AHA: Multidisciplinary approach critical for pregnant women with CVD
Managing CVD and risks for cardiac conditions before, during and after pregnancy is essential to improve outcomes for both mother and baby, according to an American Heart Association scientific statement published in Circulation.
“It’s important to have a statement out there like this to recognize that cardiovascular disease is the No. 1 pregnancy-related mortality in women,” Cardiology Today Editorial Board Member Laxmi S. Mehta, MD, FAHA, professor of medicine and director of preventive cardiology and women’s cardiovascular health at The Ohio State University Wexner Medical Center in Columbus and chair of the writing group, told Healio. “There are some careful considerations that do need to be made during pregnancy, and that cardio-obstetrics, which has emerged as an important multidisciplinary field, can allow an excellent team approach to the optimal management of cardiovascular disease during pregnancy.”
Prepregnancy counseling
Counseling should also be done by a specialized cardio-obstetrics team before a woman conceives to discuss potential maternal and fetal risks, according to the scientific statement.
“It’s an essential conversation that needs to occur, as well as a discussion of medication safety during pregnancy and what are the cardiac hemodynamic changes that can occur during pregnancy in that particular patient,” Mehta said in an interview. “Depending on whether they’re already coming in with cardiac issues can impact outcomes as well as if they don’t have any medical problems, having those discussions during pregnancy is essential.”
Several medical conditions can occur during pregnancy including hypertensive disorders, which can be classified as gestational hypertension, chronic hypertension, preeclampsia/eclampsia and chronic hypertension with superimposed preeclampsia. Monitoring pregnant women with these conditions while treating them accordingly is important. Strategies including lifestyle and behavioral modifications may benefit these women, although data from large randomized controlled trials on its benefit are lacking, according to the scientific statement.
“One important thing about these hypertensive disorders people need to take away is that having them can increase a female’s lifetime cardiovascular disease risk,” Mehta told Healio.
Hypercholesterolemia can also occur, as triglycerides, total cholesterol and LDL can increase during pregnancy and reach peak levels at delivery. Major lipoprotein levels often decline within 3 months after delivery to prepregnancy levels, according to the statement. Health care professionals should screen for dyslipidemia before pregnancy. The conditions that should be addressed during pregnancy include familial hypercholesterolemia and severe hypertriglyceridemia, although pharmacological treatment may pose fetal risks. Statins, for example, are contraindicated for pregnant women. Women with familial hypercholesterolemia can be treated with bile acid sequestrants, and LDL apheresis is a last-resort option for severe cases.
Ischemic heart disease can potentially be fatal in pregnant women, according to the statement.
“Ischemic heart disease during pregnancy is a rare entity, but unfortunately it could be potentially fatal as well,” Mehta told Healio. “Recognizing ischemic heart disease is essential. Not attributing it to chest pain or heartburn is going to be key, and recognizing that women can have spontaneous coronary dissection or myocardial infarction with nonobstructive disease during their pregnancy is essential. The higher risks of myocardial infarction are in the third trimester and postpartum periods.”
Diagnosing and managing pregnant women with cardiomyopathy can be challenging, as peripartum and dilated cardiomyopathy can resemble other conditions with similar pathophysiology, according to the scientific statement. The treatment of pregnant women with HF should focus on afterload reduction, rhythm control, controlling volume status and anticoagulation if necessary.
“During pregnancy, it can be challenging because with fluid shifts that occur, their volume status is going to be essential in trying to find the right diuretic regimen,” Mehta said in an interview. “It is also crucial to have appropriate rhythm control because arrhythmias can also worsen heart failure, which can be more problematic in pregnant women.”
Preconception evaluation by a cardio-obstetrics team is recommended for women with a history of valvular heart disease regardless of prior treatment and pathogenesis, according to the statement. In addition, pregnant women with mechanical prosthetic valves have an increased risk for maternal and fetal morbidity and mortality, so careful management of anticoagulation regimens throughout pregnancy is essential.
“Careful consideration prepregnancy and then careful monitoring throughout pregnancy is essential to reduce mortality,” Mehta told Healio. “It does require planning in terms of delivery methodologies. Understanding the volume status is key, as well as if a patient has certain conditions. They may be more at risk if they have a left-sided stenotic valvular lesion that may put them at higher risks of heart failure or mortality.”
Women after pregnancy
Monitoring after pregnancy is also critical for these women, in addition to conversations about future pregnancies and contraception.
“Cardiovascular considerations during pregnancy isn’t just during pregnancy,” Mehta said during an interview. “The first year postpartum is such a crucial time period. A lot of things can happen. ... It’s not just about seeing your gynecologist at the 6-week follow-up and you’re done; they really need monitoring, making sure their blood pressure is staying under control, making sure their heart failure doesn’t worsen, making sure they’re following that heart-healthy diet and getting the adequate nutrition.”
Not only is this statement important for cardiologists, but also for other health care professionals who care for pregnant women, Mehta said. “It’s important for medical students, residents, fellows, nurses, pharmacists in medicine itself should recognize this is a field that they need to learn more about and not think that [it’s just for gynecologists]. Understanding that this is really going to be a team, and a strong team together can really be educational for the patient, but also most importantly improve the outcomes both from a morbidity and a mortality standpoint and improve outcomes for the fetus as well.” – by Darlene Dobkowski
For more information:
Laxmi S. Mehta, MD, FAHA, can be reached at laxmi.mehta@osumc.edu; Twitter: @drlaxmimehta.
Disclosures: Mehta reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Collapse
Mehta LS, et al. Circulation. 2020;doi:10.1161/CIR.0000000000000772.