Cardio-Obstetrics
2019; Lippincott Williams & Wilkins; Volume: 12; Issue: 2 Linguagem: Português
10.1161/circoutcomes.118.005417
ISSN1941-7705
AutoresMelinda B. Davis, Mary Norine Walsh,
Tópico(s)Maternal and fetal healthcare
ResumoHomeCirculation: Cardiovascular Quality and OutcomesVol. 12, No. 2Cardio-Obstetrics Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBCardio-ObstetricsTeam-Based Care to Improve Maternal Outcomes Melinda B. Davis, MD and Mary Norine Walsh, MD Melinda B. DavisMelinda B. Davis Melinda B. Davis, MD, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI 48109. Email E-mail Address: [email protected] Division of Cardiovascular Medicine, Department of Internal Medicine and Department of Obstetrics and Gynecology, University of Michigan (M.B.D.). and Mary Norine WalshMary Norine Walsh St Vincent Heart Center, Indianapolis, IN (M.N.W.). Originally published18 Feb 2019https://doi.org/10.1161/CIRCOUTCOMES.118.005417Circulation: Cardiovascular Quality and Outcomes. 2019;12:e005417Maternal MortalityDespite global improvements in maternal mortality, the rate of pregnancy-related deaths in the United States has been rising.1 Pregnant women in the United States have a higher risk of death than in any other industrialized country. The reasons for this are complex. Black women have a 3 to 4× higher risk of maternal mortality than white women,2 underscoring alarming trends in the racial-ethnic disparities in this country. Insufficient access to care, socioeconomic inequalities, and variable quality of care all require attention. Additionally, maternal demographics and risk factors have changed over time. At the time of pregnancy, women are older and have more chronic medical conditions, such as obesity, hypertension, and diabetes mellitus.1 Cardiovascular disease is now a leading cause of maternal death and severe morbidity.2State-wide maternal mortality review committees have shed light on cardiovascular-related maternal deaths. In Illinois, Briller et al3 found that of 140 maternal deaths from 2002 to 2011, more than a fifth (22%) were related to cardiovascular disease. The most common causes were related to acquired cardiovascular disease (97.1%), including cardiomyopathy (27.9%), stroke (22.9%), hypertensive disorders (12.9%), arrhythmias (10.7%), and coronary disease (9.3%). Relatively fewer deaths were related to congenital heart disease (2.9%). In California, nearly a quarter (24.9%) of the pregnancy-related deaths from 2002 to 2006 were attributed to cardiovascular disease, and two-thirds of these deaths were related to cardiomyopathy.4Maternal deaths were deemed to be potentially preventable in approximately a quarter of the cases reviewed by these 2 state committees.3,4 Preventability was assessed by whether specific and feasible actions could have been implemented to lead to a nonfatal outcome, such as evaluating the cause of severe shortness of breath in a postpartum woman.4 The complex problems facing high-risk obstetric populations require a team-based approach including cardiology, maternal-fetal medicine, obstetrics, anesthesiology, and nursing.Hemodynamic Changes and Unmasking RiskThe physiological changes of pregnancy involve multiple hormonal and vascular adaptations, substantial increases in volume, cardiac output and heart rate, decreased systemic vascular resistance, and increased hypercoagulability. Diagnosing cardiac conditions, such as heart failure and arrhythmias, during pregnancy can be challenging as the signs and symptoms can mimic those of normal pregnancy. Obstetrics teams must be alert for symptoms that are outside the norm, and cardiologists should understand the significant hemodynamic changes that occur during pregnancy, labor, and delivery and the normal physical findings in each