Challenges and Updates in the Management of Arrhythmias During Pregnancy and Postpartum

Podcast Discussion With Nishaki Mehta, MD, and Zeynep Alpay-Savasan, MD

In this episode, we are highlighting a discussion on challenges and updates in the management of arrhythmias during pregnancy and postpartum. Dr Mehta is a cardiac electrophysiologist and Dr Alpay is a maternal fetal medicine specialist; both are located at Corewell Health in Michigan. 

This episode is also available on Spotify and Apple Podcasts!

Nishaki Mehta, MD: I am Nishaki Mehta, a cardiac electrophysiologist at Corewell Health. I am grateful to highlight the germane and rising epidemic of heart disease in pregnancy, especially near Mother's Day. It is so important. I am excited to be joined by my partner-in-crime, Dr Alpay, to highlight our efforts to bring more attention to this topic and hopefully move the field forward.

Zeynep Alpay-Savasan, MD: I am Dr Alpay, and I am maternal fetal medicine specialist at Corewell Health.

Mehta: We would like to start by talking about heart disease in pregnancy. In literature, which is primarily derived from billing and coding data such as the National Inpatient and National Readmission databases, there has been a steep increase in heart disease in pregnancy. But what is even more unfortunate, is that there has been an increase in maternal mortality over the last decade. Sadly, the United States is number one in maternal mortality among all advanced nations, and I really think that we can do better.

Alpay-Savasan: Yes, I completely agree. Cardiovascular disease in pregnancy is certainly more common now compared to 20-30 years ago. To emphasize some of the numbers, in the United States, this is seen in approximately 1%-4% of all pregnancies, and there has been a 20% rise since the early 2000s. In addition, the prevalence of major adverse cardiac events in pregnancy has increased by 18%-20%. This is a very significant number when we think about outcomes in reproductive-age women. As you emphasized, cardiovascular disease is unfortunately now the leading cause of maternal mortality, especially in the United States, where it is approximately 30%.

Mehta: That is very shocking. I am on the Institutional Review Board for research, and one of the issues I find is that it has been difficult to study heart disease in women who are pregnant or postpartum because they are defined as a vulnerable population. So, a lot of our clinical practices stem from observations or from expert opinion guidelines. With that in mind, Dr Alpay and I talked about better ways to study how to improve maternal health in heart disease, and we founded the COPPER registry, which stands for Cardiovascular Outcomes in Pregnancy and Postpartum Period. The goal of this registry is to collectively contribute our experiences across the United States and hopefully, worldwide, to determine how to best help these women. Importantly, pregnancy is a repeat event, so we want to learn how to best prepare these patients for their next pregnancy. We would love to talk with participating centers and centers that are interested in ways to come together and find patterns of what is working and what is not working, to help this vulnerable population. I think a key part of it is that we are very fortunate at Corewell to have a strong maternal fetal medicine department, but a lot of hospitals across the country do not have one. So, cardiologists and obstetricians must work together, and in a data-free zone. We are hoping that the insights from the COPPER registry can especially guide care of these patients in areas where access is difficult.

Alpay-Savasan: Yes, that is true. The COPPER registry is going to help not only patients in the United States, but I am hoping from all around the world as well. Assessing risk in patients before getting pregnant, finding these risks and understanding them, identifying which patients have a higher risk for cardiovascular complications and mortality during pregnancy and how to manage that, and lower the risk for not only the mother but also the baby, is all extremely important.

Mehta: Along those lines of our current registry, there are some other registries that exist in this space, but they mostly focus on women with congenital heart disease. In my practice, in the last 7 years as an electrophysiologist, we have started seeing more heart disease that is new onset during pregnancy and the postpartum period. So, I really think we need to broaden our understanding to new-onset heart disease. I think a lot of that has to do with the fact that women are now older at their first pregnancy or repeat pregnancies, and there is an entire array of infertility treatments. I understand that 1 in 8 couples are infertile, and the impact of infertility treatments, including the hormonal surges, on cardiovascular disease is unexplored territory. Understanding the interaction will be helpful as we support these women as they start their families.

Alpay-Savasan: Yes, you are right. The risk assessment tools that we have now have some limitations. The focus in the last few years was to help mainly women and girls with congenital heart disease improve their quality of life and survival, and it has been extremely successful. That increases our clinical practice to see more of these young, childbearing age women with congenital heart disease. But there is a huge increase in women with acquired heart disease as well. One of the top reasons is maternal age. We are seeing more women planning their pregnancies later in life, postponing their family planning until later in life. So, we see more women with advanced maternal age getting pregnant for the first time. Infertility or reproductive issues have increased, so that also increases couples needing more assisted reproductive techniques and treatments. However, one of the other main reasons that acquired heart disease is on the rise is the change in maternal demographics, not only age, but coexisting comorbidities have increased. In the general population—not only women—we have seen an increase in obesity, diabetes, and hypertension. These coexisting medical conditions significantly increase the risk of cardiac problems, as you know. We certainly see it more commonly in reproductive-age women and in pregnancy too.

Mehta: Absolutely. All of these travel together and it is a vicious cycle, one propagating the other. But the other part I learned over the course of working with our maternal fetal department and founding the COPPER registry was that the post trimester or postpartum period represents a very vulnerable period to lose patients and have them suffer from repeated hospitalizations and adverse events. I will share with you what I do to make sure that we capture these patients in the postpartum period, but I would love to hear what obstetricians and maternal fetal medicine specialists do as well. From what I understand, there is a huge racial socioeconomic disparity in the care of women who are pregnant or postpartum. But it is really highlighted in the postpartum period, when 40% of women do not show up for their postpartum visits. Since this is a very high-risk period for cardiac adverse events, I have been starting to not only follow them through pregnancy, but in the postpartum period, conduct telephone visits or set reminders so we can check in on them. Not too long ago, I was a geriatric pregnancy and I still recall the postpartum period where, with a new child and lack of sleep was exhausting. I can totally see why a woman would miss her doctor appointments, especially if she lacks a support system. So as a system, I think we need to better support them for at least the next 6 to 12 weeks postpartum?

