We often think of pregnancy as being something solely taken care of and overseen by an obstetrical care provider and possibly a primary care physician, but in this conversation with cardiologist, Dr. Rachel M. Bond, we discuss how having a cardiologist is also an integral part of the care team for some pregnant individuals.
preconception cardiovascular health and evaluation
acquired versus congenital heart disease, cardiovascular health in pregnancy
cardiovascular physiological changes in pregnancy
why some people find out they have heart disease for first time during pregnancy
postpartum cardiovascular health and disease
peripartum cardiomyopathy and more!
Heart health in pregnancy
Cardiovascular disease and cardiomyopathy are leading causes of maternal mortality, and, as such, are important topics to discuss.According to ACOG, the most recent data show that cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths.Contributing factors to these maternal deaths include:
barriers to prepregnancy cardiovascular disease assessment
missed opportunities to identify cardiovascular disease risk factors during prenatal care
gaps in high-risk intrapartum care
delays in recognition of cardiovascular disease symptoms during the postpartum period
For those with pre-existing heart conditions, a cardiologist needs to be involved when making decisions about when and how a baby will be delivered. This is also true for those with acquired heart disease or cardiovascular complications that develop during pregnancy. Whenever possible, optimization of maternal cardiovascular health should be achieved before pregnancy. This starts with having an annual routine wellness visit including blood work to check things like cholesterol, as well as sharing with your physician family medical history, especially if family members have had heart attacks.
Race/Ethnicity: Non-Hispanic black individuals have a 3.4 times higher risk of dying from cardiovascular disease-related pregnancy complications compared with non-Hispanic white individuals. This disparity can be explained in part by exposure to structural, institutional, and systemic barriers that contribute to a higher rate of comorbidities.
Age: Age older than 40 years increases the risk of heart disease-related maternal death 30 times the risk for younger than 20 years.
Hypertension: Hypertensive disorders affect up to 10% of pregnancies and can lead to maternal morbidity and mortality. Severe and early-onset hypertension during pregnancy put at an increased risk of cardiac compromise during or following delivery. In pregnancies complicated by hypertension, the incidence of myocardial infarction and heart failure is 13-fold and 8-fold higher, respectively, than in healthy pregnancies.
Obesity: Prepregnancy obesity increases maternal death risk due to a cardiac cause, especially if associated with moderate-to-severe obstructive sleep apnea.
*The presence of one or more of these risk factors should raise the threshold for suspicion that a patient is at-risk for maternal heart disease and pregnancy-related morbidity and mortality.
Who needs a cardiologist?
Persons with known cardiovascular disease should be evaluated by a cardiologist ideally before pregnancy or as early as possible during the pregnancy for the following reasons:
To accurately diagnosis and assess the effect pregnancy will have on the underlying cardiovascular disease
To assess the potential risks to the pregnant person and fetus
To optimize the underlying cardiac condition
Thanks to improved technology and advancements in medicine, we are now seeing more persons with congenital heart conditions make it to reproductive age and having children. For these individuals, there should be a conversation between the cardiologist and obstetrical care provider to decide what is best for the patient.
Symptoms to watch for during your pregnancy
One of the most important parts of my discussion with Dr. Bond is at minute 15:00 where we discuss some of the symptoms that could indicate cardiovascular conditions.
These symptoms include:
Needing to sleep with more pillows because you feel very out of breath when lying horizontal
Swelling in the legs that doesn’t go away when you elevate your legs
Pain or pressure in your chest
The symptoms of cardiovascular conditions can overlap with some symptoms that are considered normal during pregnancy, but if you are having these symptoms or they are worsening, speak with your obstetrical care provider. You may need to be seen by a cardiologist.
The CDC Hear Her Campaign
The CDC Hear Her Campaign is a great resource as well. You and your support person(s) should know what the urgent maternal warning signs are. Having this knowledge can help save lives. I encourage everyone who is pregnant or within the first year after delivery to look at the info from CDC and keep this info on hand.
