Cardiovascular Disease and Pregnancy Program

This article appeared in the Spring 2011 issue of Cardiovascular Update.

Cardiovascular Disease and Pregnancy Program Provides Expert Evaluation and Care

Directed by maternal-fetal medicine specialist Katherine Economy, MD, and cardiologists Reena Pande, MD, and Anne Marie Valente, MD, the Cardiovascular Disease and Pregnancy Program at Brigham and Women’s Hospital is a multidisciplinary program offering expert, coordinated care for women with congenital and other pre-existing heart and vascular disease or cardiovascular conditions arising during pregnancy.

With vast experience in managing cardiovascular issues in pregnancy, Program specialists collaborate to develop a detailed and personalized care plan for each patient – beginning before conception and continuing through pregnancy, labor and delivery, and the post-partum period. A comprehensive assessment of each patient’s condition and symptoms is performed with advanced cardiovascular imaging techniques that are safe for use during pregnancy. Necessary adjustments are made to medications early in pregnancy or prior to pregnancy, if the patient is seen before conception.

“Each patient’s care plan outlines her individual issues and encompasses anesthesiology and many other disciplines,” said Dr. Economy.

Pre-pregnancy Evaluation and Intervention

Whenever possible, cardiovascular issues are addressed prior to pregnancy, including coordinating care with cardiac surgeons, interventional cardiologists, and electrophysiologists, in order to manage existing cardiovascular conditions safely during pregnancy. For women with congenital heart disease or other pre-existing cardiovascular conditions who are considering pregnancy, Program specialists communicate risks of pregnancy, as well as steps that should be taken prior to pregnancy. For example, recommendations may include an improvement in fitness level prior to pregnancy to help in managing the changes in hemodynamics that occur during pregnancy.

Collaboration with BACH

Program specialists also work closely with the Boston Adult Congenital Heart (BACH) Service, a program jointly offered by Brigham and Women’s Hospital and Children’s Hospital Boston for young adult patients with congenital heart disease. Patients who are followed in the BACH program are provided with seamless care during pregnancy by specialists in the Cardiovascular Disease and Pregnancy Program.

“The collaboration between the Cardiovascular Disease and Pregnancy Program and the Boston Adult Congenital Heart Service provides patients with a consistent team of providers, who often have cared for them from childhood through early adulthood and into pregnancy,” said Dr. Valente, who also is Director of Outpatient Services for BACH.

Program specialists also address other cardiovascular issues that may arise during pregnancy, including systemic hypertension, pulmonary embolism, deep vein thrombosis, and other conditions, using a multidisciplinary approach to care.

“We work together in order to quickly and safely respond to cardiovascular changes and conditions that may occur during pregnancy,” said Dr. Pande. “These include deep vein thrombosis, pulmonary embolism, cardiac arrhythmias, and a variety of other issues.”

Case Studies

Congenital Heart Disease and Pregnancy

A 21-year-old woman suffering from fatigue and cyanosis was referred to the Boston Adult Congenital Heart (BACH) Service. Cardiac evaluation determined she had tetralogy of Fallot (TOF) with pulmonary artery atresia. Over the next four years, she underwent a series of staged imaging, catheterizations, functional testing, and surgical procedures to establish effective and controlled pulmonary blood flow, and alleviate intracardiac shunting. She experienced a great increase in exercise tolerance, with resolution of her cyanosis. After counsel, she became pregnant and remained under the care of both cardiologists and high-risk maternal fetal medicine specialists in the BWH Cardiovascular Disease and Pregnancy Program. At 39 weeks gestation, labor was induced, and she underwent successful vaginal delivery of a healthy baby girl.

Pulmonary Embolism Developing after Cesarean Section

A 45-year-old otherwise healthy woman underwent a scheduled cesarean section complicated by vaginal bleeding. On the first post-partum day, she developed tachycardia, hypoxia, and shortness of breath. A CT scan of the chest was performed and identified a filling defect in the distal left main pulmonary artery with extension into the lobar branches – consistent with a pulmonary embolism. An echocardiogram revealed right ventriclar enlargement and hypokinesis. She was evaluated by a cardiovascular medicine specialist in collaboration with her high-risk maternal fetal medicine specialist in the BWH Cardiovascular Disease and Pregnancy Program. She was safely initiated on unfractionated heparin for anticoagulation. She was ultimately transitioned to Coumadin, which was continued for a six-month treatment period without complication. She was seen in the Watkins Cardiovascular Clinic at one month and six months after discharge and was doing very well without further clinical symptoms.

Katherine Economy, MD
Co-director, Cardiovascular Disease and Pregnancy Program,
Maternal-Fetal Medicine Specialist,
Division of Maternal Fetal Medicine,
Brigham and Women’s Hospital

Reena Pande, MD
Co-director, Cardiovascular Disease and Pregnancy Program,
Cardiologist and Vascular Medicine Specialist,
Division of Cardiovascular Medicine,
Brigham and Women’s Hospital

Anne Marie Valente, MD
Co-director, Cardiovascular Disease and Pregnancy Program,
Cardiologist and Adult Congenital Heart Disease Specialist,
Division of Cardiovascular Medicine,
Brigham and Women’s Hospital;
Director, Outpatient Services,
Boston Adult Congenital Heart (BACH) Service,
Brigham and Women’s Hospital and Children’s Hospital Boston