Cardio-Obstetrics Clinic Seeks to Optimize Maternal and Fetal Outcomes

Today, women born with congenital heart disease are not only surviving into adulthood; they are thriving and contemplating pregnancy. Their improved survival, along with a rise in maternal age and increases in obesity, diabetes and hypertension, has made cardiovascular disease a leading cause of maternal morbidity and mortality in the United States.

Yet the risk of cardiovascular complications should not automatically rule out pregnancy, say Cleveland Clinic specialists. Coordinated subspecialty care can reduce the impact of pre-existing and acquired cardiovascular disease on maternal and fetal health and allow many women to enjoy uncomplicated pregnancies.

To that end, Cleveland Clinic has established a Cardio-Obstetrics Clinic for preconception consultation, pregnancy management and delivery planning. Heading the clinic are Jeffrey Chapa, MD, Head of the Maternal-Fetal Medicine Section in the Ob/Gyn & Women’s Health Institute, and David Majdalany, MD, Director of the Adult Congenital Heart Disease Center in the Sydell and Arnold Miller Family Heart & Vascular Institute.

Located in the Heart & Vascular Institute, the Cardio-Obstetrics Clinic offers women with acquired or congenital heart disease a unique opportunity to receive a comprehensive cardiac evaluation focused entirely on childbearing and pregnancy.

Pregnancy and the heart

Cardiovascular disease complicates 1 to 2 percent of U.S. pregnancies. “Pregnancy poses a significant physiologic stress to the heart and blood vessels, which is generally well-tolerated by healthy women,” notes Dr. Chapa. “However, for women with underlying cardiovascular disease — whether congenital or acquired — the added strain can result in significant cardiovascular dysfunction, leading to adverse maternal and fetal outcomes.”

Specific conditions that place women at risk during pregnancy include:

• Congenital heart disease (particularly those causing cyanosis) and/or its treatments
• Cardiomyopathy and hypertrophic cardiomyopathy
• Valvular disease
• Coronary artery disease
• Arrhythmias
• Aortic disease

Streamlined assessments

“The Cardio-Obstetrics Clinic provides the whole spectrum of care, from pre-pregnancy counseling to care throughout pregnancy, delivery and the post-partum period,” explains Dr. Majdalany. “Patients see specialists from cardiology and obstetrics on the same day, and, if necessary, receive referrals to additional specialists.”

Maternal echocardiography and fetal ultrasound services are offered on-site. Women also meet with a genetics counselor and a cardiovascular dietitian.

“Care is individualized to achieve the best outcome for both the mother and the baby,” says Dr. Majdalany.

The individualized plan for high-risk pregnancy management and delivery can come together relatively quickly, adds Dr. Chapa: “It’s the collaborative effort that makes a difference, as each specialist contributes his knowledge base to optimize maternal and fetal outcomes.”

Deliveries take place in Cleveland Clinic Children’s Special Delivery Unit (SDU), which is uniquely designed to manage both maternal and fetal critical illness. The unit has two labor and delivery suites, plus an operating room large enough to accommodate teams for mother and child.

If mothers require close postpartum monitoring, they can be admitted to a cardiac intensive care unit nearby. A pediatric hybrid cardiac catheterization suite is adjacent to the SDU if needed. The SDU staff make every effort to keep the mother and newborn together.

Easing fears and mitigating risk

One of the driving forces behind the Cardio-Obstetrics Clinic is the need to correct the abundant misinformation that prevents some women with heart disease from even considering pregnancy, says Dr. Chapa.

“We worry so much about the patient for whom pregnancy is not recommended due to the increased risk for adverse outcomes. Yet, more commonly, we see patients with heart disease who are simply told they should never consider getting pregnant,” he explains. “In reality, if you look at their disease, many are probably good candidates to conceive and are likely to have successful pregnancies and deliver healthy babies.”

Pre-pregnancy planning important

Dr. Majdalany adds that another concern is loss of follow-up and a suboptimal transition of care as young congenital heart disease patients reach adulthood; in some cases, pregnancy is one of the first stresses these young women face. He says that, ideally, they should have an evaluation with a cardiologist and high-risk obstetrician before becoming pregnant so that tailored treatment can be initiated to create a low-risk pregnancy.

Dr. Chapa and Dr. Majdalany acknowledge that controversy surrounds the management of certain types of complex congenital heart disease, and that data are limited. Through their experience in the Cardio-Obstetrics Clinic, they hope to contribute to the literature on optimal care for these high-risk pregnancies.

To refer patients to the Cardio-Obstetrics Clinic, call 855.REFER.123.