Maternal Fetal Medicine, Cardiology Collaborate on High-Risk Pregnancies
Watch a video to learn more about her.
Joanne Quinones, MD
Maternal fetal medicine
More women with congenital or acquired cardiac disease are reaching reproductive age and achieving pregnancy, requiring complex care that addresses both cardiovascular and maternal fetal health.1 Lehigh Valley Health Network (LVHN) optimizes such care through the region’s first heart and pregnancy program.
A focused approach
The program, which includes LVHN’s large contingent of high-risk pregnancy specialists, is one of the largest in Pennsylvania and the nation. It’s part of LVHN’s Heart and Vascular Program for Women, which provides specialized care for and prevention of heart disease in women at all stages of life. More than 180 patients with cardiac issues have been treated through the heart and pregnancy program since its inception in 2010.
LVHN’s comprehensive, multidisciplinary team approach includes maternal fetal medicine (MFM) specialist Joanne Quiñones, MD, and LVHN cardiologist Amy Ahnert, MD, with LVPG Cardiology.
“Pregnancy has significant impact on the cardiac system for all patients, and women with pre-existing conditions, risk factors or cardiac complaints must be closely monitored and assessed by specialists who work together as a team,” says Quiñones, an obstetrician who completed a three-year MFM fellowship. MFM subspecialists have advanced knowledge of the medical, surgical, obstetrical, fetal and genetic complications of pregnancy and their effects on both the mother and the fetus.
Approximately 1 to 3 percent of all pregnant women will experience cardiac complications, which are responsible for 10 to 15 percent of maternal mortality.2 Hypertension is the most common medical problem during pregnancy, complicating approximately 15 percent of all pregnancies.3 Other disease categories the team treats include:
- Congenital structural issues (congenital heart disease, valvular disease, coarctation of the aorta)
Acquired structural disease (rheumatic heart disease, prosthetic valves, electrical disorders, Marfan syndrome, coronary artery disease)
- Functional disorders (hypertension, arrhythmias, cardiomyopathy)
Some women also may present with cardiac complaints (palpitations, near syncope, dizziness or chest pain/pressure) without a history of cardiac disease.
Women with known cardiac disease or risk factors ideally should receive evaluation and counseling prior to conception or early in pregnancy.4 Although the risk during pregnancy depends on the patient and her specific heart disease, the LVHN team identifies and quantifies risks to mother and fetus through personal and family health history, imaging and other assessments. The program’s clinical team provides preconception counseling for women with issues such as congenital heart block, prosthetic heart valves, bicuspid aortic valves and inherited arrhythmias such as catecholaminergic polymorphic ventricular tachycardia (CPVT), long QT syndrome, hypertrophic cardiomyopathy and Marfan syndrome, among others.
Collaborative management of patients
While early diagnosis and counseling are important, the majority of women referred to the program are pregnant and past the midpoint of their pregnancies. The specialists schedule appointments together so that cardiac and obstetric issues such as medication exposure, mode of delivery and postpartum care can be evaluated and assessed concurrently.
“It’s a very dynamic visit, with information gathered and shared among the clinicians and the patient,” Quiñones says. “Patients benefit from that kind of interaction and appreciate the coordination among specialists.”
Cardiac output increases during labor and delivery, making this period of pregnancy potentially dangerous for pregnant women with cardiac disease. In particularly complex cases, the team conducts simulations to prepare for deliveries by women with cardiac disease. These simulations are taught by members of the obstetrics simulation team (obstetric nurses, MFM specialists and cardiology fellows) and include residents, nursing staff from the labor and delivery unit and progressive care unit, and other providers.
LVHN’s division of MFM educates obstetric caregivers on complex pregnancy care in a variety of forums. In 2014, Quiñones and her cardiology and MFM colleagues presented two posters at the third International Congress on Cardiac Problems in Pregnancy in Venice, Italy. The studies focused on the program’s collaborative cardiology and MFM practice and the role of cardiac MRI during pregnancy5,6. Ahnert, Quiñones and anesthesiologist Rafael Martinez, MD, with Allentown Anesthesia Associates, also shared their experiences treating a woman with CPVT, presenting at the 2014 annual meeting of the International and North American Societies of Obstetric Medicine.
“CPVT is a very rare disease, occurring in only 1 in 10,000 patients, and many cardiologists will never see a case in their career,” Ahnert says. “Our experience with CPVT was successful in that the patient was able to carry to term and have a successful delivery. The patient is now contemplating a second pregnancy, and our team will be there to help her.”
- “Management of cardiovascular diseases during pregnancy.” V. Regitz-Zagrosek et al. Curr Probl Cardiol. 2014; 39(4-5), 85-151.
- “Pregnancy complicated by valvular disease: An update.” M. Nanna et al. J Am Heart Assoc. 2014; 3: e000712.
- “Management of hypertension before, during, and after pregnancy.” P.R. James et al. Heart. 2004; 90:1499-1504.
- “Pregnancy and delivery in cardiac disease.” T. Ruys et al. J Cardiol. 2013; 61(2):107-112.
- “Experience at the Center for Heart and Pregnancy: a collaborative cardiology and maternal fetal medicine practice.”J. Quiñones et al. Poster presented at The 3rd International Congress of Cardiac Problems in Pregnancy, Venice, Italy, February 21-23, 2014.
- “Is there a role for cardiac magnetic resonance imaging during pregnancy? Experience at Lehigh Valley Health Network.” J. Quiñones et al. Poster presented at The 3rd International Congress of Cardiac Problems in Pregnancy, Venice, Italy, February 21-23, 2014.
To refer a patient to the heart and pregnancy program, call 610-402-CARE.
— Summer 2015