JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 77, NO.

14, 2021

ª 2021 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

JACC FOCUS SEMINAR: CARDIO-OBSTETRICS

JACC FOCUS SEMINAR

Team-Based Care of Women With

Cardiovascular Disease From
Pre-Conception Through Pregnancy
and Postpartum
JACC Focus Seminar 1/5

Melinda B. Davis, MD,a Katherine Arendt, MD,b Natalie A. Bello, MD, MPH,c Haywood Brown, MD,d Joan Briller, MD,e
Kelly Epps, MD,f Lisa Hollier, MD,g Elizabeth Langen, MD,h Ki Park, MD,i Mary Norine Walsh, MD,j
Dominique Williams, MD,k Malissa Wood, MD,l Candice K. Silversides, MD,m Kathryn J. Lindley, MD,k on behalf of
the American College of Cardiology Cardiovascular Disease in Women Committee and the Cardio-Obstetrics
Work Group

ABSTRACT

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related
to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive
appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice.
A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and
delivery, and ensure close follow-up during the postpartum period when CVD complications remain common.
The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect
to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key
time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum
complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should
receive appropriate education and longitudinal follow-up. (J Am Coll Cardiol 2021;77:1763–77)
© 2021 by the American College of Cardiology Foundation.

From the aDivision of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan,
USA; bDepartment of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA; cDepartment of
Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA; dDepartment of Ob-
stetrics and Gynecology, University of South Florida, Tampa, Florida, USA; eDivision of Cardiology, Department of Medicine,
University of Illinois at Chicago, Chicago, Illinois, USA; fDivision of Cardiology, Inova Heart and Vascular Institute, Fairfax, Vir-
ginia, USA; gDepartment of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA; hDepartment of Ob-
Listen to this manuscript’s stetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA; iDivision of Cardiovascular Medicine, University of
audio summary by Florida College of Medicine, Gainesville, Florida, USA; jDivision of Cardiology, St. Vincent Heart Center, Indianapolis, Indiana,
Editor-in-Chief USA; kCardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA;
Dr. Valentin Fuster on l
Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; and the
JACC.org. m
Division of Cardiology, Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, University
of Toronto, Toronto, Ontario, Canada.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ in-
stitutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit
the Author Center.

Manuscript received November 30, 2020; revised manuscript received January 19, 2021, accepted February 8, 2021.

ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2021.02.033

1764 Davis et al. JACC VOL. 77, NO. 14, 2021

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M
ABBREVIATIONS aternal morbidity and mortality
AND ACRONYMS HIGHLIGHTS
in the United States has been ris-
ing over the past several decades
Cardio-obstetrics involves clinicians from
ACOG = American College of
Obstetricians and
(1). Cardiovascular disease (CVD) is now the multiple specialties focused on pregnant
Gynecologists leading cause of pregnancy-related deaths, patients from preconception through the
APO = adverse pregnancy and many of these are preventable (2). There postpartum period.
outcome are a number of explanations for these

Risk assessment tools can guide conver-
CVD = cardiovascular disease trends: women are now older, have more car-
sations about maternal and fetal risks in
HF = heart failure diovascular risk factors, and have more
women with cardiovascular disease who
PPCM = peripartum complex cardiac disease at the time of their
are pregnant or considering pregnancy.
cardiomyopathy first birth (3). In response to this, calls for
cardio-obstetric models of care and improved compe-
The cardio-obstetrics team should antic-
tencies have emerged (4–7). A recent American Heart ipate potential cardiovascular complica-
Association Scientific Statement on cardiovascular tions of pregnancy, labor and delivery,
considerations in caring for pregnant patients high- and the postpartum period.
lighted several important aspects of cardio-

Postpartum care is an ongoing, integral
obstetrics care (8). In this issue of the Journal, on
component of cardio-obstetrical patient
behalf of the American College of Cardiology CVD in
management.
Women Committee and the Cardio-Obstetrics Work
Group, we present a 5-part Focus Seminar that ad-
preconception counseling, determining the fre-
dresses a wide breadth of topics in this emerging
quency of monitoring during pregnancy, and guiding
field. This document, “Cardio-Obstetrics Part 1:
the level of care needed during delivery and post-
Team-Based Care,” describes the risk stratification
partum. Additionally, women with CVD may deliver
of pregnant women with cardiac disease, the team-
preterm or have low-birth-weight babies, and these
based model of cardio-obstetrics, the hemodynamic
fetal and neonatal risks should be discussed, as well
changes of labor and delivery, postpartum moni-
as potential inheritability of certain conditions.
toring, and the short- and long-term complications af-
For women at excessive risk of severe morbidity or
ter delivery (Central Illustration).
mortality, other options such as adoption or gesta-

