Growth of Cardio-Obstetrics Care Presents Challenges, Opportunity

For several years, congenital heart specialists have been counseling their female patients who hoped to give birth despite their existing health conditions.

Because these patients are living much longer with a better quality of life, it's now possible for much of this population to safely take on motherhood. And in recent years, the field of cardio-obstetrics has expanded from caring for women who have existing congenital heart diseases to treating a wider range of prenatal and postpartum patients.

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"A lot of changes happen during pregnancy that put increased stress on the heart," says Melinda Davis, M.D., assistant professor of internal medicine at the University of Michigan Frankel Cardiovascular Center. "Sometimes, women with underlying disorders can manifest symptoms during pregnancy.

"And as we're seeing women become pregnant at an older age and with more existing medical problems, we find we need combined expertise from both obstetrics and cardiology to provide the best care."

To address the evolving field, Davis co-authored a new perspective in Circulation: Cardiovascular Quality and Outcomes with Mary Norine Walsh, M.D., of St. Vincent Heart Center in Indianapolis.

Davis, also an assistant professor of obstetrics and gynecology at U-M's Von Voigtlander Women's Hospital, spoke more about current approaches to cardio-obstetrics — and how to improve medical care for pregnant women with cardiovascular disease.

What is cardio-obstetrics and who might need that specialty care?

Davis: There's been a lot of attention recently to increased risk of maternal morbidity and mortality in the United States. Statewide studies have found more than one-fifth of maternal deaths were related to cardiovascular disease such as heart failure or stroke. It's important to address these concerns.

Today, there are several aspects of cardio-obstetrics. Here at Michigan Medicine, we care for women with complex cardiac conditions who become pregnant, as my colleagues Timothy Cotts, M.D., and Mark Norris, M.D., have been doing with great results for some time for our congenital patients. We are also working with women who are diagnosed with cardiovascular disease during pregnancy, requiring expertise in both cardiology and obstetrics.

During pregnancy, some women develop new conditions, such as peripartum cardiomyopathy (heart failure that happens at the end of pregnancy and right after delivery) or irregular heart rhythms. Sometimes a condition may have already existed but didn't cause any issues until the stress of pregnancy essentially unmasked the problem.

SEE ALSO: Women with Congenital Heart Disease: Safe Pregnancy Is Possible

Finally, we're also finding that several conditions that occur during pregnancy may be associated with increased risk of cardiovascular disease down the road — including preeclampsia, hypertension, gestational diabetes and preterm birth, and it's important to pay attention to those risks and monitor them throughout the life span.

How are hospital systems addressing cardio-obstetrics, and what are the current best practices?

Davis: We find a team-based approach is ideal, and many institutions are launching multidisciplinary collaborations in the same way heart valve teams, aortic disease teams and heart failure teams come together to provide comprehensive care.

Our cardio-obstetrics team at Michigan Medicine includes experts in maternal fetal medicine, adult congenital heart disease, cardiology, nursing, pharmacy, and anesthesiology. We have regular meetings to discuss our pregnant patients with heart disease.

What challenges persist in cardio-obstetrics?

Davis: A major challenge is the diagnosis itself, because a lot of symptoms we'd look for from a heart standpoint are similar to those of normal pregnancy, such as shortness of breath, swelling in the legs, weight gain or needing to sit up at night.

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Additionally, medical trainees should have more exposure to pregnancy and heart disease since this is a growing field. There are unique changes that happen to the cardiovascular system during pregnancy and special considerations for labor and delivery.

Furthering the research is also important. There are several different types of cardiovascular diseases that occur in the setting of pregnancy, and we need more research to better understand the ideal way to treat these conditions. Women can get involved in research studies or enroll in a registry.  

With bigger numbers and ongoing research, we will be able to more effectively advise and treat pregnant women with these complex conditions.