A new statement issued today by the American Heart Association emphasizes the importance of taking a multidisciplinary approach to the management of cardiovascular disease during pregnancy and outlines heart care before, during and after pregnancy.
Dr. Laxmi Mehta, a cardiologist at The Ohio State University Wexner Medical Center, chaired the statement, which described how cardio-obstetrics has become an important team in managing heart-related problems during pregnancy.
The number of pregnancy-related deaths in the United States has more than doubled over the last two decades and the main cause is cardiovascular disease, according to the American Heart Association.
Pre-existing conditions such as diabetes and high blood pressure have contributed to the increased rate of death as well as advanced maternal age, which is associated with pre-term birth, preeclampsia and chronic hypertension.
Maternal mortality is on the rise, and the need is greater than ever for a cardio-obstetrics program like here at The Ohio State University Wexner Medical Center. These pregnancy heart teams comprehensively manage cardiovascular disease during pregnancy and ultimately help reduce pregnancy-related deaths."
Dr Laxmi Mehta, Director of Preventative Cardiology and Women's Cardiovascular Health, Wexner Medical Center.
A cardio-obstetrics team is often comprised of obstetricians, cardiologists, anesthesiologists, maternal fetal medicine specialists, geneticists, nurses and pharmacists who work together to develop a comprehensive approach for managing cardiovascular disease prior to, during pregnancy, delivery and postpartum.
The authors said preconception counseling by the cardio-obstetrics team is essential for women with pre-existing cardiac conditions or a history of preeclampsia, which is characterized by high blood pressure starting after 20 weeks of pregnancy.
"Being pregnant can put a lot of stress on the body, especially the heart," Mehta said. "During the first trimester of a normal pregnancy, the heart rate increases and blood pressure decreases. In the second and third trimesters, the heart rate and blood pressure increase and don't decrease until after birth. For those with certain cardiovascular diseases, these up-and-down swings can be dangerous."
Mehta and the other authors outlined medical conditions in pregnancy and recommendations for medication and care. Hypertensive disorders are the most common and include preeclampsia, gestational hypertension, chronic hypertension and chronic hypertension with superimposed preeclampsia.
The authors noted that women who develop preeclampsia have a 71 percent increased risk of cardiovascular death, are 2 ½ times more at risk of coronary artery disease and four times more at risk of heart failure during their lifetime.
Other medical conditions addressed in the statement included ischemic heart disease, arrhythmias, aortic disease, deep venous thrombosis, pulmonary embolism and valvular heart disease.
"A lot of women are unaware that having any of these issues during pregnancy puts them at a higher risk of developing heart disease in the future, and it may surface years down the road," Mehta said. "That's why it's so important for women with pregnancy-related heart disease to continue to see a cardiologist regularly after they've delivered their baby."
When it comes to labor and delivery, the authors recommended most women with cardiovascular disease have vaginal births instead of cesarean sections unless there are obstetric problems such as breech presentation, fetal heart rate abnormalities or failure to progress to labor.
They noted that the cardio-obstetrics team formulates delivery plans in women with high risk conditions on a case-by-case basis.
"General understanding of cardiovascular disease during pregnancy should be a core knowledge area for all cardiovascular and primary care clinicians," Mehta said.
"Involvement of the cardio-obstetrics team from pre-conception to postpartum care is critical because these experts working together can help identify ways to prevent maternal morbidity and mortality. Additionally, clinicians and women should be aware of elevated lifetime risks of cardiovascular disease in women who have adverse pregnancy outcomes like preeclampsia."
Mehta, L.S., et al (2020) Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. doi.org/10.1161/CIR.0000000000000772.