Summary of Recommendations and Conclusions from ACOG PB 212: "Pregnancy and Heart Disease"
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
Referral to a hospital setting that represents an appropriate maternal level of care dependent upon the specific cardiac lesion is recommended for all pregnant patients with moderate- to high-risk cardiac conditions (modified WHO risk classes III and IV) because outcomes are significantly better for women in these facilities.
It may be helpful to obtain a baseline BNP level during pregnancy in women at high risk of or with known heart disease, such as dilated cardiomyopathy and congenital heart disease.
All pregnant and postpartum patients with chest pain should undergo standard troponin testing and an electrocardiogram to evaluate for acute coronary syndrome.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
Women with known cardiovascular disease should be evaluated by a cardiologist ideally before pregnancy or as early as possible during the pregnancy for an accurate diagnosis and assessment of the effect pregnancy will have on the underlying cardiovascular disease, to assess the potential risks to the woman and fetus, and to optimize the underlying cardiac condition.
Discussion of cardiovascular disease with the woman should include the possibilities that 1) pregnancy can contribute to a decline in cardiac status that may not return to baseline after the pregnancy; 2) maternal morbidity or mortality is possible; and 3) fetal risk of congenital heart or genetic conditions, fetal growth restriction, preterm birth, intrauterine fetal demise, and perinatal mortality is higher when compared with risk when cardiovascular disease is not present.
A personalized approach estimating the maternal and fetal hazards related to the patient’s specific cardiac disorder and the patient’s pregnancy plans can provide anticipatory guidance to help support her decision making. For some patients, the prepregnancy evaluation may suggest a pregnancy risk that is unacceptable. For those women, reproductive alternatives, such as surrogacy or adoption, and effective contraceptive methods should be discussed.
All women should be assessed for cardiovascular disease in the antepartum and postpartum periods using the California Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum toolkit algorithm.
All pregnant and postpartum women with known or suspected cardiovascular disease should proceed with further evaluation by a Pregnancy Heart Team consisting of a cardiologist and maternal–fetal medicine subspecialist, or both, and other subspecialists as necessary.
Testing of maternal cardiac status is warranted during pregnancy or postpartum in women who present with symptoms such as shortness of breath, chest pain, or palpitations and known cardiovascular disease whether symptomatic or asymptomatic, or both.
An echocardiogram should be performed in pregnant or postpartum women with known or suspected congenital heart disease (including presumed corrected cardiac malformations), valvular and aortic disease, cardiomyopathies, and those with a history of exposure to cardiotoxic chemotherapy (eg, doxorubicin hydrochloride).
Congenital heart disease in the woman should prompt fetal echocardiography, and conversely, identification of congenital heart disease in a fetus or neonate may prompt screening for parental congenital heart disease.
Any pregnant woman who presents with an arrhythmia should undergo evaluation to assess the cause and the possibility of underlying structural heart disease.
Pregnant or postpartum women who present with shortness of breath, chest discomfort, palpitations, arrhythmias, or fluid retention should be evaluated for peripartum cardiomyopathy. An echocardiogram is generally the most important diagnostic test.
Every pregnant or postpartum patient with chest pain or cardiac symptoms should have consideration of acute coronary syndrome.
Women with stable cardiac disease can undergo a vaginal delivery at 39 weeks of gestation, with cesarean delivery reserved for obstetric indications.
A postpartum follow-up visit (early postpartum visit) with either the primary care provider or cardiologist is recommended within 7–10 days of delivery for women with hypertensive disorders or 7–14 days of delivery for women with heart disease/cardiovascular disorders.
Advocate for yourself!
I’d like to leave you with this...
You know your body better than anyone so if you are having pregnancy symptoms that feel “off” or something worries you, talk to your physician. You are your own best advocate. If you have a physician that brushes everything off as being because you’re pregnant or you do not feel they are really listening to you, then look for another physician. There are physicians out there who will hear you.
Shannon M. Clark, MD, MMS is a double board certified ObGyn and Maternal-Fetal Medicine Specialist, and founder of Babies After 35. In her roles as a clinician, educator and researcher at UTMB-Galveston, she focuses on the care of people with maternal and/or fetal complications of pregnancy. Dr. Clark has taken a special interest in pregnancy after the age of 35, which according to age alone, is considered a high-risk pregnancy.