From the Guidelines
A cardioobstetrics program is essential for managing pregnant women with cardiovascular disease or cardiac risk factors, and should include pre-conception counseling, risk stratification, regular monitoring throughout pregnancy, specialized delivery planning, and postpartum follow-up, as recommended by the 2018 AHA/ACC guideline for the management of adults with congenital heart disease 1. The program should be a multidisciplinary healthcare service that focuses on managing pregnant women with cardiovascular disease or cardiac risk factors, including maternal-fetal medicine specialists, cardiologists with expertise in pregnancy, obstetric anesthesiologists, and specialized nurses working collaboratively to provide comprehensive care. Some key components of the program include:
- Pre-conception counseling to determine maternal cardiac, obstetrical, and fetal risks, and potential long-term risks to the mother, with input from an ACHD cardiologist 1
- Risk stratification to identify women at high risk of maternal morbidity or mortality, including those with pulmonary arterial hypertension (PAH), Eisenmenger syndrome, severe systemic ventricular dysfunction, severe left-sided obstructive lesions, and/or ACHD AP classification ID, IID, IIID [1]
- Regular monitoring throughout pregnancy, including fetal echocardiography when either parent has CHD, to assess fetal risk and determine the course of action at the time of delivery [1]
- Specialized delivery planning, including contingency plans for anticipated complications related to the presence of CHD, and clear documentation of the care plan to ensure all providers are aware of the risks and expected outcomes [1]
- Postpartum follow-up to monitor for potential complications and provide ongoing care. Medication management is also crucial, with careful consideration of drugs like beta-blockers (labetalol, metoprolol), calcium channel blockers (nifedipine), and anticoagulants (low molecular weight heparin) that have acceptable safety profiles in pregnancy [1]. The program should implement a clear communication system between all specialists, with protocols for emergency situations and regular team meetings to discuss complex cases [1]. This integrated approach is essential because the physiological changes of pregnancy, including increased blood volume and cardiac output, can significantly exacerbate underlying cardiac conditions and increase maternal morbidity and mortality if not properly managed [1].
From the Research
Overview of Cardioobstetrics Program
- A cardioobstetrics program is crucial for managing cardiovascular complications in pregnant women with pre-existing heart disease 2, 3, 4, 5, 6
- The program involves a multidisciplinary team approach, including cardiologists, obstetricians, and other healthcare professionals, to optimize maternal, obstetrical, and fetal outcomes 2, 3, 4, 6
Key Components of a Cardioobstetrics Program
- Risk stratification and management strategies for pregnant women with pre-existing heart disease or heart failure 2, 3, 4
- Preconception counseling and early antepartum risk factor identification and modification 3, 4
- Collaborative care between cardiologists and obstetricians to manage cardiovascular complications during pregnancy and the postpartum period 2, 3, 4, 6
- Use of risk scores and classification systems, such as the Cardiac Disease in Pregnancy II (CARPREG II) risk score and the modified World Health Organization (mWHO) risk classification system, to guide clinical decision-making 2
Importance of a Cardioobstetrics Program
- Cardiovascular disease is a leading cause of death in pregnant women and women in the postpartum period in the United States 4
- A cardioobstetrics program can help reduce maternal morbidity and mortality by providing specialized care and management of cardiovascular complications during pregnancy and the postpartum period 3, 4, 5, 6
- The program can also help address disparities in cardiovascular disease outcomes among nonwhite and lower-income women 4