AHA News: Could 'Cardio-Obstetrics' Curb Rise in Pregnancy-Related Deaths?

TUESDAY, Feb. 19, 2019 (American Heart Association News) -- More collaboration between cardiologists and obstetricians could help curb the nation's soaring death rate among pregnant women, according to a new report urging more team-based care for these vulnerable mothers.

Pregnant women in the United States have a higher risk of dying than women in any other industrialized country. The reasons behind these deaths are complex but include racial-ethnic disparities and insufficient access to care.

Changes in maternal demographics over the years also have played a key role: More pregnant women are older, and many have chronic medical conditions such as obesity, diabetes and high blood pressure – all risk factors for heart disease and stroke.

Cardiovascular disease is now a leading cause of maternal death. Encouraging development of cardio-obstetric teams could help this growing population of women, from pregnancy to postpartum, say the authors of a perspective published Monday in the American Heart Association's journal Circulation: Cardiovascular Quality and Outcomes.

"In this country, the risk of morbidity and mortality related to pregnancy is appalling. We can and must do better," the authors write. "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."

Women who have pregnancy-related health problems -- including preeclampsia, gestational diabetes and preterm birth -- are at higher risk for heart disease years later. Yet many women fail to see an internist or cardiologist until a problem arises. That's partly because, for many women, the only doctor they see after pregnancy is the gynecologist for their annual exam.

"It's ingrained in many of us, 'Go get your Pap smear,' but it's not ingrained in us to think, 'Should I check my fasting glucose? What is my cholesterol?'" said cardiologist Dr. Melinda Davis, one of the paper's authors and an assistant professor at the University of Michigan in Ann Arbor.

"It's important to get plugged into a preventive care system as soon as possible. Access to care, education, awareness, and scheduling – it all plays into it."

The field of cardio-obstetrics is emerging. Dr. Mary Norine Walsh, co-author of the perspective and immediate past president of the American College of Cardiology, laid out her vision for cardio-obstetrics during the 2018 meeting of American College of Obstetricians and Gynecologists. The event helped create an online community around cardio-obstetrics and its research and has helped promote awareness around the discipline.

The just-published paper says cardio-obstetrics is "a clear area of need for improved quality of care" but for now, physicians receive no formal training in this field. Instead, existing teams have learned by practice, with cardiologists and obstetricians combining their expertise with those in maternal fetal medicine, anesthesia and nursing.

"It does happen by experience," said Dr. Lisa Hollier, president of the American College of Obstetricians and Gynecologists. She was not part of the new paper. "That said, these multidisciplinary teams are an excellent example of all of us working together … to plan a safe pregnancy and delivery for these women."

These teams can help prevent gaps in communication and coordination of care that can lead to failure in recognizing warning signs of cardiovascular events and delays in their diagnosis and treatment, said Hollier, chief medical officer for obstetrics and gynecology at Texas Children's Health Plan in Houston.

Those types of delays and communication gaps are a leading factor in maternal death. The perspective noted that in the most recent statewide reviews of all maternal deaths reported in California and Illinois, about a quarter of the cases were deemed preventable.

Hollier said about 60 percent to 70 percent of all pregnancy-related maternal deaths in her state of Texas were believed to be preventable.

"We all have opportunities to remind providers about the importance of the handoff from their pregnancy care to whoever the clinician is that will be seeing them for the long term -- sometimes that is an internist and sometimes it is still the OB-GYN," she said. "We just need to make sure that all the physicians who are seeing these women are providing those important primary care services."