Heart Disease in Pregnancy and Postpartum Depression

Pregnant women considered to be high risk require the expertise of a collaborative maternal-fetal medicine team that brings together all of the healthcare providers needed to reduce the risk of complications and increase the chance of a healthy pregnancy and successful birth. NewYork-Presbyterian/Weill Cornell Medical Center’s Department of Obstetrics and Gynecology cares for a high number of older pregnant women and others determined to be at high risk. The department has been expanding its portfolio of maternal-fetal medicine services to meet their needs, including a specialized focus on obstetric cardiology and postpartum depression.

It’s an optimal blend of skills and expertise: U.S.News & World Report ranks NewYork-Presbyterian as the #4 hospital in the nation for Gynecology, Cardiology and Heart Surgery, and Psychiatry in the latest “Best Hospitals” survey. Patients benefit from a personalized team that includes nationally recognized specialists from all of these fields.

A Dedicated Obstetric Cardiology Program

According to the American College of Obstetricians and Gynecologists, heart disease is the leading contributor to maternal mortality — accounting for 26.5 percent of pregnancy- related deaths annually, with 23 percent attributed to peripartum cardiomyopathy. Recognizing the increased risk of heart disease during pregnancy, NewYork-Presbyterian/Weill Cornell established a multidisciplinary program that unites physicians from obstetrics, maternal-fetal medicine, cardiology, and obstetric anesthesiology along with obstetric nurses and others involved in the care of these patients. Led by Inna V. Landres, MD, Director of Obstetric Cardiology and a maternal-fetal medicine specialist, the group meets every month to discuss each patient and pool their input to customize a plan of care.

“Mothers with acquired or congenital cardiac disease have nearly 100 times higher mortality than pregnant women without cardiac disease,” explains Dr. Landres. Many patients in the program had heart disease before they became pregnant, such as those with congenital heart defects. Others had it but did not know until they began prenatal care when testing discovered a problem. Still others had no heart disease previously but developed peripartum cardiomyopathy while pregnant.

Early on, signs and symptoms of cardiac disease in pregnancy may mimic those of common pregnancy issues, such as swelling in the legs and feet or shortness of breath. These symptoms are not uncommon as pregnancy progresses but may also be indicators of congestive heart failure. High blood pressure or periodic headaches may be normal for one patient but indicate an elevated risk of preeclampsia in another. “The physiologic changes of pregnancy, including increased blood volume and vascular stress, can stress the heart and exacerbate any preexisting cardiac conditions — especially moving into the second trimester and onward to delivery,” says Harsimran S. Singh, MD, MSc, Co-Director of Obstetric Cardiology and Director of Adult Congenital Heart Disease.

“It is important to know what each patient’s baseline is so we can determine when intervention is needed,” Dr. Landres adds. “Our team outlines everything there is to know about how to care for a patient, including medications, mode of delivery, cardiac monitoring, emergency contingency plans, and postpartum care. The plan becomes part of each patient’s electronic medical record, so it is readily available to any team member caring for her.”

Interventions may include ensuring patients take their medications as prescribed, modify certain activities, and see their cardiologists more frequently during pregnancy. The majority of patients with heart disease can deliver vaginally. During labor, Dr. Landres and the team use telemetry for monitoring and may recommend an early epidural for pain control and to prevent a rise in maternal heart rate. In rare cases, cardiac-assisted delivery is performed to facilitate delivery through the use of forceps or vacuum assistance.

Dr. Landres and the team are seeing more patients with heart disease before they become pregnant. “We encourage preconception counseling to optimize patients’ health and make sure they are aware of any potential risks before pregnancy,” she says.

“Women with cardiac disease can have an increased risk of complications during and after pregnancy. The goal of our multidisciplinary approach to their care is to help mitigate that risk,” concludes Dr. Singh. “This program is a great example of how different specialties can break down academic silos, all in pursuit of optimizing the health of our patients. We learn a lot from each other from the discussions and are able to formulate evidence-based and collaborative care plans. As a result, patients benefit.”

The obstetric cardiology program at NewYork-Presbyterian/Weill Cornell has a patient coordinator to help schedule appointments, including coordinating obstetric and cardiology appointments for the same day. To refer a patient, contact (212) 746-3266.

Universal Screening for Postpartum Depression

Postpartum depression is a common postnatal issue, occurring in approximately 9-10 percent of women postpartum. Women with a history of depression or anxiety, those with chronic medical conditions, and those carrying fetuses with congenital anomalies are at increased risk of depression and anxiety during and after pregnancy. Untreated postpartum depression can lead to adverse consequences for both mother and baby. Identifying and treating affected women is therefore doubly important.

With leadership by maternal-fetal medicine specialist Emilie L. Vander Haar, MD, the team at NewYork-Presbyterian/Weill Cornell is working to implement a universal tool to identify a patient’s risk of postpartum depression early, so intervention can begin sooner. “Screening currently varies from provider to provider. We want to develop a consistent screening program so patients at risk for postpartum depression can be diagnosed sooner and linked to our psychiatry providers as needed,” Dr. Vander Haar explains.

Many women who are taking medications for depression or anxiety and then become pregnant believe they have to go off of their medications during pregnancy, further raising their anxiety or deepening their depression. The maternal-fetal medicine team initiates a discussion with each patient and her psychiatrist to identify the most appropriate medication to control her symptoms during pregnancy. “For these patients, the benefits of taking a psychiatric medication during pregnancy far outweigh the risks,” says Dr. Vander Haar.

Obstetric team members throughout NewYork-Presbyterian/Weill Cornell are collaborating to devise a screening program that would be accessed and used by providers at all NewYork-Presbyterian campuses and obstetric practices via the electronic medical record system. Says Dr. Vander Haar, “My hope is that we can also use this as a research tool to better understand postpartum depression, identify patients early, and treat them as quickly as possible.”