Review: Delivering Coordinated Cardio-Obstetrics Care
Key findings
- The American Heart Association and the American College of Obstetricians and Gynecologists support having a multidisciplinary cardio-obstetrics team provide wraparound care for women at risk of peripartum cardiovascular complications
- History-taking by primary care providers should include questions about cardiac conditions and symptoms of exercise intolerance; any diastolic or loud murmurs warrants referral to echocardiography or a cardiologist with expertise in cardio-obstetrics
- Women at risk of CV complications should meet at least once per trimester with their cardiologist and maternal-fetal specialist, who should develop a formal delivery plan by the end of the second trimester or the beginning of the third
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The increasing rate of maternal mortality in the U.S. is due in large part to higher rates of cardiovascular disease during pregnancy. The American Heart Association and the American College of Obstetricians and Gynecologists (ACOG) support having a multidisciplinary cardio-obstetrics team provide wraparound care for women at risk of peripartum cardiovascular (CV) complications.
A cardio-obstetrics team is normally composed of obstetricians/gynecologists, maternal and fetal medicine (MFM) specialists, cardiologists with subspecialty training and experience in cardio-obstetrics and adult congenital heart disease, anesthesiologists, primary care physicians, advanced practice providers and allied health professionals. It may also include neonatologists and geneticists.
Anna C. O'Kelly, MD, MPhil, resident of the Department of Medicine at Massachusetts General Hospital, Doreen DeFaria Yeh, MD, associate director of the Mass General Adult Congenital Heart Disease Program and co-director of the Mass General Cardiovascular Disease and Pregnancy Service, and Nandita Scott, MD, co-director of the Cardiovascular Disease and Pregnancy Program, recently published in Cardiology Clinics the importance of coordinated cardio-obstetrics care from preconception through the postpartum period.
Preconception
The One Key Question initiative recommends asking women of reproductive age, "Would you like to become pregnant in the next year?" The preconception period is an important opportunity to identify women who may be at higher risk of CV complications.
Careful history-taking by primary care providers is essential and should include questions about prior cardiac conditions or procedures and symptoms of exercise intolerance. The physical examination should include assessment for cardiac abnormalities—any diastolic or loud murmurs (grade 3 or greater) should be evaluated with echocardiography. When in doubt, the patient should be referred to a cardiologist with expertise in cardio-obstetrics.
Preconception counseling by subspecialists is critical for women with pre-existing structural or congenital heart disease, hypertension or ischemic heart disease. For some maternal congenital and cardiac diseases, pregnancy is contraindicated due to prohibitive risk.
Pregnancy and Peripartum
There are no clear guidelines for follow-up during pregnancy, but expert opinion is that women at risk of CV complications should meet at least once per trimester with their cardiologist and MFM specialist. A formal delivery plan should be developed by the end of the second trimester or the beginning of the third. This plan should include any medication changes indicated before delivery and contingencies for potential obstetric and cardiac emergencies.
Expert consensus recommends serial echocardiography every trimester for women with valvular disease and cardiomyopathy and more frequently for patients with symptoms or severe disease. ACOG recommends surveillance every four to six weeks throughout pregnancy for women with congenital aortopathy.
Postpartum
More than half of pregnancy-related deaths occur during the year after delivery. ACOG recommendations for follow-up are:
- Women with congenital or acquired CV disease: See a cardiologist or primary care provider within seven to 14 days of delivery
- Women with hypertensive disorders of pregnancy: Check blood pressure within seven to 10 days after delivery; also within 72 hours after delivery if hypertension is severe
During the postpartum period, women are at high risk of being lost to follow-up considering how fragmented the health care system is. Reliance on specialty clinics is not realistic for all women, so the postpartum period is an especially important time for coordination between primary care physicians, cardiologists and allied health professionals.
Women with CV complications of pregnancy are at higher risk of future CV disease. They and women who have established CV disease need to be counseled early and often that they will need lifelong cardiac care.
The review also gives tips for creating a dedicated cardio-obstetrics team, addresses how to train cardiologists in cardio-obstetrics and lists some system-level changes needed to support cardio-obstetrics care.
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