Feature | Creating a High-Risk Pregnancy and Cardiovascular Clinic

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Cardiovascular disease is estimated to be present in 1-3 percent of pregnancies. And the incidence is increasing. As a cardiologist who has a special interest in pregnant women with cardiovascular disease, and as a mother of twins, I'm challenged academically and emotionally in treating these patients.

Pregnancy is an exciting time for expecting parents and it's difficult for an expectant mother to learn that her heart and health are at jeopardy, and that this can affect her and even her unborn child.

It's often said that pregnancy is nature's stress test – one lasting nine months! This stress on the body of a pregnant woman manifests as an increased heart rate and plasma volume and a cardiac output that increases close to 50 percent.

In pregnant women with cardiovascular disease, this can result in a high-risk pregnancy.

The critical juncture of the physical stress and the emotional stress in pregnant women who are facing a high-risk pregnancy represents a key time that requires addressing both components to achieve success.

Therefore, I partnered with my colleagues to establish a high-risk pregnancy and cardiovascular clinic at UMass Memorial Medical Center. We work with maternal fetal medicine and anesthesiology to provide a multidisciplinary team.

We also involve, when needed, specialists from electrophysiology, cardiothoracic surgery and the structural heart team with a special interest in cardiovascular disease and pregnancy intervention.

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We perform a detailed history and physical, including preconception counseling regarding the safety of pregnancy, and assess the short- and long-term risks to the mother and her baby.

It has been shown that it's possible for women with cardiovascular conditions to deliver a healthy baby – by preparing for pregnancy, ideally before conception, and with regular clinic visits with the multidisciplinary team.

Prevention of cardiovascular events is also part of our clinic's focus. The data are now clear that women who experienced gestational hypertension, gestational diabetes and preeclampsia during their pregnancy are at higher risk for future cardiovascular events.

Lifelong screening and continuous education for lifestyle behaviors and reducing other cardiovascular risk factors are essential for these women.

It's been said that we are products of our past, but we don't have to be prisoners of it. There is significant truth and empowerment from this insight for women with heart disease. By creating our clinic, we are indeed empowering these women to have healthy pregnancies and optimally manage their risk and short and long-term cardiovascular outcomes.

Training Our Fellows

Along with providing better care for our cardiac pregnant patients, we're also enhancing the training of our cardiology fellows by increasing their exposure to this patient population.

A fellow once said to me: "My greatest fear as an attending is getting a call about a pregnant woman with cardiac symptoms."

This comment opened my eyes wide with the realization that we have a lot of work to do to prepare our fellows for this growing population.

In 2018, we performed a needs assessment to assess the knowledge of our fellows on the management of cardiovascular conditions in pregnancy and their attitude toward curriculum development.

We incorporated cardiac disease and pregnancy topics into our didactic core curriculum, covering topics such as management of valvular disease and anticoagulation in pregnancy, as well as management of gestational hypertension, gestational diabetes, aortopathies, and acute coronary syndromes.

After these lectures were conducted, we saw a mild but not robust improvement in the knowledge assessment. It's clear we have more work to do. As a result, we've refined and enhanced our curriculum for the next year.

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The incidence of pregnant women with heart disease is increasing as more women with congenital heart disease are reaching childbearing age, along with advanced maternal age and a higher incidence in cardiovascular risk factors in the general population.

Heart disease is now the leading cause of nonobstetric mortality. As cardiologists, we need to create multidisciplinary teams to improve access and provide specialized care to this vulnerable population.

We need original investigations in this patient population so we can better understand and care for these women who have been historically excluded from research studies.

Just as importantly, we need to educate each other about successful strategies, and how to create a dedicated clinic that incorporates specialists from multiple areas of expertise that are in constant communication regarding each pregnancy and the coordinated plan for delivery. And we need to discuss successful strategies regarding the training of our cardiology fellows to provide them the education and confidence to treat this vulnerable population.

Finally, we need to educate women in the community with cardiovascular disease regarding the importance of preconception counseling, monitoring and controlling their cardiac risk factors before and during pregnancy and the plan for a successful delivery and postpartum care.

If we can accomplish this as a medical community, I'm confident that the health and outcomes of our pregnant women with cardiovascular disease will significantly improve.

Getting Intensive About Cardio-Obstetrics at ACC.20/WCC

Cardio-obstetrics gets a special focus in this year's Intensive session at ACC.20/WCC. The afternoon session features the 51st Annual Louis F. Bishop Keynote given by Lisa Marie Hollier, MD, MPH, president of the American College of Obstetricians and Gynecologists.

Cardiology spoke with Mary Norine Walsh, MD, MACC, and Kathryn Lindley, MD, FACC, co-chairs of the Intensive, to learn more about this emerging field and what to expect from the session.

Cardio-obstetrics is relatively new. What is it and why this new field?

Cardio-obstetrics broadly encompasses the intersection of pregnancy and cardiovascular disease. This includes preconception and contraception counseling for women with cardiovascular disease and multidisciplinary pregnancy planning and management for women with preexisting or newly acquired cardiovascular conditions.

It also includes long-term cardiovascular risk counseling and preventive care for women with adverse pregnancy outcomes such as preeclampsia, which are associated with increased long-term risk of atherosclerotic cardiovascular disease.

What does this Intensive mean for patients?

Improved patient care. Collaborative efforts between multiple disciplines have made possible the progress we've seen in cardio-obstetrics and the Intensive brings together experts from cardiology, obstetrics and gynecology, maternal fetal medicine, and public health.

As our patients become more complex, so must the care we deliver and the research we conduct be more interdisciplinary. Advancing patient care also requires optimizing our care delivery through innovative health care delivery platforms and modernizing health care access for patients.

This Intensive aims to address the problems and potential solutions to the contribution of cardiovascular disease to maternal mortality from a wide lens – how can we as a cardiovascular community partner with others in practice, in the research community, and in health care policy to address the barriers to health?

What will participants leave with at the end of the day?

This will be an exciting Intensive. A patient will share her story of her life-threatening experience as a new mom. Experts will discuss the reasons behind the staggering rates of maternal cardiovascular deaths and major morbidity.

And we'll hear from experts who have developed multidisciplinary cardio-obstetrics programs at their own institutions.

Attendees will leave with a greater understanding of the scope of the problem, the growing need for experts in patient care and clinical research, and a desire to incorporate their own personal expertise into this exciting, growing field.

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This article was authored by Colleen Harrington, MD, FACC, an assistant professor of medicine at the University of Massachusetts School of Medicine in Worcester, MA, and an adjunct assistant professor of medicine at the Johns Hopkins School of Medicine in Baltimore. Reach out to Harrington using @md_harrington.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Valvular Heart Disease, Vascular Medicine, Anticoagulation Management and ACS, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Hypertension

Keywords: ACC Publications, Cardiology Magazine, Pregnancy, Diabetes, Gestational, Hypertension, Pregnancy-Induced, Pregnancy, High-Risk, Cardiovascular Diseases, Pre-Eclampsia, Risk Factors, Incidence, Exercise Test, Plasma Volume, Needs Assessment, Vulnerable Populations, Acute Coronary Syndrome, Anesthesiology, Postnatal Care, Heart Rate, Maternal Age, Mothers, Mothers, Cardiac Output, Life Style, Curriculum, Patient Care Team, Electrophysiology, Heart Valve Diseases, Anticoagulants, Ambulatory Care, Ambulatory Care, Power, Psychological, Counseling

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