stage.The long-term risk of cardiovascular disease among women with complications during pregnancy is increasingly recognized. Preeclampsia, hypertensive disorders of pregnancy, gestational diabetes mellitus, and preterm birth have all been associated with increased maternal cardiovascular risk later in life.5,6 Pregnancy has been compared with a stress test whereby subclinical cardiovascular disease may be unmasked by the hemodynamic changes. Women with demonstrated increased future risk of cardiovascular disease should be identified, educated, followed, and treated when appropriate. Effective communication among cardiologists, obstetricians, primary care physicians, and patients is essential, but the ideal approach for following and managing these patients over the long-term requires further research.Team-Based CareA cardio-obstetrics team requires a group of dedicated individuals committed to caring for this growing population of women. Similar to other multidisciplinary teams within cardiology, such as advanced heart failure and transplant cardiology, cardio-oncology, and valvular heart disease, team-based care requires commitment and effective communication. At many institutions, regular interdisciplinary meetings involve discussion of labor and delivery plans for all the pregnant women with any type of cardiovascular disease.7 In attendance are experts from cardiology, obstetrics, maternal-fetal medicine, anesthesia, and nursing (Figure). A primary focus is the patient's progress with the pregnancy and a plan for safe delivery. Additional expertise, as needed, is provided by pharmacists, social workers, and case managers. Patient preferences and shared-decision making are important. Nurse navigators can play a pivotal role by supporting and linking the patient with various specialists, particularly when visits are not concurrent. Some programs opt to have shared clinic space for maternal-fetal medicine specialists and cardiologists to improve communication and reduce barriers for patients who need multiple appointments or travel long distances.Download figureDownload PowerPointFigure. The key components of a cardio-obstetrics team.Late referral to a higher level of care has been cited as a contributing factor in preventable maternal deaths.3 Systems that support timely referrals, as well as close followup postpartum, could potentially improve maternal outcomes. Within the first 6 weeks postpartum, before the standard postpartum visit, is a high-risk time for complications.3 The American College of Obstetrics and Gynecology Presidential Task Force on Redefining the Postpartum Visit recommends that all women have a follow-up visit within the first 3 weeks postpartum.8Cardio-obstetrics teams also provide care and expertise around pregnancy planning. Women with cardiac disease, previous pregnancy complications and those with risk factors are counseled by the multidisciplinary team, often along with genetics counselors. Estimates of complications recurrence, suggested mode of delivery, and intensity of intrapartum monitoring and follow up are shared with patients and their families. Such planning allows for shared decisions about conception planning.Quality of Care and Specialized TrainingDespite cardio-obstetrics being a clear area of need for improved quality of care, physicians do not receive formal training in this field. Most team members involved in the care of these patients have learned through experience. There are no formal training requirements during cardiovascular disease fellowship. The Core Cardiovascular Training Statement 4 states briefly that exposure to various specialty experiences is recommended, including "an obstetric clinic visited by pregnant patients with heart disease, optimally in the context of an