Matters of the Heart: Improving the Care Delivered to Parturients with Cardiac Disease

Jordan Francke, MD MPH

The National Vital Statistics System (NVSS) reports have shown that maternal mortality rates in the United States have continued to increase in recent years, from 20.1/100,000 live births (LBs) in 2019, to 23.8/100,000 LB in 2020, and 32.9/100,000 LBs in 2021. A panel of experts on this topic explored the underlying reasons for this phenomenon and opportunities for improvement during the session, “Cardio‐Obstetric Anesthesia: Optimizing the Anesthesia Pregnancy Heart Team for Safe and Equitable Care,” on Saturday, May 18 during the 2024 Annual Meeting, presented by IARS and SOCCA. Ruth Landau, MD, Virginia Apgar Professor of Anesthesiology and Division Chief of Obstetric Anesthesia at Columbia University Irving Medical Center, moderated this engaging discussion.

Hanna Hussey, MD, assistant professor of anesthesiology and associate program director of the obstetric anesthesiology fellowship at the University of Alabama at Birmingham, began by introducing the audience to the concept of a “delivery framework,” which is an individual care approach that assesses for each parturient 1) who they are and what their birth plans and goals are, 2) what type of delivery is most indicated for them and optimal timing, and 3) what type of facility and anesthetic approach would best serve their needs. She reminded the audience that a pregnancy heart team includes many specialists: maternal-fetal medicine, obstetric anesthesiologists, intensivists, and even hematologists, but that the most vital member of the team is the patient themselves and providers should endeavor to honor their wishes whenever possible.

Dr. Hussey reviewed an observational study on the Registry of Pregnancy and Cardiac Disease (ROPAC), illustrating that of 5,739 patients in the study, the cardiac lesion with the highest association of complications was pulmonary arterial hypertension. Many of the parturients within this study fared reasonably well due to thoughtful risk-stratification and individualized care. One of the most robustly studied and comprehensive obstetric risk stratification systems is the Modified WHO Classification of Maternal Cardiovascular Risk, and she illustrated its utility by applying it to an example patient with hypertrophic obstructive cardiomyopathy undergoing a cerclage. She ended by highlighting the ACOG Levels of Maternal Care: Obstetric Care Consensus No. 9, which among other recommendations, advocated for high-risk cardiac patients to be managed by obstetric fellowship-trained (or equivalent) anesthesiologists.

The following presenter, Carlos M. Delgado Upegui, MD, an assistant professor of anesthesiology and pain medicine and associate director of their obstetric anesthesia division at the University of Washington, focused on ethnic and racial disparities presenting in obstetric patients. He displayed evidence that non-White patients exhibited higher rates of myocardial infarction, peripartum cardiomyopathy, and stroke, and all of these were elevated even after adjusting for confounders like maternal age, socioeconomic status, and medical comorbidities (https://pubmed.ncbi.nlm.nih.gov/35944667/). Special attention was given to patients of American Indian and Alaskan Native background, a population that Dr. Delgado Upegui encounters frequently at the University of Washington. Approximately 40% of these individuals live within a reservation, rural, or frontier community, where access to antenatal care is difficult. These patients also face significantly higher rates of peripartum cardiomyopathy, pre-eclampsia, obesity, and hypertension, all of which may be associated with life-threatening complications to mother or baby (https://pubmed.ncbi.nlm.nih.gov/37254753/).

Dr. Delgado Upegui concluded by reminding the audience that representation in research and medicine matters. Many studies do not report the race of study participants at all, or do not stratify race beyond “White and non-White” (therefore losing granular details about key demographic groups including patients of Indigenous, Hispanic, Asian and Pacific Islander backgrounds). He also reminded the group of the power of having a perinatal workforce that reflects the backgrounds of the patient population it serves.

Patrick Hussey, MD, an assistant professor at the University of Alabama at Birmingham, shared his perspective on the topic as a cardiac anesthesiologist and his particular interest in the intersection of cardiac disease and the parturient. He first illustrated to the audience the importance of obstetric contingency plans, including that 1 in 12,000 deliveries results in maternal cardiac arrest. This is most commonly from hemorrhage (38.1%), but may also be due to heart failure (15.2%), amniotic fluid embolism (13.3%), or sepsis (11.2%) (https://pubmed.ncbi.nlm.nih.gov/24694844/). Dovetailing from Dr. Delgado Upegui’s presentation, Dr. Hussey highlighted data indicating rates of ischemic vs. nonischemic cardiomyopathy in pregnancy vary widely based on race and merit further investigation (https://pubmed.ncbi.nlm.nih.gov/24443515/).

Dr. Hussey ended the session with a special plug to remember that point-of-care ultrasound can be an indispensable tool in an anesthesiologist’s arsenal when managing a parturient with cardiac disease, allowing for dynamic monitoring of volume status, flow turbulence, and biventricular global systolic function in real time.