CardioNerds (Amit Goyal and Daniel Ambinder), Cardio-OB series co-chair and University of Texas Southwestern Cardiology Fellow, Dr. Sonia Shah, episode lead fellow, Dr. Kaitlyn Ibrahim (Temple University now practicing with Lankenau Heart Group), join Dr. Afshan Hameed (Maternal-Fetal Medicine, Obstetrics & Gynecology, UC Irvine), Dr. Paul Forfia (Co-Director, Pulmonary Hypertension, Right Heart Failure & CTEPH Program, Temple University Hospital), and Dr. Marie-Louise Meng (Obstetric and Cardiothoracic Anesthesiology, Duke University) to discuss pregnancy and multidisciplinary critical care.

Three experts from varied subspecialties including Cardiology, Pulmonary Hypertension, Maternal Fetal Medicine, Cardiac Anesthesia and Obstetrical Anesthesia guide listeners through a case of a patient with a congenital conotruncal ventricular septal defect, Eisenmenger physiology, and pulmonary hypertension who becomes pregnant. The discussion touches on pre-conception risk assessment, pulmonary hypertension medical therapy in pregnancy, maternal monitoring during pregnancy, development of detailed multidisciplinary delivery plans and accessibility of such plans, and peri- and post-partum multidisciplinary management of high-risk patients.

Audio editing and episode introduction by CardioNerds Academy Intern, Christian Faaborg-Andersen.

Pearls • Notes • References • Guest Profiles • Production Team

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1. Cyanotic congenital heart disease presents multiple risks to the fetus, the most significant being intrauterine growth restriction. In a patient with Eisenmenger physiology, maternal oxygenation should be monitored closely throughout pregnancy, as hypoxia is often a marker of increased right to left shunting in these patients.
2. In patients with pulmonary hypertension, the RV-PA coupling relationship is the best indicator of maternal cardiovascular reserve through the pregnancy and post-partum period. The goal of therapy is to get the pulmonary vascular resistance down to a point where the right heart can adapt to that load and function either at a normal or a near-normal level.
3. When a high-risk patient meets with Anesthesia, it is important to consider the A’s: 1. Airway (anticipating any potential difficulties); 2. Access (whether this may present a challenge at the time of delivery); 3. Anxiety (specifically differentiating true hemodynamic changes in high-risk patients versus physiologic changes from anxiety); 4. Anticoagulation (knowledge of what agent the patient is on to determine safety of neuraxial anesthesia); 5. Availability (determining who else needs to be in the room, i.e. CT surgery, cardiothoracic anesthesia, ECMO team); 6. Arena (where is the safest place for this patient to deliver).
4. In patients with a shunt who undergo a Cesarean section, the uterus should not be exteriorized due to risk of venous micro air emboli.
5. As Dr. Forfia says, “panic is more dangerous sometimes than pulmonary hypertension!” Meaning, it is important to meet as a multidisciplinary team to develop a clear, easily accessible delivery plan for the patient. It is also prudent to have “everyone functioning in the environment they function best” like delivering the baby on the labor and delivery floor where all the necessary equipment and team members are available and bringing in other experts if needed rather than a cardiac operating room.

For a deep dive into Pregnancy & Pulmonary Hypertension, enjoy:

• Episode #124 with Dr. Candice Silversides.
• Episode #144 – Case Report: A Mother with Shortness of Breath

1. How does a multidisciplinary team play a role in the care for a high risk cardio-obstetrics patient, particularly one with congenital heart disease and pulmonary hypertension?

• According to the 2018 ESC guidelines, a multidisciplinary team is required to care for the pregnant patient with PH. This should include a PH expert at an experienced center for pregnancy and cardiac disease. Maternal outcomes in patients with PH have improved with targeted therapies as well as a multidisciplinary, team-based approach.
• A multidisciplinary team for a high-risk cardio-obstetrics patient should have representation from several subspecialties, typically including Cardiology (and in patients with PH, a PH expert should be included), Maternal Fetal Medicine, and Anesthesiology. Additional subspecialities can be added depending on the underlying diagnosis of the patient and any potential challenges anticipated at the time of delivery. (i.e. CT Surgery if ECMO may be needed).
• The key is consistent membership within the group for optimal team dynamics, working relationships, and continuity of patient care. Familiarity among group members helps to facilitate improved communication.
• Team members should be experienced in the care of high-risk cardio-obstetrics patients. As Dr. Forfia mentions during the podcast, panic can be the downfall of a well-functioning team in a high stake setting and is often dangerous to the patient.
• Frequent meetings should happen amongst group members to discuss patients and to form individualized, multidisciplinary delivery plans. The delivery plan should detail each aspect of labor and delivery, include the names and contact information of providers involved in the patient’s care, and should be easily accessible (ideally in a prominent location in the patient’s electronic medical record).
• If possible, providers should be allowed to work in their usual environment. For example, a high-risk patient should deliver on the L&D floor/L&D OR with OB/MFM and other members of the multidisciplinary team should come to that area. This ensures all necessary equipment and experienced staff will be present during the delivery.

