ACOG: Think CVD Before, During, and After Pregnancy

NASHVILLE — Pregnant women should be screened for cardiovascular disease (CVD) before pregnancy, diagnosed appropriately during pregnancy, and then followed closely after pregnancy, the American College of Obstetricians and Gynecologists (ACOG) said here.

Not only should all pregnant and post-partum women should be screened for CVD, but providers should be able to separate CV signs and symptoms from the normal symptoms of pregnancy, reported the ACOG Presidential Task Force on Pregnancy and Heart Disease.

Moreover, pregnant women with moderate to high risk cardiac conditions should be referred to appropriate hospital settings, the authors noted.

These recommendations appear as a practice bulletin in Obstetrics and Gynecology, and were discussed at a press conference by takes force members at the ACOG annual meeting.

Lisa Hollier, MD, ACOG president, and lead author on the practice bulletin said that the purpose of this guidance is to “eliminating preventable maternal deaths.”

“We have seen a rise in the rates of maternal mortality due to acquired cardiac disease in pregnancy. It’s critical that we as physicians develop expertise in recognizing which signs and symptoms of pregnancy are normal, and which are abnormal [and indicative of CVD] so we can save women’s lives,” she said.

Afshan Hameed, MD, executive member of the Pregnancy and Heart Disease Task Force, offered her thoughts via phone, emphasizing the importance of awareness and education to prevent maternal mortality. Hameed said that often, a pregnant woman has presented with symptoms, such as shortness of breath, fatigue or cough, only to be dismissed or misdiagnosed.

But screening all pregnant women and postpartum women for CVD could help with early diagnosis and treatment, she said.

“We believe if we have universal screening by using the cardiovascular disease algorithm [recommended by the task force], we have the potential to discover undiagnosed cardiovascular disease and improve maternal mortality and morbidity. The overwhelming majority of women who have died are not aware they had cardiovascular disease,” she said.

Janet Wei, MD, liaison for the American College of Cardiology, and practice bulletin co-author, emphasized the importance of a “pregnancy heart team,” a multi-disciplinary team consisting of at least an ob/gyn and a cardiologist. This team would establish a comprehensive plan for delivery.

Wei also emphasized one of the key recommendations of the bulletin, which is referral to an appropriate hospital setting for pregnant patients with moderate-to-high risk cardiac conditions.

“All labor and delivery units should have a plan for tertiary referral in place in advance of the patient coming in to see you for a cardiac condition, to know who and where to refer them,” she said.

James Martin, MD, chair of ACOG’s Pregnancy Heart Task Force, said that this care needs to extend into the postpartum period, noting that stroke risk in pregnant women with hypertensive disorders is highest 5-6 days after delivery. However, he added that this risk is not as well-defined for CVD; that the risk continues through pregnancy, accelerates post-partum and can persist long afterward.

However, Martin said that 40% of women do not return for postpartum care.

“Perhaps it reflects our need to change payment models so doctors and patients recognize the importance of coming back, [because] the end of pregnancy is the beginning of the rest of their life,” Martin said.

Moreover, once a woman is identified as being at risk of postpartum CVD, she needs to be seen more often than a routine postpartum patient, he said. Among these recommendations is a comprehensive CV visit at 12 weeks postpartum.

“We need to get insurers and payers to fund that — it doesn’t need to be ob/gyns, maybe it would be better to have cardiologists do [that exam],” Martin said.

While the majority of recommendations were supported by level C evidence (defined as based primarily on consensus and expert opinion), several were based on “limited or inconsistent” scientific evidence (level B). In addition to referral to an appropriate hospital setting, other level B recommendations include:

• Obtaining a baseline brain natriuretic peptide (BNP) level during pregnancy for women either at risk of or with known heart disease
• Pregnant and postpartum women with chest pain should undergo standard troponin testing and an echocardiogram to evaluate for acute coronary syndrome
• Patients should be counseled to avoid pregnancy or consider induced abortion if they have severe heart disease, severe valvular stenosis, or severe types of Marfan syndrome