RISK STRATIFICATION tional carriers can be explored. Women may also be

encouraged to consider how they would feel about
Pregnancy is associated with significant hemody- the need to terminate a pregnancy at a pre-viable
namic changes (Figure 1) that may be poorly tolerated gestational age should the woman become unable to
by women with underlying CVD (3). Heart failure (HF) tolerate the hemodynamic changes of early to mid-
and arrhythmias are the most common complications pregnancy, though most women become symptom-
among women with pre-existing CVD (9). Women atic later in pregnancy. Given the complexities of
may also present during pregnancy with previously these difficult choices, conversations should occur
undiagnosed CVD or develop new CVD during preg- before conception with awareness of local laws that
nancy, such as peripartum cardiomyopathy (PPCM). may limit access to these medically indicated
The risk of cardiovascular complications during procedures.
pregnancy is variable, comparable to the general
population for some women with CVD but prohibi- CARDIO-OBSTETRICS TEAM
tively high risk for others such that pregnancy is not
recommended. Several risk stratification tools are Multidisciplinary collaboration is key to successful
available to guide pregnancy planning, including the management of women with CVD pursuing preg-
CARPREG II (Cardiac Disease in Pregnancy Study), nancy, and coordinated cardio-obstetrics clinics have
ZAHARA (Zwangerschap bij Aangeboren HARtAf- been shown to decrease adverse cardiac complica-
wijking [Pregnancy in Women With Congenital Heart tions during pregnancy (9). Women with CVD should
Disease]), and modified World Health Organization ideally be evaluated before conception for discus-
classification methods (Tables 1 to 3) (9–11). Although sions about pregnancy risks, optimization of their
no tool is perfect, they are good starting points and cardiovascular health, substitutions of teratogenic
can be combined with lesion-specific data and medications, and education about the need for regu-
patient-specific information to refine risk assessment. lar surveillance through pregnancy and postpartum.
Estimates of pregnancy risks are useful for Members of the cardio-obstetrics team will vary based
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C ENTR AL I LL U STRA T I O N The Cardio-Obstetrics Model of Care

Davis, M.B. et al. J Am Coll Cardiol. 2021;77(14):1763–77.

The cardio-obstetrics model of care involves multiple specialists working together and with the patient to address issues from preconception, through pregnancy and
delivery, and the postpartum period. APO ¼ adverse pregnancy outcomes; CARPREG II ¼ Cardiac Disease in Pregnancy study; CVD ¼ cardiovascular disease;
mWHO ¼ modified World Health Organization; ZAHARA ¼ Zwangerschap bij Aangeboren HARtAfwijking (Pregnancy in Women With Congenital Heart Disease) study.
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F I G U R E 1 Hemodynamic Changes From Baseline During Pregnancy

50 Cardiac Output

40
% Change from Pre-Pregnancy

Stroke Volume
30

20 Heart Rate

10

–20
SVR

–40
4 8 12 16 20 24 28 32 36 Post-
Partum
Pregnancy (Weeks)

Significant changes in cardiac output, heart rate, stroke volume, and systemic vascular resistance occur during pregnancy. SVR ¼ systemic
vascular resistance.

on the complexity of the patient’s cardiac condition,

but those with intermediate- and high-risk conditions
T A B L E 1 CARPREG II Risk Prediction Model should be cared for by a multidisciplinary team
CARPREG II Predictors Points experienced in the management of cardiac disease in
Prior cardiac event or arrhythmia 3 pregnancy (Table 4) (3,6). For patients without CVD,
Baseline NYHA functional class III to IV or cyanosis 3 but with cardiovascular risk factors including chronic
Mechanical valve 3 or gestational hypertensive disorders or other
Ventricular dysfunction 2
adverse pregnancy outcomes (APOs), multidisci-
High-risk left-sided valve disease/LVOT 2
obstruction
plinary collaboration may be important for reducing
Pulmonary hypertension 2 short- and long-term cardiovascular complications
Coronary artery disease 2 related to pregnancy.
High-risk aortopathy 2 Pre-pregnancy counseling and close monitoring
No prior cardiac intervention 1 throughout gestation is needed for optimal outcomes.
Late pregnancy assessment 1
From an operational standpoint, regular multidisci-
CARPREG II Score Predicted Risk, %
plinary team meetings are essential to facilitate
0 to 1 5
patient-centered decisions about testing, disease
2 10
3 15 management, and coordinated delivery plans.
4 22 Contraception should also be discussed with patients
>4 41 before delivery to facilitate tubal ligation or long-
acting reversible contraception (intrauterine devices
CARPREG ¼ Cardiac Disease in Pregnancy Study; LVOT ¼ left ventricular outflow
tract; NYHA ¼ New York Heart Association. or progesterone implants) at delivery when desired
and feasible.
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guidance of the multidisciplinary cardio-obstetrics

T A B L E 2 ZAHARA Risk Prediction Model Derived From Patients
With Congenital Heart Disease
team (3,14).

