Diana S. Wolfe
Key Points
•Care of a pregnant woman with cardiac disease requires collaboration between various disciplines
•The multidisciplinary team bridges the gap in communication, promoting appropriate care of the pregnant cardiac patient
•Academic, administrative, and logistic support is needed to create a cardio-obstetric team at a given institution
•A “Triad” solution to improve maternal mortality due to cardiovascular disease includes patient education, universal cardiovascular disease screening, and a multidisciplinary team approach
•Advocacy for establishing a cardio-obstetric team should continue at local and national levels
Introduction
The concept of team effort to care for a patient is not novel, especially when there is a high risk of morbidity and mortality. The goal is to bring together skill sets from maternal-fetal medicine (MFM), cardiology, anesthesia, neonatology, and other subspecialties as needed to optimize patient care. Cardiovascular disease in pregnancy is the number one indirect obstetric cause of pregnancy-related mortality ratio in the United States [1]. The 2006–2010 pregnancy-related mortality ratio was 16.0 deaths per 100,000 live births, a total of 14.6% due to cardiovascular conditions and 11.8% due to cardiomyopathy [1]. Improved data collection of severe maternal morbidity and maternal near-miss (SMM/MNM) has illustrated that cardiac disease is a significant contributing indicator in the United States [2]. The definition of SMM/MNM has evolved from the initial WHO definition that attempted to establish a comparable description across facilities to encourage health quality improvement [13]. The 2011 SMM/MNM definition includes five disease-specific, four management, and seven organ dysfunction−based criteria including cardiovascular dysfunction. In the United States, the Centers for Disease Control and Prevention (CDC) uses a large all-payer hospital inpatient care database for SMM/MNM surveillance. These indicators are based on three guiding principles [3]:
1.State-level availability of data in most states, territories, and large metropolitan areas
2.Presence of an established evidence base in the literature
3.Quality of the indicator was sufficient for population level surveillance and the planning and evaluation of public health interventions
A validation study of the CDC SMM/MNM index was applied to 67,468 deliveries across 16 California hospitals and found a sensitivity of 0.99 and a positive predictive value of 0.44 [4]. The American College of Obstetricians and Gynecologists (ACOG) and the Alliance for Innovation on Maternal Health updated the 2009 set of 25 CDC SMM/MNM indicators [3]. Based on the revised 21 indicator index, rates for the majority of SMM/MNM indicators increased in the United States between 1993–2014 [4]. Acute myocardial infarction was among those indicators that increased. This information implies the need for public health surveillance and clinical audit to ultimately improve quality obstetric care. A team of experts is required to care for complex obstetric patients including the cardiac pregnant patient.
Multidisciplinary Team
The cardio-obstetric team comprises a multidisciplinary team of the patient, physicians, nurses, and administration that includes the following team members at the minimum: MFM, cardiology, anesthesia, neonatology, labor and delivery (L&D), and critical care staff. The approach mirrors the “heart team” model, traditionally known as a team of cardiologists and cardiothoracic surgeons who manage most at-risk cardiac surgical patients [5]. The pregnancy heart team is now employed internationally, and outlined in the most recent European Society of Cardiology Guidelines [6]. The mobilization of this framework came from the devastating findings of the U.S. maternal mortality rate in recent years whereby cardiac disease is the number one contributor in the United States [1]. Due to the complexity of the cardiac pregnant patient, an exchange of expertise and knowledge among experts including MFM and cardiology is strongly advisable to optimize maternal and fetal outcomes.
Our Experience
At Einstein/Montefiore in the Bronx, New York, we created an MFM–Cardiology outpatient joint program in February 2015 in response to the rising contribution of cardiovascular conditions to pregnancy-related morbidity and mortality [1]. The aim was to establish a multidisciplinary program to optimize the care of high-risk pregnant patients with known or suspected cardiac disease. In these instances, there is a real potential for communication barriers or gaps in care when specialists individually see patients at different times, locations, and/or health systems.
To create a cardio-obstetric team, an institution needs administrative and academic support from both departments, i.e., obstetrics and gynecology and cardiology. The office space where patients are seen is a key component because it has to be designed to accommodate both maternal and fetal testing. The logistics including billing are often a challenge because each specialty and its staff are most accustomed to their own needs for detailed physical exam and testing. However, a collaborative environment can be established with administrative support from both specialties. Trainee participation is key to modeling this multidisciplinary work and therefore academic support to build this into fellows’ required rotations is recommended. In addition to the outpatient setting described, an inpatient team is essential for management of the pregnant cardiac patient.
At Einstein/Montefiore we have established an outpatient cardio-obstetric team that is composed of both MFM and cardiology attendings and fellows who see patients together in the same space at least 3 times per month. The cardiologists include subspecialists in interventional cardiology, noninvasive imaging, and congenital heart disease. The space where we see our patients has multiple expert areas within cardiology including pulmonary hypertension, heart failure, electrophysiology, and so on. Our office is able to provide a risk assessment through both maternal and fetal assessment. We have cardiac testing readily available including echocardiogram, EKG, pacemaker interrogation, and other vascular studies including lower extremity Doppler studies. We utilize sonograms and Doppler tones to assess fetal well-being as well as fetal echocardiography study within the same space. Our examination rooms consist of a gynecology table with the appropriate lighting and examination tools to provide for our pregnant patients and also to serve our postpartum and preconception patients. In this environment, as a team, together we have the ability to establish risk assessment each trimester (Table 2.1) and commence delivery planning. For our postpartum and preconception patients, reproductive life planning and birth control counseling is emphasized. The team demonstrates their collaboration to the patient, delivering the same message, clarifying any confusion while they are counseled in person by both MFM and cardiology. In addition to our outpatient team, we have an inpatient cardio-obstetric team where the delivery plans are finalized. We meet monthly in the cardiac intensive care conference room. All members of the team are represented to review the major concerns and exchange an understanding of both cardiac and obstetric risks (Figure 2.1). We use a template (see Figure 2.2) to present the case and a review checklist as a reminder of all aspects of the intrapartum and peripartum time period.
Sample Pregnancy Follow-Up Checklist | |||
Frequency of Follow-Up | |||
Cardiologist | Laboratory | Diagnostic Testing | |
First trimester | □ Once □ Every 4 weeks □ Every 2 weeks □ Every week | □ BNP □ CBC □ TSH □ INR □ Other | □ EKG □ Echocardiogram □ Holter monitor □ Exercise stress test □ Other |
□ Pregnancy termination | |||
Second trimester | □ Once □ Every 4 weeks □ Every 2 weeks □ Every week | □ BNP □ CBC □ TSH □ INR □ Other | □ EKG □ Echocardiogram □ Holter monitor □ Exercise stress test □ Other |
□ Anesthesia consultation □ Multidisciplinary meeting □ Delivery planning □ Contraception plan | |||
Third trimester | □ Once □ Every 4 weeks □ Every 2 weeks □ Every week | □ BNP □ CBC □ TSH □ INR □ Other | □ EKG □ Echocardiogram □ Holter monitor □ Other |
□ Contraception □ Medication review □ Follow-up plan with cardiology | |||
Postpartum | □ 1 week □ 2 weeks □ 4 weeks | □ BNP □ CBC □ TSH □ INR □ Other | □ EKG □ Echocardiogram □ Holter monitor □ Other |
Abbreviations: BNP, B-type natriuretic peptide; CBC, complete blood count; TSH, thyroid stimulating hormone; INR, international normalized ratio; EKG, electrocardiogram. | |||
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