2. What are the important considerations during the Anesthesia evaluation of a high-risk pregnant patient?

• When a high-risk patient meets with Anesthesia during pregnancy, the A’s should be considered, listed below:
• Airway: It is important to perform an assessment of the patient’s airway prior to delivery to anticipate any potential difficulties and to ensure that the appropriate equipment is available at the time of delivery if a difficult airway is anticipated.
• Access: Potential intravenous access sites should be assessed prior to delivery to determine whether access may present a challenge at the time of delivery.
• Anxiety: An Anesthesiologist for a high-risk patient should be adept at differentiating true hemodynamic alterations versus physiologic changes from anxiety to provide appropriate therapy and counseling.
• Anticoagulation: A subset of high-risk cardiac patients will be on chronic anticoagulation therapy during pregnancy. Knowledge of a patient’s anticoagulant is critical in determining the safety of neuraxial anesthesia. It is also important to highlight that Eisenmenger’s can lead to thrombocytopenia, which (if severe enough) can be a contraindication to neuraxial anesthesia.
• Availability: It is vital to determine who will need to be available for a high-risk patient’s delivery, particularly which specialists, but also which subspecialists (i.e. cardiac anesthesia, cardiologists with expertise in pulmonary hypertension, ECMO team etc.). This allows adequate planning and staffing at the time of delivery.
• Arena: The multidisciplinary team should discuss the best place for the patient to deliver (i.e. the L&D floor, L&D OR, cardiac OR) depending on the expected course of delivery. Often, it is best to have the patient delivery on a dedicated obstetrical floor and bring any necessary consultants there to ensure all necessary equipment for the delivery and experienced obstetrical staff are present.

3. What are some pearls for the multidisciplinary management of high-risk cardio-obstetrics patients and specifically those with pulmonary hypertension and a shunt lesion during delivery?

• As mentioned previously, a detailed delivery plan should be created in advance of delivery with input from the multidisciplinary team caring for the patient. This should be easily accessible by all team members at the time of delivery.
• Most of these patients should deliver by 37 weeks gestation at a center with cardiology and intensive care unit support if needed.
• Patients with pulmonary hypertension should avoid Valsalva/pushing as much as possible. This is accomplished by an assisted second stage of labor.
• Patients with uncorrected cyanotic congenital heart disease should be considered for antibiotic prophylaxis for endocarditis at the time of delivery.
• In patients with an intracardiac shunt, all intravenous lines should have filters to prevent paradoxical air embolism. Additionally, the OB team should avoid “exteriorizing” the uterus during a C-section due to risk of paradoxical air embolism. This is particularly important in right-to-left shunt lesions.
• Fetal heart rate can serve as the “5th vital sign” of the mother during the time of delivery and can add to the overall assessment of the mother and fetus.
• Specialized Anesthesia care may involve the insertion of a central line and/or arterial line for close hemodynamic monitoring during delivery and in the immediate post-partum period.

4. What are the interdisciplinary critical care considerations in the post-partum period for high-risk patients, and specifically those with pulmonary hypertension and shunt lesions?

• According to the 2018 ESC guidelines, the highest risk period is during puerperium and early post-partum where fluid shifts and hemodynamic changes are the greatest. As part of the delivery plan, immediate post-partum care should also be specified. Often high-risk patients may need to be monitored and managed in an ICU setting or on a Cardiology primary service with the OB/MFM, Anesthesiology, and Cardiology/PH teams participating in co-management.
• Meticulous fluid balance and optimization of RV function are important determinants of an optimal outcome in patients with PH who are post-partum.
• Frequent monitoring of volume status and oxygenation by experts in Cardiology and Pulmonary Hypertension is key in the early post-partum period in these patients. If progressive volume overload is seen, diuretics should be administered.
• Fluid mobilization in the early post-partum period is a cause of right ventricular volume overload and right heart failure and may lead to increased shunting.

