“In the face of a high risk of pregnancy complications… the decision to conceive will be a personal one. Women with high risk pre-existing medical conditions can only make an informed choice about whether or not to conceive if they are actually informed about the risks”
MBRRACE-UK, 2016
Maternal heart disease complicates 1-4% of pregnancies. Therefore, in Scotland between 500 and 2,000 live births are to mothers with cardiovascular disease (CVD). While the majority of these women will tolerate pregnancy well, some will have an increased risk of cardiac events in pregnancy. Maternal cardiac events can also have an impact on fetal outcome.
Many women with CVD can adapt to the physiological changes of pregnancy. However, for some women these normal changes in pregnancy can exacerbate pre-existing abnormal haemodynamics. Co-morbidites, obesity, increasing maternal age and previous pregnancy complications can all increase pregnancy risk.
Sadly, in the United Kingdom, cardiovascular disease remains the leading cause of maternal death, accounting for almost a quarter of all maternal deaths. While many of these deaths occurred in women who did not know that had a cardiac condition prior to pregnancy, there were lessons to be learned from maternal deaths in women who had a known cardiac diagnosis before pregnancy (full report here)
A key recommendation is:“Prepregnancy counselling should be available both within the paediatric cardiology transition service and to women of child bearing age with known cardiac disease. This should include provision of appropriate contraceptive advice.”
What can healthcare professionals do?
As healthcare professionals we have a responsibility to routinely inform women with known cardiovascular disease about any potential risk they may have in pregnancy. This should take place even when that risk is deemed to be low.
We can all start this conversation.
It is important to refer to specialists in obstetric cardiology if the patient is medium-high risk or we are unsure of how to determine risk or need further advice.
What is preconception counselling?
Preconception counselling (PCC) requires a personalised approach to care in partnership with the patient which will allow the woman to make an informed choice about whether or not to pursue a pregnancy. This will also inform contraceptive choice and decisions relating to pursuit of assisted conception therapies.
Preconception counselling allows clinicians to identify pregnancy risk for women with CVD. It ensures robust assessment of follow-up and assessment for women with moderate-high risk in pregnancy and appropriate reassurance for women who have a low risk in pregnancy.
The information provided should include:
- pregnancy risk stratification which includes maternal cardiac risk, maternal risk of fertility treatment if pursued, maternal obstetric risk and fetal and neonatal risks
- long-term effects of pregnancy on the heart
- where appropriate maternal life expectancy
- risk of recurrence of congenital or inherited cardiac disease
Preconception counselling provides an opportunity to:
- optimise cardiac status prior to a pregnancy. This may include where there is an indication for cardiac intervention
- recommend safe, effective methods of contraception
- review cardiac medications and their use in pregnancy, making plans to adjust medication if appropriate and under ongoing clinical supervision
- referral for genetic consultation if appropriate
- recommend a healthy lifestyle, including smoking cessation and weight management
- inform women of who to contact on confirmation of pregnancy to ensure appropriate review and follow-up though pregnancy
- discuss alternative routes to having a child if the woman choses not to pursue pregnancy
Who should receive preconception counselling?
All women of childbearing age with CVD should be provided with information about their risk in pregnancy. CVD includes all cardiac diagnoses – inherited, congenital and acquired disease of the heart and major vessels and arrhythmia.
Who should provide preconception counselling?
All healthcare professionals can play a role in the provision of preconception counselling. The extent of that role will vary depending on our expertise in the area of obstetric cardiology. It is important that women have an accurate assessment of risk. Some women have risk overestimated which can cause psychological distress while others have risk underestimated which can lead to unknowing pursuit of a high risk pregnancy.
Women with moderate–high risk in pregnancy should be counselled by a cardiologist and obstetrician with expertise in the management of cardiac disease in pregnancy.When referring women for preconception counselling please advise continued use of contraception or initiation of contraception especially for women in whom pregnancy poses moderate–high risk.
How do we assess risk?
The modified World Health Organisation (mWHO) classification of maternal cardiovascular risk is recommended for risk predication for women with a known cardiac condition in pregnancy.
For risk estimation, as a minimum, an ECG, echo, assessment of NYHA class and clinical examination should be performed. In cases of aortic pathology, complete aortic imaging by CT scanning or MRI is necessary for appropriate pre-conception counselling. For appropriate patients a cardiopulmonary exercise test, Holter monitoring and NT-proBNP can add additional information to assist in risk estimation.
What will SOCN do?
The Scottish Obstetric Cardiology Network are working on a range of tools to assist healthcare professionals to start the conversation with women about contraception and pregnancy and develop pathways to facilitate timely pre-conception counselling for women with the right specialist at the right time.
We are developing:
- standards of PCC for a range of healthcare professionals
- a patient information leaflet about the importance of PCC and questions they should ask of the healthcare professional here
- learning resources for a range of healthcare professionals to assist in starting the conversation
- a checklist to assist in appropriate PCC topics for healthcare professionals who are not specialists in obstetric cardiology
- pathways to facilitate timely PPC with appropriate specialists relevant to the patients condition and co-morbidities