Advances in Women's Health

Cardiovascular disease is now the leading cause of maternal morbidity and mortality in the United States. The increase in its prevalence is attributed to a number of factors, including delayed childbearing with rising rates of births among individuals above the age of 35; higher rates of cardiovascular risk factors such as diabetes, hypertension, and obesity, including in young people; and survival of those born with congenital heart defects to childbearing age. In fact, findings from a multicenter study led by NewYork-Presbyterian/Columbia faculty and published June 5, 2022, online in the Journal of Maternal-Fetal & Neonatal Medicine showed that in the United States maternal congenital heart disease is becoming more common among deliveries and risk for severe morbidity is increasing.

Dr. Stephanie Purisch

“Recognizing the crisis of maternal morbidity and mortality and that cardiovascular disease is a leading cause of pregnancy-related deaths and complications, there has been a push nationally, supported by the American College of Obstetricians and Gynecologists [ACOG] to establish multidisciplinary cardio-obstetric teams to care for these high-risk patients,” says Stephanie E. Purisch, MD, Co-Director of the Mothers Center Heart Program in the Department of Obstetrics and Gynecology at NewYork-Presbyterian/Columbia University Irving Medical Center. As a maternal-fetal medicine specialist, Dr. Purisch has focused her clinical and research pursuits on women with medically complicated pregnancies.

The Heart Program is a core component of the Mothers Center, which was established four years ago by Mary E. D’Alton, MD, Chair of Obstetrics and Gynecology at Columbia, along with faculty in the Division of Maternal-Fetal Medicine at NewYork-Presbyterian/Columbia. The Mothers Center provides coordinated multidisciplinary support for women with a wide range of complex medical and surgical problems, such as cardiovascular disease, diabetes, neurovascular disease, organ transplants, and placenta accreta. A large proportion of patients seen in the Mothers Center have cardiac conditions, so the creation of a dedicated heart program was a logical progression in the commitment to providing highly specialized services to this population.

Dr. Jennifer Haythe

“The Mothers Center Heart Program is near and dear to me and is my main clinical passion,” notes Dr. Purisch, who co-directs the program with Jennifer Haythe, MD, a cardiologist with advanced training in heart failure and particular expertise in cardio-obstetrics at NewYork-Presbyterian/Columbia. “Pregnancy can be a time when seemingly healthy women are at risk for cardiac complications. Our program comprises a team of maternal-fetal medicine specialists, cardiologists, obstetric anesthesiologists, and critical care OB nurses who take care of women prior to pregnancy, during pregnancy, and in the postpartum period. Importantly, our patients can be seen by their maternal-fetal medicine physician and their cardiologist on the same day, back-to-back, in the same practice location allowing us to seamlessly communicate and collaborate at the physician level and provide expedited and thorough care to our patients.”

The proximity of specialists and continuity of care are hallmarks of the Mothers Center Heart Program. Multidisciplinary conferences are held to review cases and coordinate patient care. Maria Sheikh, MD, MPH, an OB anesthesiologist with NewYork-Presbyterian/Columbia, consults with each patient and their respective physicians to aid with safe delivery planning.

Protocols for Healthy Pregnancies

“Appropriate preconception guidance and collaborative prenatal care, including close maternal and fetal surveillance, with a tightly planned delivery enables women with incredibly complex cardiac conditions to achieve healthy pregnancies,” says Dr. Purisch. “Because cardiology encompasses so many different conditions, we have on board specialists in congenital heart disease, general cardiology, and cardiac electrophysiology. On a case-by-case basis, we can involve interventional cardiologists and cardiothoracic surgeons across NewYork-Presbyterian/Columbia, as needed. We also have a dedicated prenatal genetic counselor on our team because we are increasingly learning more about underlying genetic abnormalities in women with cardiac disease. Genetic testing can be very informative not only for the mother’s medical care, but also for identifying risks to a fetus. This is a resource that is unique and new to our program. For patients who are not healthy enough for a pregnancy, we work with our family planning colleagues to ensure appropriate contraception counseling is provided.”

“We see an incredible number of very complicated patients at NewYork-Presbyterian/Columbia. In the past 18 months or so we took care of over 80 patients with complicated pre-existing heart disease.” — Dr. Stephanie Purisch

Patients who have a diagnosis of heart disease prior to becoming pregnant and those whose diagnosis is revealed at the time of pregnancy are followed at a number of time points in their pregnancy. “Preconception counseling is universally recommended by professional societies – ACOG, the American Heart Association, and the European Society of Cardiology – for any woman with cardiovascular disease,” says Dr. Purisch. “We see women with known congenital or acquired heart disease for a preconception pregnancy risk assessment to make sure that their health is optimized, their medications are safe for pregnancy, and that they have any necessary screening or testing before they get pregnant.”

