium (MMR of 1.5 per 100,000 NV). Deaths from cardiac causes accounted for the majority (n=28), with 26 deaths secondary to cardiac disease aggravated by pregnancy (indirect deaths) and 2 deaths related to peripartum cardiomyopathy (direct deaths). Deaths from vascular causes (n=13) corresponded to 9 aortic dissections and 4 ruptures of large vessels, including 3 ruptures of the splenic artery. Preventability of death (possible or probable) was found in 56% of cases compared with 66% in the previous triennium. Care was considered sub-optimal in 57% of cases, down from 72% in the 2013-2015 triennium. In women with known cardiovascular disease, the areas for improvement concern multidisciplinary follow-up, repeated assessment of the cardiovascular risk (WHO grade) and early referral to an expert centre (expert cardiologists, obstetricians, anaesthetists and intensive care). In all pregnant women or women who have recently given birth, a cardiovascular etiology should be considered in the presence of suggestive symptoms (dyspnea, chest or abdominal pain). Ultrasound "point of care" examination (fluid effusions, cardiac dysfunction) and cardiac enzymes assay can help in the diagnosis. Finally, the woman must be involved in her own care.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.