interdisciplinary approach to high-risk pregnancy"9; however, many fellows will not have such an opportunity, and formal metrics are lacking. Cardiologists would benefit from training about hypertensive management during and after pregnancy, medications that can safely be used during pregnancy and lactation, the maternal cardiovascular benefits of breastfeeding, long-term outcomes for women with pregnancy-related risk factors, interpretation of biomarkers and echocardiographic changes during pregnancy, and the complex effects of hemodynamic changes during pregnancy, labor and delivery on various types of cardiovascular physiology. Cardiovascular indications for cesarean section is needed expertise to avoid unnecessary surgical interventions. More organized training could be broadly explored. As cardio-obstetrics programs develop and formalize, training opportunities for fellows will naturally grow.Research and CollaborationImproving quality of care for this population also requires collaboration among researchers. The heterogeneous nature of cardiac diseases in child-bearing women, and the relative rarity of each condition, makes robust research challenging. Multicenter collaboration and registries are important for furthering our understanding. The Registry of Pregnancy and Cardiac Disease, established by the European Observational Research Program, has provided significant insights and has also drawn attention to the wide variety of care practices and settings that exist at an international level.10 Additional registry development can help us understand ways to improve quality of care in this specialized population.11 Long-term risk reduction for women with complications during pregnancy, such as preeclampsia, hypertensive disorders, gestational diabetes mellitus, and preterm birth can be addressed longitudinally as the cardiovascular risk does not abate over time. Communities of researchers and clinicians will need to work together to create evidence-based best practices. Research at a population health level will better determine the independence of preeclampsia, eclampsia, and gestational hypertension as cardiovascular risk factors.Forming Professional CommunitiesAt the 2018 American College of Obstetrics and Gynecology meeting, one of us (Dr Walsh) presented her vision for cardio-obstetrics and emphasized the importance of collaboration and teamwork, establishing the social media hashtag #CardioObstetrics. The hashtag has helped create an online community around this emerging discipline with users sharing recent studies and literature as well as promoting awareness. Clearly, there is broad interest, and we expect this field will grow exponentially in the years to come. In this country, the risk of morbidity and mortality related to pregnancy is appalling. We can and must do better. By working together and forming dedicated teams and communities, we can improve the health of women with cardiovascular disease and those at risk, thereby benefiting mothers and their families for the decades that follow.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Melinda B. Davis, MD, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI 48109. Email [email protected]umich.eduReferences1. Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System.https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm. Accessed November 25, 2018.Google Scholar2. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011–2013.Obstet Gynecol. 2017; 130:366–373. doi: 10.1097/AOG.0000000000002114CrossrefMedlineGoogle Scholar3. Briller J, Koch AR, Geller SE. Maternal cardiovascular mortality in Illinois, 2002–2011.Obstet Gynecol. 2017; 129:819–826. doi: 10.1097/AOG.0000000000001981CrossrefMedlineGoogle Scholar4. Hameed AB, Lawton ES, McCain CL, Morton CH, Mitchell C, Main EK, Foster E. Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy.Am J Obstet Gynecol. 2015; 213:379.e1–379.e10. doi: 10.1016/j.ajog.2015.05.008CrossrefGoogle Scholar5. Ying W, Catov JM, Ouyang P, Hopkins J. Hypertensive disorders of pregnancy and future maternal cardiovascular risk classification and epidemiology of HDP.J Am Heart Assoc. 2018; 7:9382. doi: 10.1161/JAHA.118.009382LinkGoogle Scholar6. Hauspurg A, Ying W, Hubel CA, Michos ED, Ouyang P. Adverse pregnancy outcomes and future maternal cardiovascular disease.Clin Cardiol. 2018; 41:239–246. doi: 10.1002/clc.22887CrossrefMedlineGoogle Scholar7. Mann S, Hollier LM, McKay K, Brown H. What we can do about maternal mortality - and how to do it quickly.N Engl J Med. 2018; 379:1689–1691. doi: 10.1056/NEJMp1810649CrossrefMedlineGoogle Scholar8. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 736 Summary: optimizing postpartum care.Obstet Gynecol. 2018; 131:949–951. doi: 10.1097/AOG.0000000000002628CrossrefMedlineGoogle Scholar9. Halperin JL, Williams ES, Fuster V, Cho NR, Iobst WF, Mukherjee D, Vaishnava P, Smith SC, Bittner V, Gaziano JM, Giacomini JC, Pack QR, Polk DM, Stone NJ, Wang S, Balady GJ, Bufalino VJ, Gulati M, Kuvin JT, Mendes LA, Schuller JL, Narula J, Chandrashekhar YS, Dilsizian V, Garcia MJ, Kramer CM, Malik S, Ryan T, Sen S, Wu JC, Ryan T, Berlacher K, Lindner JR, Mankad SV, Rose GA, Wang A, Dilsizian V, Arrighi JA, Cohen RS, Miller TD, Solomon AJ, Udelson JE, Garcia MJ, Blankstein R, Budoff MJ, Dent JM, Drachman DE, Lesser JR, Grover-McKay M, Schussler JM, Voros S,Wann LS, Hundley WG, Kwong RY, Martinez MW, Raman SV, Ward RP, Creager MA, Gornik HL, Gray BH, Hamburg NM, Mohler ER, White CJ, King SB, Babb JD, Bates ER, Crawford MH, Dangas GD, Voeltz MD, Calkins H, Awtry EH, Bunch TJ, Kaul S, Miller JM, Tedrow UB, Jessup M, Ardehali R, Konstam MA, Mathier MA, Manno BV, McPherson JA, Sweitzer NK, O'Gara PT, Adams JE, Drazner MH, Indik JH, Kirtane AJ, Klarich KW, Newby LK, Scirica BM, Sundt TM, Warnes CA, Bhatt AB, Daniels CJ, Gillam LD, Stout KK, Harrington RA, Barac A, Brush JE, Hill JA, Krumholz HM, Lauer MS, Sivaram CA, Taubman MB, Williams JL. ACC 2015 core cardiovascular training statement 4 (COCATS 4) (revision of COCATS 3).J Am Coll Cardiol. 2015; 65:1721–1723. CrossrefGoogle Scholar10. Roos-Hesselink JW, Ruys TP, Stein JI, Thilén U, Webb GD, Niwa K, Kaemmerer H, Baumgartner H, Budts W, Maggioni AP, Tavazzi L, Taha N, Johnson MR, Hall R; ROPAC Investigators. Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology.Eur Heart J. 2013; 34:657–665. doi: 10.1093/eurheartj/ehs270CrossrefMedlineGoogle Scholar11. Florio K, Daming TB, Grodzinsky A. Poorly understood maternal risks of pregnancy in women with heart disease.Circulation. 2018; 137:766–768. doi: 10.1161/CIRCULATIONAHA.117.031889LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Bhatia K, Shehata N and D'Souza R (2022) Anaesthetic considerations and anticoagulation in pregnant patients with mechanical heart valves, BJA Education, 10.1016/j.bjae.2022.01.004, 22:7, (273-281), Online publication date: 1-Jul-2022. Thakkar A, Hailu T, Blumenthal R, Martin S, Harrington C, Yeh D, French K and Sharma G (2022) Cardio-Obstetrics: the Next Frontier in Cardiovascular Disease Prevention, Current Atherosclerosis Reports, 10.1007/s11883-022-01026-6, 24:7, (493-507), Online publication date: 1-Jul-2022. Bello N, Agrawal A, Davis M, Harrington C, Lindley K, Minissian M, Sharma G, Walsh M and Park K (2022) Need for Better and Broader Training in Cardio‐Obstetrics: A National Survey of Cardiologists, Cardiovascular Team Members, and Cardiology Fellows in Training, Journal of the American Heart Association, 11:8, Online publication date: 19-Apr-2022. Mulvagh S, Mullen K, Nerenberg K, Kirkham A, Green C, Dhukai