ZAHARA Predictors Points FETAL COMPLICATIONS OF

Prior arrhythmia 1.5 PREMATURE DELIVERY
Cardiac medications before pregnancy 1.5
NYHA functional class $II 0.75
If the maternal condition deteriorates or if a woman
Left heart obstruction 2.5
Moderate or severe mitral regurgitation 0.75
presents with new serious cardiac disease, the cardio-
Moderate or severe tricuspid regurgitation 0.75 obstetrics team may need to discuss the need for a
Mechanical valve 4.25 premature delivery with the patient. Input should be
Cyanotic heart disease (corrected or uncorrected) 1 obtained from maternal fetal medicine and/or
ZAHARA Score Predicted Risk, % neonatology regarding the likely outcome for the
0–0.5 2.9
neonate, which will depend on gestational age, fetal
0.51–1.50 7.5
growth, and the presence or absence of structural or
1.51–2.50 17.5
genetic anomalies. At extremely low gestational ages
2.51–3.50 43.1
>3.50 70.0
(22 0/7 to 24 6/7 weeks), the National Institute of
Child and Human Development (NICHD) Extremely
NYHA ¼ New York Heart Association; ZAHARA ¼ Zwangerschap bij Aangeboren Preterm Birth Outcomes Tool can be used to help
HARtAfwijking (Pregnancy in Women With Congenital Heart Disease) study.
guide counseling and recommendations. Morbidity
and mortality estimates for later gestational ages are
presented in Table 5 (15). Although care should be
TIMING OF DELIVERY
taken to not recommend premature delivery without
consideration of neonatal risks, deterioration of
A detailed, individualized delivery plan should be
maternal status may jeopardize both the maternal
created by the cardio-obstetrics team through shared
and fetal lives.
decision-making with the patient. Delivery plans
should be created early, usually between 20 and
CARDIOVASCULAR HEMODYNAMICS OF
28 weeks of gestation, and recorded in the medical
LABOR AND DELIVERY
record. The plan should be easily accessible to all
health care professionals involved with the woman’s
Many variables influence the hemodynamic state of a
care. This document should include recommenda-
woman during delivery (Figure 2). Although it may
tions regarding the location, timing, and mode of
not be possible to precisely predict the effects of
delivery, intrapartum monitoring, management of
various birth events or interventions, there are cen-
complications and necessary resources, and a plan for
tral themes to the hemodynamic patterns of vaginal
postpartum surveillance (3). Some women at high risk
and Cesarean birth. Additionally, medications
for postpartum complications may benefit from
commonly used during labor and delivery may need
monitoring in a coronary care unit postpartum.
to be modified for women with CVD—while keeping in
In the absence of spontaneous onset of labor or
mind that maternal hemorrhage is a life-threatening
indicated delivery before term, scheduled induction
condition that is also poorly tolerated by women
of labor for pregnant women with stable cardiac dis-
with significant underlying CVD (Table 6).
ease may be considered at 39 weeks of gestation with
Cesarean delivery usually reserved for obstetric in- VAGINAL DELIVERY. Labor and the associated uter-
dications (12,13). Earlier delivery may be indicated for ine contractions, pain, and anxiety result in increases
women with certain high-risk conditions with serious in heart rate, systolic blood pressure, and cardiac
cardiac complications or hemodynamic instability. output, which become greater as women progress
Pregnant women with CVD should deliver at a hos- through the first stage of labor. Effective neuraxial
pital with the appropriate maternal and neonatal labor analgesia reduces labor pain and thereby miti-
level of care for the degree of risk (14). The resources gates these hemodynamic effects; however, increases
needed to minimize maternal and fetal complications in cardiac output with contractions can occur even
should be anticipated, outlined and documented with effective analgesia (16,17). Immediately after
before delivery and included in the delivery plan. It is epidural or spinal anesthesia, post-analgesia hypo-
preferable to have women with moderate and tension may occur due to vasodilatory effects of the
severely complex heart disease deliver in tertiary or local anesthetic or the sudden elimination of labor
quaternary centers where care is provided under the pain resulting in a drop in plasma catecholamines.
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and cardiac output, with a compensatory increase in

T A B L E 3 Modified WHO Risk Stratification Model
cardiac output with the release of Valsalva (16,18,19),
Modified WHO Class Conditions Predicted Risk, % a large study demonstrated that Valsalva in the sec-
I—No higher risk than Uncomplicated, small or mild lesions including 2.5–5 ond stage of labor was not associated with significant
the general population pulmonary stenosis, VSD, PDA,
and mitral valve prolapse with no more hemodynamic changes or adverse outcomes, sup-
than trivial mitral regurgitation porting the notion that Valsalva should be liberalized
Successfully repaired simple lesions including
during the second stage of labor (12). Additional
ostium secundum ASD, VSD, PDA,
and TAPVD important hemodynamic changes can happen at birth
Isolated PVCs and PACs when increases in heart rate, stroke volume, and
II—Small increased risk of Unoperated ASD 5.7–10.5 cardiac output occur due to sudden decompression of
maternal morbidity and Repaired tetralogy of Fallot
mortality the inferior vena cava and autotransfusion from the
Most arrhythmias
contracting evacuated uterus (20,21).
Coarctation of the aorta without
significant gradient or aneurysm CESAREAN DELIVERY. Unlike with vaginal delivery,
(repaired or unrepaired)
complete insensitivity to surgical stimulation is
Long QT syndrome
II to III Mild LV impairment 10–19
needed for Cesarean delivery. Neuraxial analgesia is
Hypertrophic cardiomyopathy preferred over general anesthesia because it allows
Marfan syndrome without aortic dilation the patient to experience childbirth while avoiding
Heart transplant airway manipulation and the tocolytic effect of, and
Native or tissue valve disease not unwanted fetal exposure to, volatile anesthetics.
considered WHO class IV
Neuraxial anesthesia may be contraindicated if a pa-
Bicuspid aortic valve without aortic dilatation
III—Significant risk of Mechanical valve 19–27 tient received recent antithrombotic therapy because
maternal morbidity Systemic RV of the risk of spinal epidural hematoma (22). The
and mortality
Post-Fontan operation hemodynamic effects of neuraxial analgesia are more
Cyanotic heart disease pronounced for Cesarean delivery than labor anal-
Other complex congenital heart repair gesia because the nerve block must be higher and
Aortic dilation without known fibrinogen
disease
more dense. Neuraxial analgesia causes a sympa-
Coarctation of the aorta with residual thectomy, resulting in a decrease in systemic vascular
gradient or aneurysm (repaired resistance, increase in heart rate, and decrease in
or unrepaired)
mean arterial pressure; therefore, vasoactive medi-
Marfan syndrome with aortic root
dilation <45 mm or following aortic cations such as phenylephrine or norepinephrine are
replacement typically administered during block onset. Although
Bicuspid aortic valve with aortic root dilation
45 to 50 mm
spinal anesthesia provides a denser and more reliable
IV—Pregnancy Pulmonary arterial hypertension of any cause 40–100 block, it causes more rapid sympathectomy than a
contraindicated Severe left ventricular dysfunction (LVEF slowly titrated epidural block. For patients with pre-
<30% or NYHA functional class III to IV)
load dependent conditions, an alternative option is a
Previous peripartum cardiomyopathy with
any residual impairment of LV function
sequential combined spinal epidural—a small amount
Severe left heart obstruction (AVA <1 cm or 2 of local anesthetic placed in the intrathecal space
peak gradient >50 mm Hg; MVA <1.5 cm2) followed by slowly dosing the epidural catheter (23).
Marfan syndrome with aortic dilation
Given the significant hemodynamic effects of various
>45 mm
Bicuspid aortic valve with aortic
medications, an experienced anesthesiologist is an
dilation >50 mm essential member of the cardio-obstetrics team.