Alpay-Savasan: Yes, that is unfortunately an ongoing challenge for my field. During pregnancy, many patients are mostly compliant with their care, but once they have the baby, the postpartum period is a challenging time for many reasons, some of which you mentioned—you are busy now with a child at home, your whole life has changed, there is less sleep, and more work at home. Moms definitely make their babies their priority and they do not consider watching their own health very much. So that has been a challenge. In the early postpartum period and later in the postpartum period, we see an increased risk of complications, cardiac issues, and hypertension problems. Because of the physiologic changes seen in postpartum period, it increases the risk of cardiovascular disease in pregnancy. During the postpartum period, there is also a higher risk of developing thromboembolic events (blood clots), hypertension, and preeclampsia. The postpartum period carries a huge risk for mental health in these patients as well. We are working on getting these postpartum patients to be seen or followed closely by their obstetricians or any relevant specialist. Telehealth, phone consults, phone follow-ups, and video visits have been very helpful. Since the pandemic, we started doing many of our visits and consultations by telehealth, it has been extremely helpful. So, in the postpartum period, using that telehealth opportunity is very helpful to our patients and for us as well.

Mehta: Yes. Another key insight that changed my practice of being engaged in this effort is promoting lactation. There have been signals in the cardiovascular field that lactation does not just help the baby, like we learned in medical school, but it also really promotes long-term heart health in the mothers. Along with the demands of the postpartum period, I think lactation is also a fairly stressful journey. Often, when I walk into a postpartum room to see a new consult, I see that the first thing the mother has done is stop breastfeeding. I am hoping our efforts through COPPER and our efforts to engage in education will help cardiologists recognize that we should support lactation more for the long-term benefits. It is like exercise. It is going to help the woman over the next 5 to 10 years. At Corewell, my department was very supportive of my personal breastfeeding journey, but I have also heard about other universities where they have less clinical demands on women who are breastfeeding or make it more conducive to support this journey. However, I think we should also relay the same encouragement to our patients. Also, one of the biggest myths that we overcame was that a lot of drugs were not safe for the breastfeeding mother, but there are easy-to-find metrics called the Relative Infant Dose, and if the Relative Infant Dose is less than 10% for a medication, it is safe for the child. So, I really think we should not be scared about drug exposure to the child. We can wisely choose a lot of cardiac medications and keep maternal health in mind as we encourage women who want to breastfeed, understanding that it is a win-win situation on all fronts. How do you tackle that?

Alpay-Savasan: Yes, we strongly encourage breastfeeding for all our patients. There are extremely rare cases that we tell the patient not to breastfeed. You are right with the medication use—in some subspecialties, they are a little hesitant to recommend that patients continue breastfeeding when they are on any type of medication. But many of the medications that are being used by the mother are actually quite safe for the baby too. So overall, breastfeeding is definitely very helpful to the mother and baby, and we always encourage our patients to try to continue breastfeeding. There are a lot of opportunities and resources on lactation for our patients. It can be challenging for a new mom to learn how to breastfeed and such, but we have a lot of resources that our patients can use, and once they are capable and understand how to breastfeed, it is a great bonding experience for both the mom and baby. In the long term, it has many benefits for both maternal health and for the child's health too. There is growing evidence that breastfeeding decreases the risk of cardiovascular disease, but also other health conditions, even in the long term. The risk of breast cancer has been shown to be reduced in these moms. It also increases the baby’s immune system, significantly reducing the risk of infections, autoimmune conditions, and overall metabolic health. So, I completely agree that it is very important to explain the benefits to the patient and encourage them to continue breastfeeding, not only in early postpartum, but for a couple of months after that at least.

Mehta: That was very helpful. The benefits impact the cardiac realm and really help the mother. So, if I had to summarize how my clinical practice has changed in this realm, I would say a couple things. I see a lot more women who are getting new heart disease during pregnancy, so I have really tried to do a better job of following them not only through the different trimesters, but most importantly, during the postpartum period. I am also using the intervals between pregnancies to better counsel them on their subsequent pregnancies. Also, sometimes if there is a supraventricular tachycardia (SVT), I will do an ablation between pregnancies, as it might be the best window for them. Finally, I have been a lot better about supporting lactation if the mother so desires and raising awareness on that front. If there are any ways we can help colleagues across the country with our experience, or have them join us in this research effort, we would be honored to work with them.

Alpay-Savasan: I am excited to hear that physicians in the non-obstetrics field are realizing how important all these issues are, including the preconception consultation of getting the patient ready and optimizing their health before they get pregnant or between pregnancies, educating them, and close monitoring during pregnancy and the postpartum period, as well as how important the follow-ups and education of these patients are. As a subspecialist in the cardiac field, I appreciate you helping our patients, even when they are not pregnant.

Mehta: Dr Alpay, I would like to thank you again. Not only have you been a fantastic clinical counterpart, but you have also been a passionate research advocate for our patients. One of the joys of managing complex patients is having a multidisciplinary team that is as passionate. I really think we are making a difference, and I am so grateful for your time today to share our experience with the larger community.

Alpay-Savasan: Thank you, I am honored to be your colleague and help our patients, especially working on this COPPER registry that I strongly believe is going to be a big help in the future, not only to clinicians, but also to patients with cardiovascular disease. Thank you for inviting me.