5. If the unexpected happens, what are pearls for cardiac arrest in a pregnant patient?

• Cardiac arrest in the pregnant patient can have many possible causes. Initial steps including establishing IV access above the diaphragm, administering 100% oxygen, and relieving aortocaval compression with continuous left lateral displacement of the gravid uterus. This helps to improve maternal hemodynamics during compressions.
• The gravid uterus causes upward displacement of the internal organs. According to the AHA guidelines, chest compressions should be delivered with the patient supine, with constant left lateral displacement of the gravid uterus to relieve aortocaval compression. In the past, a 30-degree left lateral decubitus tilt was recommended, however it has been shown that this decreases the effectiveness of chest compressions and is therefore no longer recommended.
• If the patient was receiving IV Magnesium pre-arrest, this should be stopped, and IV/IO Calcium Chloride or Calcium Gluconate given.
• The pregnant patient’s airway undergoes significant changes during pregnancy, with increased friability and mucosal secretion. The upward displacement of internal organs also increases the risk of aspiration. The upward shift of the diaphragm leads to decreased functional residual capacity, increased metabolic demand, and potentially faster desaturation.
• Defibrillation doses and standard ACLS medication doses remain the same in the pregnant patient. During a cardiac arrest, no medications should be withheld for concerns of teratogenicity.
• If the pregnant patient does not respond to intervention and lacks return of spontaneous circulation, Cesarean section must be considered immediately within the first 4-5 minutes of CPR for optimal maternal and fetal outcomes. This should be done at the site of the cardiac arrest if it was an in-hospital cardiac arrest.

1. Li Q, Dimopoulos K, Liu T, et al. Peripartum outcomes in a large population of women with pulmonary arterial hypertension associated with congenital heart disease. Eur J Prev Cardiol. 2019; 26:1067-1076.

2. Presbitero P, Somerville J, Stone S, Aruta E, Spiegelhalter D, Rabajoli F. Pregnancy in cyanotic congenital heart disease. Outcome of mother and fetus. Circulation. 1994; 89:2673 – 2676.

3. Regitz-Zagrosek V, Roos-Hesselink J.W., Bauersachs J, et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy: the task force for the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). Eur Hear J. 2018; 39:3165-3241.

4. Jeejeebhoy FM, et al. Cardiac arrest in pregnancy. A scientific statement from the American Heart Association. Circulation. 2015; 132: 1747-1773.

Dr. Kaitlyn Ibrahim has graduated cardiology fellowship from Temple University Hospital. She is currently a non-invasive cardiologist with a focus on women’s health as part of the Lankenau Heart Group.

Dr. Afshan Hameed is a Clinical Professor of both Cardiology and Maternal Fetal Medicine at the University of California, Irvine.  Dr. Hameed has served on multiple guideline committees on heart disease and pregnancy for the American College of Obstetrics and Gynecology and serves on the California Maternal Quality Care Collaborative (CMQCC) Pregnancy Associated Mortality Review Advisory Committee (PAMR) that reviews all cases of maternal mortality to identify gaps in care for quality improvement opportunities. She also serves on the writing committee for the Heart Rhythm Society’s “Arrhythmias in Pregnancy Guidelines” and as an expert to help create an Obstetrics Basic Life Support curriculum to integrate into the American Heart Association Life Support Program.

Dr. Paul Forfia is a Professor of Medicine at Temple University Hospital and Co-Director of the Pulmonary Hypertension, Right Heart Failure, and CTEPH Program at Temple University Hospital. He is a renowned expert in the management of patients with right heart failure and PH and has grown the program at Temple to one of the largest in the country.

Dr. Marie-Louise Meng is an assistant professor of anesthesiology at Duke University who has completed additional fellowships in both obstetrical anesthesia and cardiothoracic anesthesia. She is also a physician-scientist researching the role of echocardiography and biomarkers in identifying women at risk of cardiovascular complications after pregnancies complicated by preeclampsia.

• Natalie Stokes, MD
• Sonia Shah, MD
• Amit Goyal, MD
• Daniel Ambinder, MD