A Complex Adult Congenital Heart Disease Case in Pregnancy: A Multidisciplinary Approach.

Multidisciplinary teams decrease the likelihood of adverse pregnancy outcomes in high-risk pregnant cardiac patients. We present the case of a patient with complex congenital heart disease and a mechanical mitral valve, whose treatment included warfarin until delivery despite the discovery of placental hematomas. A multidisciplinary approach mitigated both maternal and fetal adverse pregnancy outcomes.

Women's Cardiovascular Health: Prioritizing the Majority Minority.

Women make up the majority of the global population, and [...].

Alliance for Innovation on Maternal Health: Consensus Bundle on Cardiac Conditions in Obstetric Care.

Cardiac conditions are the leading cause of pregnancy-related deaths and disproportionately affect non-Hispanic Black people. Multidisciplinary maternal mortality review committees have found that most people who died from cardiac conditions during pregnancy or postpartum were not diagnosed with a cardiovascular disease before death and that more than 80% of all pregnancy-related deaths, regardless of cause, were preventable. In addition, other obstetric complications, such as preeclampsia and gestational diabetes, are associated with future cardiovascular disease risk. Those with cardiac risk factors and those with congenital and acquired heart disease require specialized care during pregnancy and postpartum to minimize risk of preventable morbidity and mortality. This bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people with cardiac conditions and to respond to cardio-obstetric emergencies. This bundle is one of several core patient safety bundles developed by the Alliance for Innovation on Maternal Health that provide condition- or event-specific clinical practices for implementation in appropriate care settings. The Cardiac Conditions in Obstetric Care bundle is organized into five domains: 1) Readiness , 2) Recognition and Prevention , 3) Response , 4) Reporting and Systems Learning , and 5) Respectful Care . This bundle is the first by the Alliance to be developed with the fifth domain of Respectful Care . The Respectful Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into elements in each domain.

Maternal Outcomes in Women with Peripartum Cardiomyopathy versus Age and Race-Matched Peers in an Urban US Community.

Peripartum cardiomyopathy (PPCM) is idiopathic systolic congestive heart failure around pregnancy. Comparisons with matched controls are lacking. We investigated maternal characteristics and outcomes up to 12 months in a cohort admitted to Montefiore Health System in Bronx, New York 1999−2015 (n = 53 cases and n = 92 age and race-matched controls, >80% Black or Hispanic/Latina). Compared to peers, women with PPCM had more chronic hypertension (24.5% vs. 8.8%, p = 0.001), prior gestational hypertension (20.8% vs. 5.4%, p = 0.001), prior preeclampsia (17.0% vs. 3.3%, p = 0.001), familial dilated cardiomyopathy (5.7% vs. 0.0%, p = 0.04), smoking (15.1% vs. 2.2%, p = 0.001), lower summary socioeconomic scores (−4.12 (IQR −6.81, −2.13) vs. −1.62 (IQR −4.20, −0.74), p < 0.001), public insurance (67.9% vs. 29.3% p = 0.001), and frequent depressive symptoms. Women with PPCM were often admitted antepartum (34.0% vs. 18.5%, p = 0.001) and underwent Cesarean section (65.4% vs. 30.4%, p = 0.001), but had less preterm labor (27.3% vs. 51.1%, p = 0.001). Women were rarely treated with bromocriptine (3.8%), frequently underwent left ventricular assist device placement (9.4% and n = 2 with menorrhagia requiring transfusion and progesterone) or heart transplantation (3.8%), but there were no in-hospital deaths. In sum, women with PPCM had worse socioeconomic disadvantage and baseline health than matched peers. Programs addressing social determinants of health may be important for women at high risk of PPCM.

The Utility of Maternal Point of Care Ultrasound on Labor and Delivery Wards.

Point-of-care ultrasonography (POCUS) refers to limited bedside ultrasound used to evaluate patients for conditions specific to the scope of their practice. Given the benefits of its application, interest in its use is increasing. We aimed to review the literature and assess the potential feasibility of using POCUS of the heart and lungs in the field of obstetrics. We aim to describe its relevance and value as an adjunctive tool for critically ill obstetric patients on labor and delivery wards.

Fetal Supraventricular Tachycardia: What the Adult Cardiologist Needs to Know.

Fetal supraventricular tachycardia management is challenging, with consequences for both the fetus and the mother. If left untreated, fetal hydrops may ensue, at which point delivery and treatment of the arrhythmia is preferred. However, if the fetus is not at term nor near-term, significant doses of antiarrhythmics may be needed to achieve adequate transplacental bioavailability. Although digoxin has classically been the mainstay of treatment, the use of flecainide or sotalol as monotherapy or in combination with digoxin is being studied. Interdisciplinary team management and shared decision-making between the physician and patient are key to achieving successful outcomes. Adult cardiologists, particularly inpatient consultation services or through burgeoning cardio-obstetrics programs, may, in some practice settings, be asked to evaluate or comanage pregnant women with fetal arrhythmia.

Links Between Maternal Cardiovascular Disease and the Health of Offspring.