ASD ¼ atrial septal defect; AVA ¼ aortic valve area; LV ¼ left ventricular; LVEF ¼ left ventricular ejection fraction; CARDIOVASCULAR MONITORING FOR LABOR
MVA ¼ mitral valve area; NYHA ¼ New York Heart Association; PAC ¼ premature atrial contraction; PDA ¼ patent
ductus arteriosus; PVC ¼ premature ventricular contraction; RV ¼ right ventricle; TAPVD ¼ total anomalous
AND DELIVERY
pulmonary venous drainage; WHO ¼ World Health Organization.

Laboring women with significant cardiac disease

should have a pulse oximeter to monitor for maternal
bradycardia, tachycardia, or hypoxemia. Telemetry
The greatest hemodynamic changes of vaginal should be used for women at risk of hemodynamically
birth occur during the second stage of labor, when the significant arrhythmias (ventricular tachycardia or
patient is pushing to deliver the infant, and during sustained supraventricular tachycardia). Arterial
delivery. Although vaginal delivery involves repeated lines are typically only needed when hypotension or
performance of the Valsalva maneuver, which can hypertension requires immediate recognition and
result in transient reductions in preload, afterload, treatment (e.g., severe aortic stenosis, severe mitral
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stenosis, or pulmonary arterial hypertension during

T A B L E 4 Cardio-Obstetrics Teams
Cesarean delivery). Central venous access is rarely
used during delivery, but may be considered for Modified Essential Potential
WHO Class Team Members Team Members
women with severe HF who are likely to require
I Obstetrician ACHD specialist
inotropic or vasopressor support.
Primary care physician Advanced practice practitioner
Cardiology consultation Geneticist
MODE OF DELIVERY IN WOMEN WITH
Nurses: outpatient, labor and delivery Other specialists
CARDIOVASCULAR DISEASE
II Obstetrician ACHD specialist
Primary care physician Advanced practice practitioner
Vaginal delivery with adequate analgesia is associ- Maternal fetal medicine Geneticist
ated with fewer maternal complications and is the Cardiology consultation Neonatologist
preferred mode of delivery with few exceptions (3). Nurses: outpatient, labor and delivery Social worker
Cesarean delivery is recommended for women with Other specialists

Marfan syndrome with dilated aorta >45 mm and III to IV Obstetrician ACHD cardio-obstetrics specialist
Primary care physician Pharmacist
some other high-risk aortopathies, women with a
Maternal fetal medicine Cardiac anesthesiologist
history of acute or chronic aortic dissection, women
Cardio-obstetrics expert Aortopathy specialist
who receive therapeutic anticoagulation with vitamin
Obstetric anesthesiologist Electrophysiologist
K antagonists, which place the fetus at risk for intra- Nurses: outpatient, labor and delivery Advanced heart failure cardiologist
cranial hemorrhage at the time of vaginal delivery, Pulmonary hypertension specialist
women with severe pulmonary arterial hypertension, Interventional cardiologist
and women in acute decompensated HF in whom Cardiac surgeon

urgent delivery is warranted (24). Cesarean delivery Intensive care team

Neonatologist
should also be considered for severe aortic and mitral
Geneticist
stenosis. Otherwise, vaginal delivery is preferred and
Hematologist
is associated with shortened hospital stay and Mental health specialist
reduced risk of sudden death, peripartum infections, Social worker
and hemorrhage (13,25). Advanced planning of the Case manager
timing and mode of delivery are vital responsibilities Advanced practice practitioner

of the cardio-obstetrics team. Understanding the he-

ACHD ¼ adult congenital heart disease; WHO ¼ World Health Organization.
modynamic changes and physiology of labor and de-
livery, and its impact on the specific condition of the
mother helps facilitate this decision.
the cardio-obstetrics team promotes maternal care in
POSTPARTUM MONITORING the antepartum/intrapartum period, establishing an
interdisciplinary plan to assess all women in the
Appropriate postpartum monitoring is important for subsequent weeks after discharge (via obstetrics,
all women, but it is critically important in women maternal fetal medicine, cardiology and/or primary
with high risk CVD. Postpartum recovery in a cardiac care) is critical in ensuring maternal safety. Many
care unit versus postpartum obstetric care unit cardiovascular complications, including pre-
should be individualized depending on clinical status eclampsia, PPCM, pulmonary embolism, and aortic
of the patient, risk for cardiac complications, and or spontaneous coronary artery dissection can occur
comfort level within each care team. Women at high postpartum. Patients must be made aware of the need
risk for hemodynamically significant arrhythmias to self-monitor and to alert their medical team if they
should be on telemetry. In most cases, cardiovascular experience “red flag” symptoms (Figure 3). Early post-
imaging is not indicated in the immediate postpartum discharge blood pressure measurement within 3 days
period. Planned postpartum length of stay varies is imperative for women with and at risk for hyper-
depending on the specific cardiovascular condition, tensive complications. The American College of Ob-
but women at highest risk for postpartum complica- stetricians and Gynecologists (ACOG) guidelines
tions should be monitored for $72 h. Hemodynamic support an initial postpartum assessment within the
changes in the postpartum period may pose signifi- first 3 weeks postpartum with interim follow-up as
cant risk to women with HF, pulmonary arterial hy- needed and a comprehensive visit no later than
pertension, or valvular disease, thus warranting 12 weeks after birth (26).
extended postpartum monitoring. The postpartum period is also an important time to
For safe discharge of both mother and infant, it is address breastfeeding, family planning and contra-
imperative to have a discharge plan in place. Just as ception, mental health, and the need for long-term
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heart disease frequently develop symptomatic HF in