A, Grewal J, Hardy M, Harvey P, Ahmed S, Hart D, Levinsson A, Parry M, Foulds H, Pacheco C, Dumanski S, Smith G and Norris C (2022) The Canadian Women's Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women — Chapter 4: Sex- and Gender-Unique Disparities: CVD Across the Lifespan of a Woman, CJC Open, 10.1016/j.cjco.2021.09.013, 4:2, (115-132), Online publication date: 1-Feb-2022. Adedinsewo D, Johnson P, Douglass E, Attia I, Phillips S, Goswami R, Yamani M, Connolly H, Rose C, Sharpe E, Blauwet L, Lopez-Jimenez F, Friedman P, Carter R and Noseworthy P (2021) Detecting cardiomyopathies in pregnancy and the postpartum period with an electrocardiogram-based deep learning model, European Heart Journal - Digital Health, 10.1093/ehjdh/ztab078, 2:4, (586-596), Online publication date: 29-Dec-2022. Windram J and Siu S (2021) "Cardio-Obstetrics": A Burgeoning Field in Need of Increased Awareness, Training, and Collaboration, Canadian Journal of Cardiology, 10.1016/j.cjca.2021.09.019, 37:12, (2076-2079), Online publication date: 1-Dec-2021. Windram J, Grewal J, Bottega N, Sermer M, Spears D, Swan L, Siu S and Silversides C (2021) Canadian Cardiovascular Society: Clinical Practice Update on Cardiovascular Management of the Pregnant Patient, Canadian Journal of Cardiology, 10.1016/j.cjca.2021.06.021, 37:12, (1886-1901), Online publication date: 1-Dec-2021. Mcilvaine S, Feinberg L and Spiel M (2021) Cardiovascular Disease in Pregnancy, NeoReviews, 10.1542/neo.22-11-e747, 22:11, (e747-e759), Online publication date: 1-Nov-2021. Bright R, Lima F, Avila C, Butler J and Stergiopoulos K (2021) Maternal Heart Failure, Journal of the American Heart Association, 10:14, Online publication date: 20-Jul-2021. Wang J and Lu J (2021) Anesthesia for Pregnant Women with Pulmonary Hypertension, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2020.06.062, 35:7, (2201-2211), Online publication date: 1-Jul-2021. Quiñones J, Walheim L, Mann K, Rochon M and Ahnert A (2021) Impact of type of maternal cardiovascular disease on pregnancy outcomes among women managed in a multidisciplinary cardio-obstetrics program, American Journal of Obstetrics & Gynecology MFM, 10.1016/j.ajogmf.2021.100377, 3:4, (100377), Online publication date: 1-Jul-2021. Siu S, Lee D, Rashid M, Fang J, Austin P and Silversides C (2021) Long‐Term Cardiovascular Outcomes After Pregnancy in Women With Heart Disease, Journal of the American Heart Association, 10:11, Online publication date: 1-Jun-2021. Davis M, Arendt K, Bello N, Brown H, Briller J, Epps K, Hollier L, Langen E, Park K, Walsh M, Williams D, Wood M, Silversides C and Lindley K (2021) Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.02.033, 77:14, (1763-1777), Online publication date: 1-Apr-2021. O'Kelly A, Scott N and DeFaria Yeh D (2021) Delivering Coordinated Cardio-Obstetric Care from Preconception through Postpartum, Cardiology Clinics, 10.1016/j.ccl.2020.09.012, 39:1, (163-173), Online publication date: 1-Feb-2021. Sharma G, Ying W and Silversides C (2021) The Importance of Cardiovascular Risk Assessment and Pregnancy Heart Team in the Management of Cardiovascular Disease in Pregnancy, Cardiology Clinics, 10.1016/j.ccl.2020.09.002, 39:1, (7-19), Online publication date: 1-Feb-2021. Meece L, Park K, Wen T, Jeng E and Ahmed M (2021) Pregnancy With a Ventricular Assist Device: A Systematic Review of the Existing Literature, Journal of Cardiac Failure, 10.1016/j.cardfail.2020.08.014, 27:2, (185-187), Online publication date: 1-Feb-2021. Wolfe N, Sabol B, Kelly J, Dombrowski M, Benhardt A, Fleckenstein J, Stout M and Lindley K (2021) Management of Fontan circulation in pregnancy: a multidisciplinary approach to care, American Journal of Obstetrics & Gynecology MFM, 10.1016/j.ajogmf.2020.100257, 3:1, (100257), Online publication