This is the third entry in our blogpost series that describe the different aspects of the Congenital Heart Disease Center's multi-disciplinary model of care. In this post, the role of Maternal-Fetal Medicine in care of CHD patients is examined and explained by Mayo Clinic Rochester obstetrician and gynecologist Carl Rose, M.D.
According to the Centers for Disease Control, there were 1.26 million women in the United States living with congenital heart disease in 2010.
Since many of these women may hope to start a family of their own, it is important that they understand risks of pregnancy in the setting of congenital heart disease.
Maternal-Fetal Medicine physician Carl Rose, M.D., says this desire from patients is on the minds of congenital heart disease cardiologists.
“Our Congenital Cardiology colleagues are very proactive in counseling patients about the potential risk of pregnancy-related complications. Management during pregnancy may require frequent medical visits with a multidisciplinary team comprised of Congenital Cardiology, Maternal-Fetal Medicine, Anesthesiology, Nursing, and occasionally other specialists, depending on the individual maternal heart condition.
This is important particularly for the stress pregnancy imparts on the cardiovascular system.
“What we become concerned about during pregnancy is worsening of an underlying condition. Usually the work the heart has to do increases by about 50 percent during pregnancy, in conjunction with an increase in circulating blood volume” Rose explained.
Generally, once a woman conceives, an early ultrasound is performed to determine if the pregnancy is viable, the number of babies, and gestational age. Following this, a detailed fetal ultrasound is done at about 18 to 20 weeks gestation, with repeat imaging every four weeks to recheck fetal growth. During pregnancy, mothers will have cardiology visits and echocardiograms periodically to assess heart function, and will also have an appointment with Congenital Cardiology in the third trimester.
“During pregnancy, especially near term, Congenital Cardiology, Maternal-Fetal Medicine, and Anesthesiology meet with parents. In addition, we hold a conference every two weeks to review upcoming deliveries of high-risk patients with regard to details pertaining to timing, method, and location of delivery” Dr. Rose said. He added, what medications they would or wouldn’t use would also be discussed.
This team approach is integral to the success of the pregnancy. Rose detailed:
"I think there's an incredible amount of value in having everyone in one room around one table discussing a single pregnant patient with the focus on safety of mother and baby. Collectively, we bring more perspectives and experience to the table - all of us are smarter together than any of us alone and it eliminates any communication issues."
During delivery, the biggest difference comes in the actual birth itself. Exclusively in the congenital heart disease patient population, due to cardiac concerns, delayed pushing, is practiced. Rose provided the reasoning for this.
“The rationale for delayed pushing is that it reduces the time during each of the Valsalva (pushing) expulsive efforts. With every maternal push, blood flow back to the heart is temporarily reduced. And as a consequence, we try to minimize the cardiac demands during labor."
After delivery, doctors and other providers will closely monitor the cardiac status of the mother as the demands on the heart typically increase further after birth and deterioration is possible within the first 24-48 hours postpartum.
What becomes challenging for the patient, the cardiologist and other providers, is that many times, potentially worrisome symptoms can be difficult to distinguish from normal symptoms of pregnancy such as fatigue, discomfort or difficulty breathing.
“We will typically advise mothers that any prolonged symptoms, particularly symptoms that occur at rest, require evaluation. We would rather have the mother present for evaluation rather than simply ascribe it to the pregnancy and miss a serious problem.”
For certain conditions, pregnancy can have a long-term deleterious effect on maternal cardiac function. In addition, some patients with artificial heart valves may experience accelerated deterioration of the artificial valve, and therefore limit the lifespan of those valves.
Pregnancy in cardiac patients has its challenges, but Dr. Rose left potential mothers a message of hope saying, "The majority of patients with congenital heart disease can have successful pregnancies."