T A B L E 5 Neonatal Mortality Estimates Based on Premature
Gestational Age
the third trimester or early postpartum period
(9,29,33). Among all pregnancy-related HF admis-
Gestational Neonatal Death Neonatal Death or
Age at Delivery, Rate/100 Live Severe Morbidity Rate/
sions, 60% occur postpartum (34), and cardiomyop-
Weeks Births 100 Live Births athy is a leading cause of maternal mortality (35,36).
24–27 14.2 71.7 In women with PPCM, worsening of left ventricular
28–31 3.0 36.6 systolic function is reported in about 20% of women
32–33 1.0 16.3
undergoing a subsequent pregnancy who have
34–36 0.5 5.4
normalization of systolic function after their index
All (24–36) 1.3 11.9
pregnancy compared with about one-half of women
Based on a population-based study of all singleton births from the state of who have not had full recovery in left ventricular
Washington from 2011 to 2012. Severe morbidity included bronchopulmonary
dysplasia, intraventricular hemorrhage $3, periventricular leukomalacia, rent-
function (29). Physiological changes associated with
inopathy of prematurity, necrotizing enterocolitis, neonatal sepsis, convulsions of pregnancy gradually return to baseline in the first few
newborn, and severe birth trauma. Data are from Richter et al. (15).
weeks postpartum. The diagnosis of HF is frequently
delayed; therefore, clinicians should maintain a high
index of suspicion with any signs or symptoms
cardiovascular follow-up if not previously reviewed.
consistent with a HF diagnosis such as shortness of
Most cardiovascular medications may be continued
breath, edema, or cough. A low threshold for echo-
during lactation (27).
cardiography and measurement of biomarkers is
POSTPARTUM COMPLICATIONS important to make a prompt diagnosis. Women who
have been on guideline-directed medical therapy for
Cardiovascular complications are frequently encoun- HF during pregnancy should have this readjusted and
tered in the first days to months postpartum. In optimized postpartum based on clinical and lacta-
women with CVD, readmissions in the first 42 days tion status.
postpartum are most commonly due to HF, arrhyth- ARRHYTHMIAS. Arrhythmias are the second most
mias, hypertensive syndromes, and pregnancy com- common cardiac indication for readmission post-
plications such as hemorrhage and infection (28) partum in women with known CVD (28). A National
(Figure 4). Women at highest risk for readmission Inpatient Sample analysis of arrhythmia burden
include those with older age, obesity, cardiomyopa- found atrial fibrillation was the most common
thy, pulmonary hypertension, pre-eclampsia/ arrhythmia, but did not address timing across the
eclampsia during pregnancy, postpartum hemor- pregnancy continuum (37). Women with long QT
rhage, and Medicaid/Medicare insurance (28). syndrome, especially LQT2 genotype are at increased
HEART FAILURE. Pregnancy-related HF may be due risk of arrhythmia during the 9 months postpartum.
to systolic dysfunction related to PPCM (29,30), dia- Treatment with beta-blockers, especially nadolol, is
stolic dysfunction (31,32) or pre-existing heart disease associated with a reduction in adverse events (38,39).
(9,33). PPCM is most commonly diagnosed in the first Maternal cardiac arrest is infrequent, estimated at
month after delivery, whereas women with structural approximately 1:12,000 admissions for delivery. The

F I G U R E 2 Factors Influencing Delivery Hemodynamics

Patient Disease Pregnancy

• Intravascular • Lesion Type • Gestational Age

Volume Status • Lesion Severity • Fetal Size
• Blood Pressure • Ventricular Function • Anesthesia Type
• Heart Rate • Comorbidities • Anesthesia Efficacy
• Body Position • Mode of Delivery
• Style of Pushing • Obstetric Medication
• Parity Administration
• Blood Loss

Several factors related to the patient, cardiovascular disease, and pregnancy status will influence the hemodynamic changes during delivery.
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T A B L E 6 Obstetric Medications and Considerations for Women With High-Risk CVD

Medication Indication Side Effects Considerations

Oxytocin Labor augmentation Hypotension Avoid bolus in complex CVD when

(Pitocin) Prevention of postpartum hemorrhage Decrease in peripheral vascular resistance possible
Large bolus can cause sudden decrease Consider use as a dilute solution in a
afterload and reflex tachycardia continuous IV infusion
Rare reports of ischemia
Terbutaline Stop premature labor, prolonged or Hypertension and tachycardia Extreme caution, contraindicated
frequent uterine contractions (1% to 10%)
Methylergonovine Stop postpartum hemorrhage Vasoconstriction leading to hypertension Avoid if possible with chronic
(Methergine) and myocardial ischemia hypertension, pre-eclampsia,
aortopathies, ischemic heart
disease
Carboprost Prostaglandin used for refractory Hypertension Avoid in women with vascular
tromethamine postpartum uterine bleeding or disease or aortic aneurysms;
(Hemabate) pregnancy termination pulmonary hypertension;
significant shunt lesions

CVD ¼ cardiovascular disease; IV ¼ intravenous.