date: 1-Jan-2021. Sharma G, Minhas A and Michos E (2021) Prevention of Cardiovascular Disease Sex Differences in Cardiac Diseases, 10.1016/B978-0-12-819369-3.00013-7, (33-54), . PURISCH S, ALGODI M, TAUB C and GOFFMAN D (2020) Evaluation and Diagnostic Testing, Clinical Obstetrics & Gynecology, 10.1097/GRF.0000000000000566, 63:4, (828-835), Online publication date: 1-Dec-2020. Balla S, Gomez S and Rodriguez F (2020) Disparities in Cardiovascular Care and Outcomes for Women From Racial/Ethnic Minority Backgrounds, Current Treatment Options in Cardiovascular Medicine, 10.1007/s11936-020-00869-z, 22:12, Online publication date: 1-Dec-2020. Blumer V and Pagidipati N (2020) Hypertensive Disorders of Pregnancy and Long-Term Heart Failure Risk, Hypertension, 76:5, (1420-1422), Online publication date: 1-Nov-2020. Ouyang P and Sharma G (2020) The Potential for Pregnancy Heart Teams to Reduce Maternal Mortality in Women With Cardiovascular Disease, Journal of the American College of Cardiology, 10.1016/j.jacc.2020.09.007, 76:18, (2114-2116), Online publication date: 1-Nov-2020. Magun E, DeFilippis E, Noble S, LaSala A, Waksmonski C, D'Alton M and Haythe J (2020) Cardiovascular Care for Pregnant Women With Cardiovascular Disease, Journal of the American College of Cardiology, 10.1016/j.jacc.2020.08.071, 76:18, (2102-2113), Online publication date: 1-Nov-2020. Sharma G, Zakaria S, Michos E, Bhatt A, Lundberg G, Florio K, Vaught A, Ouyang P and Mehta L (2020) Improving Cardiovascular Workforce Competencies in Cardio‐Obstetrics: Current Challenges and Future Directions, Journal of the American Heart Association, 9:12, Online publication date: 16-Jun-2020.Mehta L, Warnes C, Bradley E, Burton T, Economy K, Mehran R, Safdar B, Sharma G, Wood M, Valente A and Volgman A (2020) Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association, Circulation, 141:23, (e884-e903), Online publication date: 9-Jun-2020. Sharma G, Lindley K and Grodzinsky A (2020) Cardio-Obstetrics, Journal of the American College of Cardiology, 10.1016/j.jacc.2020.02.019, 75:11, (1355-1359), Online publication date: 1-Mar-2020. Pfaller B, Sathananthan G, Grewal J, Mason J, D'Souza R, Spears D, Kiess M, Siu S and Silversides C (2020) Preventing Complications in Pregnant Women With Cardiac Disease, Journal of the American College of Cardiology, 10.1016/j.jacc.2020.01.039, 75:12, (1443-1452), Online publication date: 1-Mar-2020. Crousillat D, Ghoshhajra B and Scott N (2020) Pregnancy in Familial Left Ventricular Noncompaction-Associated Cardiomyopathy, JACC: Case Reports, 10.1016/j.jaccas.2019.11.057, 2:1, (120-124), Online publication date: 1-Jan-2020. Davis M, Arany Z, McNamara D, Goland S and Elkayam U (2020) Peripartum Cardiomyopathy, Journal of the American College of Cardiology, 10.1016/j.jacc.2019.11.014, 75:2, (207-221), Online publication date: 1-Jan-2020. Haberer K and Silversides C (2019) Congenital Heart Disease and Women's Health Across the Life Span: Focus on Reproductive Issues, Canadian Journal of Cardiology, 10.1016/j.cjca.2019.10.009, 35:12, (1652-1663), Online publication date: 1-Dec-2019. Grodzinsky A, Florio K, Spertus J, Daming T, Lee J, Rader V, Nelson L, Gray R, White D, Swearingen K, Thomas M, Singh A, Magalski A and Schmidt L (2019) Importance of the Cardio-Obstetrics Team, Current Treatment Options in Cardiovascular Medicine, 10.1007/s11936-019-0789-1, 21:12, Online publication date: 1-Dec-2019. February 2019Vol 12, Issue 2 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.118.005417PMID: 30773028 Originally publishedFebruary 18, 2019 Keywordsperipartum periodcardiovascular diseasepregnancymaternal deathhypertensionPDF download Advertisement SubjectsCardiovascular DiseasePregnancyQuality and OutcomesRisk FactorsWomen, Sex, and Gender
Referência(s)