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Cardiac Disease in Pregnancy: What Do We Not Know?

Op-Med is a collection of original articles contributed by Doximity members.

The 38th Annual Meeting in Dallas started with several post-graduate courses. One of the popular among attendees was The Pregnant Cardiac Patient- At Risk of Indirect Maternal Death: How to Manage Before, During, and After Pregnancy. This course was unique to SMFM because speakers were a combination of MFM subspecialists, Cardiologists, and Anesthesiologists constituting a perfect blend of the multidisciplinary care that these high risk pregnant mothers require!

Cardiovascular disease complicates 1–4% if all pregnancies and is the leading cause of indirect maternal death. A significant number of these unfortunate cases are preventable provided both physicians/health care providers and patients are well informed. Health care providers must keep cardiac disease in the differential diagnosis when a pregnant or postpartum woman presents with cardiac symptoms which may easily be dismissed as being normal for the pregnant or postpartum period. Likewise, the patients must be educated to watch out for symptoms with worrisome features that may represent cardiac condition. These quality improvement opportunities are likely to improve care in these high risk pregnancies.

Excellent lectures and robust case discussions included an exchange of thought processes and understanding of pathophysiology. Feedback from this course has been exceptional and the attendance exceeded expectation.

The meeting brings a great motivation for both changes in practice and future research in the field of MFM. Attendees of this post-graduate will hopefully understand the key message to manage the Cardiac Pregnant patient in partnership with their multidisciplinary team.

Highlights

The Plenary Sessions were outstanding including presentations of restrospective and Randomized Control Trials (RCT). Studies were not exclusive to the USA, there were studies from several countries including France, Italy, the Netherlands, and Korea. The study designs were varied from animal models to clinical trials. Both study methods and presentations were exceptional.

Among the many impressive presentations at the Plenary sessions, a few are reported here. The oral presentations on Thursday Feb 1, 2018 opened with the TRAPP trial by Dr. Loic Sentilhes of Bordeaux University Hospital, France. This multicenter double-blinded RCT examined the impact of 1g of tranexamic acid (TXA) after vaginal delivery on the incidence of postpartum hemorrhage (PPH). The authors concluded that TXA was associated with a lower risk of PPH than placebo without higher risk of severe adverse events. Dr. Borders of North Shore University, Evanston, IL. presented a QI study on severe maternal hypertension that aimed to reduce maternal morbidity associated with hypertension in 110 hospitals statewide. The aim was to assess the improvement of key process measures associated with hypertension identification and treatment in the first full year of the initiative. Authors concluded that a statewide QI effort, including collaborative learning, rapid response data and QI support, can reduce time to treatment of severe hypertension with antihypertensives, increase provide- nurse debriefs and patient education and follow up appointments at discharge across IL.

One of the impressive basic science studies was reported by Dr. Ornaghi of University of Milan, in collaboration with Yale university. She presented an innovative basic science study on treatment of CMV infection with Valnoctamide (VCD). VCD effectively blocks CMV infection in the developing auditory system and rescues virally induced hearing impairment. Dr. Sonnaville of OLVG, Amsterdam, Netherlands presented the impact of the HYPITAT I trial on obstetric management and outcome for gestational hypertension and preeclampsia in the Netherlands. This resulted in evidence that HYPITAT I lead to an increased induction of labor rate in women with a hypertensive pregnancy at term. This was associated with significant reduction in maternal morbidy and mortality and perinatal mortality. Dr. Grossman, second year MFM Fellow at Cornell University presented her work on fetuses with abnormal NT and normal NIPT. The aim was to determine the proportion of genetic abnormalities that could be identified by NIPT in pregnancies with abnormal NT. The authors concluded that while NIPT may be reassuring in those with mildly abnormal NT, a significant proportion of abnormalities in those with NT >/= 3.5 mm would not be detected. Invasive testing should be strongly recommended when NT is abnormal especially when NT is >/=3.5 mm and in women under age 35. The next step in VCD for pregnant women infected with CMV will be a Phase I clinical trial that could potentially change the course of fetuses exposed to CMV. It could be useful to repeat the HYPITAT I study in the USA where we have a diverse population that is at even higher risk of morbidity and mortality due to hypertensive disease of pregnancy. The implementation of HYPITAT I could be even greater in the USA; however, a multi-center study on a large scale would be needed to illustrate its impact. Finally, Dr. Grossman’s retrospective study on the significance of the NT is important for counseling of the patient with this finding and decision making for diagnostic testing versus further screening with the NIPT.

Diana S Wolfe, MD, MPH

Afshan Hameed, MD

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