most common etiologies are maternal hemorrhage disease, it is now recognized that pre-eclampsia can
and amniotic fluid embolism. However, venous develop de novo postpartum. Postpartum hyperten-
thromboembolism and acute coronary syndromes, sion may also be secondary to persistence of gesta-
including spontaneous coronary artery dissection, are tional hypertension or chronic hypertension. Current
other important etiologies (40–42). Maternal cardiac ACOG recommendations include a blood pressure
arrest occurring before delivery requires management check for women with any hypertensive disorder of
modifications based on gestational age such as per- pregnancy no later than 7 to 10 days postpartum and
formance of lateral uterine displacement and rapid within 72 h for those with severe hypertension (sys-
decision for perimortem Cesarean delivery. Post- tolic blood pressure $160 mm Hg systolic
partum management need not be modified although or $110 mm Hg diastolic). Severe hypertension in a
calcium should be given if magnesium has been pregnant or a recently postpartum woman is a medi-
administered for postpartum pre-eclampsia (40). cal emergency that requires prompt treatment to
POSTPARTUM HYPERTENSION AND PRE-ECLAMPSIA. reduce risk of maternal stroke and other complica-
Pre-eclampsia is reported in approximately 2% to 8% tions (43). New-onset severe range hypertension with
of pregnancies, and contrary to the traditional or without other organ involvement requires urgent
teaching that delivery of the placenta cures the therapy with magnesium sulfate and antihyperten-
sive medications, and may necessitate early delivery
(Figure 5). New-onset tonic-clonic seizures suggest
F I G U R E 3 Signs and Symptoms Concerning for
eclampsia, which also requires emergent magnesium
Cardiovascular Complications During or After Pregnancy
sulfate in addition to blood pressure control. The
presentation of hemolysis, elevated liver enzymes,
Peripartum Red Flag Signs and Symptoms
and low platelet count (HELLP syndrome) represents
a severe form of pre-eclampsia (43). Acute cardiac
complications of pre-eclampsia include diastolic
dysfunction and pulmonary edema (32). Moreover,
Chest Pain Tachycardia
pre-eclampsia is a known risk factor for PPCM (29).
Dyspnea Non-Vagal Syncope
Orthopnea Headache Hypertension associated with symptoms of HF, pal-
Cough Visual Changes pitations, or shortness of breath should prompt ur-
Edema Hypotension/Hypertension gent evaluation for cardiomyopathy. Stroke in
pregnancy and postpartum is also strongly associated
with hypertension (44).

HEMORRHAGE AND ANTICOAGULATION. Post-

Patients and clinicians need to be aware of signs and symptoms

partum hemorrhage is defined as >1,000 ml of blood
that may signal cardiovascular complications during and after loss in the first 24 h after delivery associated with
pregnancy. signs or symptoms of hypovolemia (45). Primary
hemorrhage occurs within the first 24 h postpartum
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Cardio-Obstetrics Part 1/5 APRIL 13, 2021:1763–77

F I G U R E 4 Postpartum Complications in Women With Cardiovascular Disease

Conditions Cardiomyopathy Pulmonary Hypertension

Increasing Left-Sided Valve Stenosis Hypertensive Disorders
Risk Obesity

Heart Failure Hypertension

Potential Stroke Arrhythmia
Cardiovascular Thromboembolism Coronary Dissection
Complications Aortic Dissection

• Inpatient Monitoring of Highest Risk Patients ≥72 h

• Assessment of Volume Status, Symptoms of Heart Failure, and Consideration of BNP/NT-proBNP if at
Suggested Risk for Heart Failure
Monitoring • Telemetry Monitoring if at Risk for Arrhythmias
• Postpartum Follow-up 3 to 6 Days after Discharge for High-Risk Patients
• Low Threshold for Echocardiogram, EKG, and/or Biomarkers

Postpartum complications are more likely with certain cardiovascular conditions and additional postpartum monitoring may be needed.
BNP ¼ B-type natriuretic peptide; EKG ¼ electrocardiogram; NT-proBNP ¼ N-terminal pro–B-type natriuretic peptide.

and is most commonly secondary to uterine atony. has been associated with an elevation in systemic
Hemorrhage occurring from 24 h to 6 to 12 weeks is vascular resistance and vascular spasm and is con-
categorized as secondary and is most commonly due traindicated in hypertensive disorders of pregnancy
to uterine atony, lacerations, retained products of and CVD. Although oxytocin causes a decrease in
conception, infection, subinvolution of the placental systemic vascular resistance, if diluted and carefully
site, and inherited coagulation defects (45). Risk fac- titrated, it can be safely administered. Misoprostol
tors for hemorrhage include pre-eclampsia, anti- has few hemodynamic side effects. Hemorrhage
coagulation therapy, forceps delivery, emergency should be treated promptly and aggressively, using
caesarean delivery, and general anesthesia. In a study the safest possible medications for the patient’s car-
of women with congenital heart disease, higher diovascular condition but also weighing the risks of
CARPREG risk scores were associated with increased ongoing hemorrhage on the cardiovascular system.
risk of hemorrhage, and this was greatest in women
with Fontan circulation (46). For patients who would THE FOURTH TRIMESTER
hemodynamically decompensate with hypotension or
a drop in preload, hemorrhage should be recognized The fourth trimester is the period following delivery
and treated rapidly. through the first 12 weeks postpartum (26). This is a
Uterine atony is treated with uterotonic medica- vital period for follow-up, given that over 70% of
tions, which include oxytocin, misoprostol, carbo- maternal deaths occur postpartum, and nearly 40%
prost, and methylergonovine. The hemodynamic occur within the first 6 weeks (36). Age >30 years,
consequences of several obstetric drugs are reviewed Hispanic or non-Hispanic Black race/ethnicity, and
in Table 6. Carboprost (prostaglandin F2 alpha) causes women with multiple gestation pregnancies have an
an increase in pulmonary vascular resistance and is increased likelihood of not receiving postpartum care
contraindicated in patients with pulmonary hyper- in the first 6 months (47). Approximately 40% of
tension or right ventricular failure. Methylergonovine women do not attend postpartum visits, citing stress,
JACC VOL. 77, NO. 14, 2021 Davis et al. 1773
APRIL 13, 2021:1763–77 Cardio-Obstetrics Part 1/5

