By Christopher Cheney
Cardiovascular disease is a primary contributor to maternal mortality, particularly in the postpartum period.
Women face several cardiovascular disease risks during and after pregnancy, including heart rhythm abnormalities, heart valve conditions, congestive heart failure, and exacerbation of congenital heart defects. Recently released guidelines from the American College of Obstetricians and Gynecologists call for improved screening for cardiovascular disease during and after pregnancy as well as "pregnancy heart teams" for women at moderate to high risk for heart disease.
Jennifer Lewey, MD, is co-director of Penn Medicine's Pregnancy and Heart Disease Program, and director of the Penn Women's Cardiovascular Center in Philadelphia. Lewey earned her medical degree from Harvard Medical School and is board certified in cardiovascular disease and internal medicine.
The Penn Medicine cardiologist recently shared her approach to cardiovascular disease in pregnancy with HealthLeaders. A lightly edited version of that conversation follows.
HealthLeaders: Compare cardiovascular disease risk to other medical pregnancy risks.
Lewey: When looking at all deaths that occur during pregnancy, or in the year after delivery, one of the most common causes is cardiovascular, which includes deaths related to cardiomyopathies, congenital heart disease, valve disease, heart attacks, and stroke.
The risk varies according to the timing. We know that deaths that occur during pregnancy are more likely to be related to non-cardiovascular conditions. Deaths that occur on the day of delivery are due to obstetric causes. In the post-partum period, cardiovascular causes and cardiomyopathy in particular are much more common.
HL: When should pregnant women be assessed for cardiovascular disease?
Lewey: For assessment, there are three categories of women with cardiovascular disease.
There are women who have no cardiovascular disease who are at risk of worsening of their conditions during pregnancy given the hemodynamic changes that occur during pregnancy and delivery. These women may have congenital heart disease or acquire heart disease early in life, for example, valvular heart disease. For these women, they should be evaluated 6 to 12 weeks prior to pregnancy to evaluate their risk during pregnancy and to determine whether they need further testing to evaluate their risk.
Then there is a group of women who may have heart disease prior to pregnancy but were not diagnosed as such. A lot of these women have other risk factors for heart disease that could be diagnosed and optimized 6 to 12 months prior to getting pregnant. These are women who have obesity, severe uncontrolled hypertension, and severe diabetes.
The trickiest part are the women who don't have heart disease but develop it during pregnancy—we're not screening them before pregnancy because they don't have heart disease. This population highlights the importance of monitoring and evaluating new symptoms during pregnancy and the postpartum period.
HL: How do you coordinate care for pregnant women with cardiovascular disease?
Lewey: There needs to be communication between the primary care doctors and the cardiologists who see these women before they get pregnant, and the obstetricians and fetal medicine specialists who follow them during pregnancy.
I refer many of my patients for preconception counseling with an obstetrician prior to pregnancy—it's an opportunity for patients to learn more about their risks during pregnancy. It's also an opportunity for me to communicate with the obstetrician. The idea is we are following the patient together, before, during, and after pregnancy.
The biggest area for improvement is coordinating care after discharge, which is especially true for the women who are newly diagnosed with heart disease during pregnancy or the postpartum period.
HL: Should health systems and hospitals adopt heart care teams for pregnant women with cardiovascular disease?
Lewey: More and more large centers will be doing multidisciplinary heart care teams—it's something we certainly do at Penn. I serve as a point person for the obstetricians when questions arise. For our sickest patients, we discuss them at interdisciplinary meetings that occur at least once a month and more often if needed, so we can come up with a plan for monitoring during pregnancy and a delivery plan.
We're going to see more of these programs in response to the new guidelines and in response to the concerning rates of maternal mortality.
HL: What are the primary cardiovascular risks in the postpartum period?
Lewey: The leading cause of pregnancy-related death in the postpartum period is cardiomyopathy and the development of peripartum cardiomyopathy. Most women will present with this condition in the week after delivery. Oftentimes, it will develop after a woman has gone home from the hospital; however, they can present six months to a year after delivery.