Q&A: CVD in pregnancy prompts prenatal, postpartum heart health program

Key takeaways:

• Many women experience CV complications during pregnancy with some resulting in death.
• The Heart Disease and Pregnancy Program was designed to educate pregnant women on risks for CVD.

A substantial number of women experience CV complications during and after pregnancy. Many do not seek routine care and some die of pregnancy-related CVD.

Lehigh Valley Heart & Vascular Institute formed the Heart Disease and Pregnancy Program in 2011 to provide preconception counseling for women prior to pregnancy, especially for those with CV conditions. The program was created to ensure better education and awareness for women about potential complications that may occur in pregnancy.

The program also provides high-risk obstetrics care in a cross-specialty format between maternal-fetal medicine specialists and cardiologists. Program specialists developed steps for standard practice, such as having pregnant women presenting with cardiac-related issues seen promptly by obstetricians and a general cardiologist and having cardiologists from the program work alongside maternal-fetal medicine specialists for high-risk women.

To date, the Heart Disease and Pregnancy Program has taken care of 1,000 patients and expanded to two sites with one cardiologist and one maternal-fetal medicine specialist at each site.

“We provide direct physical exams for the care of the patients, closely follow their vital signs and perform fetal ultrasounds to assess the baby’s growth and make sure it’s appropriate,” Nidhi Mehta, MD, a cardiologist in the program, told Healio. “We also follow ultrasounds or echocardiograms in women with congenital heart disease or preexisting cardiovascular conditions to closely monitor cardiac parameters throughout the first, second and third trimester. We look at medications that are specifically focused on the heart and discuss the potential risks and benefits for both the mother and the baby and look for alternatives, if possible.”

Healio spoke with Mehta about how CV health affects pregnant women and current focuses of the Lehigh Valley Heart & Vascular Institute Heart Disease and Pregnancy Program.

Healio: How common are CV disorders and CV mortality during pregnancy and postpartum?

Mehta: According to the American College of Obstetricians and Gynecologists, CVDs constitute about 25% of U.S. pregnancy-related deaths, and up to 4% of women can be affected during their pregnancy with CV conditions. When you look at the National Heart, Lung, and Blood Institute data, about 700 women each year die from pregnancy-related problems. So, a significant number of pregnancy-related complications are attributed to CVDs.

A big factor here is the fact that there are clearly a lot of disparities in CV outcomes. We see higher rates of morbidity and mortality in women who are non-white or have lower socioeconomic incomes. Providing access in multiple locations and trying to address socioeconomic barriers of care are important.

Healio: How does pregnancy impact the CV system?

Mehta: There are significant physiologic changes that occur in pregnancy. Obviously, as the fetus is growing, the amount of blood needed — the cardiac output — increases and heart rate increases as well. The delivery and immediate postpartum period lead to more rapid CV changes. These changes can “stress” the physiologic CV system.

Healio: What are some CVD risk factors that women have prior to, during and after pregnancy?

Mehta: A big concern with risk factors is that many women are not potentially seeking routine care. So, a lot of the traditional risk factors such as prediabetes, elevated blood pressure or hypertension, obesity and lipid abnormalities that are associated with CVD later in life can be unmasked during pregnancy. Women with congenital heart disease at birth, or at a young age, who underwent surgeries and now are of childbearing age may suffer from CV complications during pregnancy when rapid physiologic changes are occurring.

Healio: What is the importance of cross-specialty communication between cardiologists and OB/GYNs (and others involved) when caring for pregnant women at risk for CVD during their pregnancy?

Mehta: The importance of cross-specialty communication is being able to provide real-time care and real-time communication. A lot of the women, such as women with congenital heart disease, are following up with a cardiologist during and prior to pregnancy. It is important that history and physical exam findings and diagnostic testing gathered during the visits are communicated in a multidisciplinary conference composed of OB/GYNs, maternal-fetal medicine specialists, anesthesiologists and cardiologists to develop a comprehensive labor and delivery plan.

Healio: What makes the institute’s Heart Disease and Pregnancy Program unique?

Mehta: The Lehigh Valley Heart & Vascular Institute’s Heart Disease and Pregnancy Program is one of few in the country. It provides specialized care to patients that have cardiac complications, to ensure a healthy pregnancy for mother and baby throughout the stages of pregnancy and postpartum. We uncover many heart-related conditions that we can provide care for, whether it’s rhythm-related abnormalities, high blood pressure, murmurs, etc.

Another big aspect of the Heart Disease and Pregnancy Program is the interdisciplinary program where both maternal-fetal medicine specialists and cardiologists work side by side to provide direct patient care with the routine assessment of cardiac signs and symptoms as well as medication management to ensure that we are closely examining both the mother and fetus throughout pregnancy.

With the physiologic changes experienced during pregnancy, many women go through what we call a “fourth trimester,” which is the first 6 weeks postpartum. Many of these women suffer from preeclampsia, which can be seen antepartum, during labor and delivery and postpartum. This population is at an elevated long-term CV risk. Because of this, Lehigh Valley Heart & Vascular Institute created the Heart Health After Preeclampsia Program, which enrolls women with cardiac complications like preeclampsia. This program promotes awareness, provides medication management and uses tools to best risk stratify these women to reduce their CV risk. Specialists track lifestyle patterns including dietary and exercise to help reduce their lifetime risk for developing CVD.

Healio: Is there anything else you’d like to add?

Mehta: Pregnancy is what I consider a ”stress test.” It helps us identify a subset of women who may develop future CVD. It’s important to understand how it impacts this population in terms of their lifetime risk for CVD. Preeclampsia, gestational high blood pressure and gestational diabetes are all important adverse pregnancy outcomes that are being studied more. We work with this at-risk pregnant population to assess and treat their risk factors sooner so that their long-term risk is reduced. This is an important piece in pregnancy.

This is a population of women that are of childbearing age, wherein their focus is potentially not on the care of themselves, but on the care of others. It’s important that if women have pregnancy complications, that they don’t just think of it as a complication only in pregnancy, but as a red flag that they need to take care of their CV health long term.