F I G U R E 5 Management of Severe Hypertension/Pre-Eclampsia During Pregnancy and in the Early Postpartum Period

Diagnostic Criteria for HELLP

Monitoring Red Flags
Signs & Symptoms * Pulmonary edema LDH ≥600 IU/l
Labs (CBC, LFTs, Cr) * New-onset
Blood Pressure headache/visual AST and ALT >2× ULN
Severe Features of Pre-eclampsia changes
• BP ≥160 and/or 110 mm Hg * HELLP Platelets <100 × 109/l
• Thrombocytopenia (<100 × 109/L)
• LFTs >2× ULN or Persistent
RUQ/epigastric pain Delivery Timing
Seizure prophylaxis mg Concentration
Early delivery may Clinical Effect
• Renal Insufficiency Magnesium: 4 to 6 g IV (mg/dl)
be needed: by 37
• Pulmonary Edema weeks if nonsevere
load over 20 to 30 mins,
• New headache maintenance dose 5-9 Therapeutic range
and no later than 34
• Visual disturbances 1 to 2 g/h
weeks with severe
features. >9 Loss of reflexes
Anti-hypertensives
>12 Respiratory paralysis
Oral immediate
release nifedipine
>30 Cardiac arrest
IV labetalol
IV hydralazine

Severe hypertension/pre-eclampsia is a medical emergency and requires prompt recognition and treatment. If this occurs during pregnancy, early delivery may be
indicated. ALT ¼ alanine aminotransferase; AST ¼ aspartate aminotransferase; BP ¼ blood pressure; CBC ¼ complete blood count; Cr ¼ creatinine; HELLP ¼ hemolysis,
elevated liver enzymes, low platelet count; IV ¼ intravenous; LDH ¼ lactate dehydrogenase; LFT ¼ liver function test; RUQ ¼ right upper quadrant; ULN ¼ upper limits
of normal.

fatigue, inconvenience, adjustments to caring for a APOs, including low birth weight, and family plan-
newborn, lack of social support, finances, trans- ning should be discussed if not previously addressed
portation, or language as major barriers (26,47,48). (51).
Telemedicine has the potential for improving
postpartum care by reducing some of the barriers to PREGNANCY COMPLICATIONS AND
care such as transportation and language barriers, LONG-TERM CARDIOVASCULAR CARE
though if not implemented appropriately may in-
crease disparities. Web-based education modules The association between APOs and long-term CVD
could also improve patient education. Telehealth and risk has become increasingly recognized. Conditions
internet-based interventions in pregnant women such as hypertensive disorders of pregnancy, gesta-
have been shown to be effective in treatment of hy- tional diabetes, preterm birth, and small for gesta-
pertensive disorders of pregnancy pre- and post- tional age are associated, not only with short-term
partum, tobacco cessation, postpartum depression, maternal and fetal morbidity and mortality, but also
and postpartum weight management (49). with long-term risk of cardiovascular events such as
Care during the fourth trimester should focus on myocardial infarction, stroke, and HF (Figure 7)
screening and early intervention, particularly for (52–58). Recent data suggest that hypertensive dis-
women at increased risk of CVD, metabolic syndrome, orders of pregnancy are also associated with a broader
chronic kidney disease, and diabetes mellitus (50). At range of CVD, including aortic stenosis and mitral
postpartum visits, clinicians should assess, counsel, regurgitation (59). Women with a history of APOs
and treat women about multiple facets of cardiovas- have a greater burden of CVD risk factors (60–62);
cular health (Figure 6). Education, risk factor modifi- however, the future cardiovascular risk associated
cation, and contraception should be addressed. Short with APOs is independent of traditional risk factors
birth intervals of <12 to 18 months or conception (63). Whether the association between APOs and
within 6 months of prior birth carry increased risk for future CVD are related to an underlying
1774 Davis et al. JACC VOL. 77, NO. 14, 2021

Cardio-Obstetrics Part 1/5 APRIL 13, 2021:1763–77

F I G U R E 6 The Fourth Trimester: From Delivery to 12 Weeks Postpartum

1 week Assess Counsel Treat

2 weeks

Physical Exam Lactation Hypertension

Blood Pressure Stress and Fatigue Management Gestational Diabetes
6 weeks Cardiovascular Symptoms Family Planning Chronic CVD Management
Mental Health Long-Term Risk of APOs Mental Health Disorders
Medication Adherence Physical Activity Referral to Social Services
Lactation Support Weight Management Referral to Primary Care or
12 weeks
Family Planning Subspecialty Care
Barriers to Care Screening for Diabetes,
Social Support Hyperlipidemia, and CVD Risk
Longitudinal
Establish Primary Care Factors
Longitudinal Assessment of CVD Contraception
Risk Factors Referral to Nutritionist

Clinicians should ACT during each postpartum visit: Assess, Counsel, and Treat. The fourth trimester includes the first 12 weeks after delivery
and serves as an important time period for assessment, counseling, and treatment to reduce the long-term risk of cardiovascular disease.
APO ¼ adverse pregnancy outcome; CVD ¼ cardiovascular disease; DM ¼ diabetes mellitus; HF ¼ heart failure; IHD ¼ ischemic heart disease;
OR ¼ odds ratio.