Maternal cardiovascular disease (CVD) during pregnancy is on the rise worldwide, as both more women with congenital heart disease are reaching childbearing age, and conditions such as diabetes, hypertension, and obesity are becoming more prevalent. However, the extent to which maternal CVD influences offspring health, as a neonate and later in childhood and adolescence, remains to be fully understood. The thrifty phenotype hypothesis, by which a fetus adapts to maternal and placental changes to survive a nutrient-starved environment, may provide an answer to the mechanism of maternal CVD and its impact on the offspring. In this narrative review, we aim to provide a review of the literature pertaining to the impact of maternal cardiovascular and hypertensive disease on the health of neonates, children, and adolescents. This review demonstrates that maternal CVD leads to higher rates of complications among neonates. Ultimately, our review supports the hypothesis that maternal CVD leads to intrauterine growth restriction (IUGR), which, through the thrifty phenotype hypothesis and vascular remodelling, can have health repercussions, including an impact on CVD risk, both in the immediate newborn period as well as later throughout the life of the offspring. Further research remains crucial in elucidating the mechanism of maternal CVD long-term effects on offspring, as further understanding could lead to preventive measures to optimise offspring health, including modifiable lifestyle changes. Potential treatments for this at-risk offspring group could mitigate risk, but further studies to provide evidence are needed.

Persistence of abnormal global longitudinal strain in women with peripartum cardiomyopathy.

OBJECTIVES: Data regarding the longitudinal relationship of global longitudinal strain (GLS) and echocardiographic parameters are lacking in peripartum cardiomyopathy (PPCM). We evaluated GLS and its correlation with change (∆) in left ventricular ejection fraction (LVEF). METHODS: We retrospectively identified women age ≥16 years hospitalized at Montefiore Medical Center in Bronx, NY from 1999-2015 with International Statistical Classification of Diseases and Related Health Problems, 9th revision codes for PPCM or an occurrence of unexplained heart failure during or up to 5 months postpartum. N = 195 charts were reviewed for inclusion/exclusion criteria, n = 53 patients met criteria for PPCM, and of those, n = 13 had a baseline and follow-up echocardiogram suitable for GLS analysis. RESULTS: Of those eligible for strain analysis, the mean age was 30 ± 6 years, 46.2% identified as Black and 38.5% as Hispanic/Latina. Baseline LVEF was 30 (25, 35)%, GLS was -13.2 (-14, -7.6)%. At a mean follow-up time of 1.2 ± 0.7 years, 11/13 had persistently mild -15.6 (-16.3, -12.7)%, and 2/13 severely abnormal GLS -7.05 (-7.1, -7.0)%. There was no correlation between baseline GLS and ∆LVEF (r = .014, P = .965). CONCLUSIONS: Global longitudinal strain is a sensitive method to identify subclinical myocardial dysfunction. In this series of women with PPCM, GLS remained persistently abnormal over time, even if LVEF improved. Future studies should examine the implication of persistently abnormal GLS in PPCM.

Maternal Mortality Due to Cardiac Disease in Pregnancy.

Maternal mortality worldwide has vastly improved over the last several decades. Unfortunately, maternal mortality in the United States has been increasing and now cardiovascular conditions are the leading case of maternal death. The calculation of maternal mortality ratios and pregnancy-related mortality ratios is accomplished by several different organizations and this data collection is often complex, tedious, and poorly understood. Here we review the history of maternal mortality in the United States and aim to better understand how this data are collected.

Pregnancy and Congenital Heart Disease: A Brief Review of Risk Assessment and Management.

Cardiac disease is a leading cause of morbidity and mortality in pregnant women. An increased prevalence of the cardiovascular disease has been found in women of childbearing age, in which the responsibility of the treating physician extends to the mother and to the unborn fetus. As a result, care of these high-risk pregnant women with cardiovascular disease including those with congenital heart disease (CHD) require a team approach including specialists in maternal-fetal medicine, adult congenital cardiology, and obstetrical anesthesia. The human body undergoes significant amounts of physiological changes during this period of time and the underlying cardiac disease can affect both the mother and the fetus. Today, most female children born with CHD will reach childbearing age. For many women with complex CHD, carrying a pregnancy has a moderate to high risk for both the mother and her fetus. This chapter will review the epidemiology, risk factors, clinical presentation including common signs and symptoms, physiological changes in pregnancy, and the medical approach including cardiac medications, percutaneous interventions, and surgical procedures for pregnant women with CHD.

Introduction to Building the Cardio-Obstetric Team.

The pregnant cardiac patient has become a national focus in the United States during the 21st century. Maternal mortality in the United States is on the rise, cardiac disease in pregnancy has been identified as the number one indirect cause and has driven the increase in maternal death rate greatly. This may be explained by the increasing number of women with congenital heart disease reaching reproductive age and a higher prevalence of chronic medical diseases. A triad solution includes cardiovascular screening, patient education and a multidisciplinary team. The Cardio Obstetric team is described here.

Addressing maternal mortality: the pregnant cardiac patient.

Cardiac disease in pregnancy is the number one indirect cause of maternal mortality in the United States. We propose a triad solution that includes universal screening for cardiovascular disease in pregnancy and postpartum women, patient education, and institution of a multidisciplinary cardiac team. Additionally, we emphasize essential elements to maximize care for the pregnant cardiac patient based on our experience at our institution in Bronx, NY.