“The Mothers Center Heart Program is not a consultative maternal-fetal medicine practice,” continues Dr. Purisch. “Patients see one of our maternal-fetal medicine specialists for all prenatal care visits during which time mom and baby are closely monitored and delivery planning is addressed. We hold multidisciplinary conferences twice a month to review cases and set delivery plans. We have a special critical care/high-risk OB unit within labor and delivery with critical care trained OB nurses. This unit provides cardiac monitoring with telemetry and other advanced monitoring so that our patients can be cared for in the hospital’s labor and delivery unit. In hospitals without this type of unit, patients may need to be cared for in an ICU. At NewYork-Presbyterian/Columbia, transferring a patient to the ICU is an infrequent event because we can manage the cardiac care on our labor and delivery floor.”

Dr. Purisch notes that patients with new cardiac complications in pregnancy or the peripartum period, such as preeclampsia, pericardium cardiomyopathy, or acute coronary syndrome, are also managed within the Heart Program. “Our program also has systems in place to facilitate postpartum transitions of care. The postpartum period is classically the period of time when the new mom falls off the radar as the attention turns to the baby. Patients who have obstetric complications such as gestational hypertension or preeclampsia, gestational diabetes, preterm birth, or fetal growth restriction may be at risk of long-term cardiovascular disease.”

To address this concern, the Mothers Center Heart Program collaborates with a program led by gynecologist Mary L. Rosser, MD, PhD, Director of Integrated Women's Health in the Department of Obstetrics and Gynecology at NewYork-Presbyterian/Columbia. Dr. Rosser partners with cardiologist Sonia Tolani, MD, to provide postpartum cardiovascular risk assessment and counseling on preventive measures in order to reduce the risk for long-term cardiovascular disease and to facilitate the transition of care for patients to internal medicine and/or cardiology.

In a study published in the November 3, 2020, issue of the Journal of the American College of Cardiology, faculty in the Division of Cardiology and the Department of Obstetrics and Gynecology at NewYork-Presbyterian/Columbia described the clinical characteristics, maternal and fetal outcomes, and heart-related hospital readmissions in a cohort of 306 pregnant women with underlying cardiovascular disease followed by the hospital’s cardio-obstetrics team. Of these, 88 women had arrhythmia (28.8 percent), 72 women (23.5 percent) had congenital heart disease, and 72 women (23.5 percent) had cardiomyopathy. Findings showed:

• Live birth occurred in 98 percent of pregnancies
• Median gestational age for delivery was 38 weeks
• Gestational diabetes occurred in 11.4 percent of patients
• Hypertensive disorders of pregnancy occurred in 21.6 percent
• ICU admission was required in 27 patients (8.8 percent)
• Following delivery, the 30-day readmission rate was only 2 percent; rate of readmission from 30 to 90 days postpartum was only 4.6 percent
• One maternal death occurred within a year of delivery in a woman with Eisenmenger syndrome

The NewYork-Presbyterian/Columbia study team concluded, “In a population of primarily Medicaid-insured pregnant women managed by a cardio-obstetrics team, maternal outcomes were encouraging and readmission rates following delivery were low.”

A Broad Commitment to Promoting Awareness of Cardio-Obstetrics

As part of her commitment to this nascent field, Dr. Purisch recently contributed her time and expertise to the American Academy of Pediatrics project on Awareness of Congenital Heart Defects (CHD) Among Healthcare Clinicians. The project was designed to reach primary care physician groups – pediatricians, obstetrician-gynecologists, internal medicine, family medicine, and emergency medicine physicians. Dr. Purisch was a member of the CHD Program Advisory Committee; she helped develop several innovative resources and education materials to promote lifelong congenital cardiology care and served as a reviewer for the video-based course, “OB/GYN Care for Patients with Congenital Heart Defects.”

Dr. Purisch is also a member of the workgroup developing a Cardiac Bundle for ACOG District II Safe Motherhood Initiative and is building a cardio-obstetrics curriculum for the maternal-fetal medicine fellowship at Columbia to ensure comprehensive training in cardio-obstetrics is provided.