F I G U R E 7 APOs and Future Cardiovascular Risk

HTN CVD IHD Stroke HF DM

RR OR 1.73 - RR 4.19 RR
Pre-eclampsia 2.37 2.74 (52) OR 1.73 OR 2.95 (2.1-8.34) (52) 2.37
(1.9-3.0) (54) (1.5-2.1) (52) (1.2-7.9) (52) (1.9-3.0) (54)

RR 1.67 RR 1.83 RR 1.83 RR 1.77 RR 2.06

Gestational HTN (1.3-2.1) (52) (1.3-2.5) (55) (0.8-4.2) (52) (1.5-2.1) (55) (1.6-2.7) (58)

RR 1.98 RR 2.09 RR 1.25 OR 0.70 OR 7.43

Gestational DM (1.6-2.5)
(52)
(1.6-2.8)
(52)
(1.1-1.5)
(52)
(0.1-5.6)
(56)
(4.8-11.5)
(57)

RR 2.01 RR 1.38 RR 1.71

Preterm Birth (1.5-2.7) (52) (1.2-1.6) (52) (1.5-1.9) (52)

OR 1.09-
3.5 (52)

Small for Gestational Age

Displayed are the pooled risks of future CVD and CVD risk factor development from systematic reviews of APOs including hypertensive
disorders of pregnancy (pre-eclampsia and gestational hypertension), gestational DM, preterm birth, and small for gestational age. Blank
spaces indicate the data have not been synthesized in a published systematic review. Values in parentheses are 95% confidence intervals.
Superscript numbers indicate corresponding reference. APO ¼ adverse pregnancy outcome; CVD ¼ cardiovascular disease composite;
DM ¼ diabetes mellitus; HF ¼ heart failure; HTN ¼ hypertension; IHD ¼ ischemic heart disease; OR ¼ odds ratio; RR ¼ relative risk.
JACC VOL. 77, NO. 14, 2021 Davis et al. 1775
APRIL 13, 2021:1763–77 Cardio-Obstetrics Part 1/5

predisposition or secondary to vascular insults that services (69,70). In order to improve maternal car-
occur at the time of pregnancy remains to be eluci- diovascular outcomes, attention to the social de-
dated. The causes are likely multifactorial and related terminants of health driving these significant
to a combination of inflammation, vascular dysfunc- disparities must be an integral part of the cardio-
tion, and accelerated development of traditional CVD obstetric model of care.
risk factors (64). Given the approximately 2- to 4-fold
increased risk of composite CVD associated with APOs CONCLUSIONS
(Figure 7), obtaining a detailed pregnancy history is a
vital component of a comprehensive cardiovascular The cardio-obstetrics model of care encompasses
risk assessment in all women. ACOG recommends management of women before, during, and after
cardiovascular assessment beyond the fourth pregnancy. Preconception counseling involves risk
trimester for women with a history of any APO, assessment, medical optimization, and contracep-
including body mass index, lipids, blood pressure, tion. During pregnancy, team-based care across mul-
and glucose measurements at 3 months postpartum tiple specialties is necessary and includes serial
and repeat assessment at 6 to 12 months postpartum antenatal monitoring and delivery planning, with an
after implementation of appropriate lifestyle in- appreciation for the hemodynamic changes of labor
terventions if abnormalities are identified on initial and delivery. After delivery, awareness of short- and
evaluation (3). Because many of these pregnancy long-term postpartum complications can help reduce
complications occur in young women who may not immediate cardiac complications and improve long-
routinely seek preventative care, it is important to term outcomes. Patient care during the fourth
raise awareness about the associated CVD risk among trimester should address CVD risk factor manage-
patients and clinicians across multiple specialties ment, contraception counseling, and prevention of
including internal medicine, family medicine, cardi- adverse events. The following issues of this 5-part
ology, endocrinology, and obstetrics/gynecology. series will provide additional guidance on the
Implementation of prevention strategies including cardio-obstetrics management of specific CVD states,
education, screening, and aggressive risk factor as well as contraception and reproductive planning.
modification throughout the life course of a woman
with an APO history may result in improvement in
FUNDING SUPPORT AND AUTHOR DISCLOSURES
long-term CVD outcomes in this population (65).

DISPARITIES IN CARE Supported by National Institutes of Health/National Heart, Lung, and

Blood Institute grants K23 HL136853-03 and R01 HL153382-01 (Dr.
Bello). Dr. Brown is a coauthor of UpToDate. Dr. Park has served as a
Substantial racial and ethnic disparities in maternal consultant for Abbott Diagnostics. All other authors have reported
morbidity and mortality exist in the United States. that they have no relationships relevant to the contents of this paper
to disclose.
Multiple social determinants of health, including
black race, Hispanic ethnicity, lack of insurance,
lower education levels, food and housing insecurity, ADDRESS FOR CORRESPONDENCE: Dr. Melinda B.
crime, and systemic racism are associated with higher Davis, Department of Medicine, Division of Cardio-
maternal morbidity and mortality (66–68). Women in vascular Medicine, University of Michigan, 1500 East
rural communities also have higher rates of pre- Medical Center Drive, SPC 5853, Ann Arbor, Michigan
pregnancy hypertension and worse maternal out- 48109-5853, USA. E-mail: [email protected].
comes, while facing declining access to obstetric Twitter: @MelindaDavisMD.

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