Dr. Jennifer Lewey (left) and Dr. Lisa Levine
Having a baby is often an exciting, happy time for expectant parents and their loved ones. But it can also be a vulnerable time for a pregnant patient’s heart.
During pregnancy, a patient’s heart undergoes changes, such as an increased heart rate and a twofold increase in blood volume pumped by the heart. “The heart is working about 50 percent harder to pump all of that blood with an increase in cardiac output,” says Penn Medicine maternal-fetal medicine specialist Lisa D. Levine, MD, MSCE. “These changes both unmask underlying heart issues but can also potentially trigger new ones.”
Cardiac complications that develop during pregnancy are the cause of more than 1 in 3 pregnancy-related deaths.
“It’s a big problem in the United States. There is not enough awareness of the fact that heart disease is the leading cause of maternal deaths, especially during the postpartum time period,” says Jennifer Lewey, MD, MPH, a Penn Medicine cardiologist. “A lot of people who come in to see us are scared. We’re here to help people through this experience because it really should be a very happy thing that they’re pregnant and having a baby. We do not offer false optimism, but no matter what happens, we’re in it together, and we'll figure it out.”
Drs. Levine and Lewey codirect the Penn Medicine Pregnancy and Heart Disease Program. Their team is available to help patients with heart conditions who are pregnant or looking to become pregnant. The program works with patients and their local doctors to develop a comprehensive care plan to improve safety before, during, and after pregnancy.
Considerations for getting pregnant with a heart condition
Pregnant patients who have a history of heart issues should talk to a specialist early in pregnancy—or even before becoming pregnant. A specialist can help by:
- Reviewing potential risks
- Closely evaluating and monitoring any existing heart conditions (for example, cardiomyopathy, arrythmias, valve disease, and aortic disease)
- Reviewing medications, as some may not be safe in pregnancy
- Possibly recommending additional testing before pregnancy, such as echocardiogram or exercise stress test to help determine whether the heart can handle the physical aspects of labor and delivery
“We spend time ensuring the person is optimally prepared as best as they can for a pregnancy,” Dr. Levine says.
“Knowledge is power, and we respect a patient’s right to decide. We give them the information they need to make an informed decision and to take steps that will make the journey of pregnancy, if they choose that, as safe as possible,” Dr. Lewey adds. “We may discuss that pregnancy is so high risk that we would recommend against pregnancy. That being said, we always support any person who does choose to get pregnant, and we will continue to care for them during their pregnancy.”
For those who decide not to proceed with pregnancy because of heart risk, the team can connect them with other options, including a gestational carrier (surrogacy) or adoption.
Monitoring heart disease in pregnancy
Heart complications can develop over the course of pregnancy, even in patients who had no previous symptoms or known risk factors. For those with a pre-existing heart condition and those who develop a heart issue during pregnancy, a specialist can offer close surveillance and expertise.
At the Penn Medicine Pregnancy and Heart Disease Program, patients can see a maternal fetal medicine physician (high-risk pregnancy obstetrician) and a cardiologist together. A patient’s primary obstetrician can also consult with the Penn Medicine team about their shared patients. “This allows us to have detailed, individualized conversations that consider maternal health and the health of the baby and how to make important decisions,” Dr. Lewey says.
The Penn Medicine Pregnancy and Heart Disease team can:
- Determine the best place to receive prenatal care and to deliver
- Discuss the ideal timing of delivery, as sometimes an earlier delivery can protect maternal health
- Discuss options for pain control (anesthesia) during labor and delivery that are safest for expectant mothers with heart issues
- Make recommendations for a method for delivery that minimizes heart strain, including assisted vaginal delivery using special instruments or C-section
- Monitor the pregnant patient’s heart with cardiac imaging tests that won’t harm the baby
- Offer interventions, including surgical options and ablations, if cardiac issues become more serious during pregnancy
- Work with your obstetrician to develop a plan if complications arise during labor and delivery
- Bring in other specialists to maximize maternal health, including social workers, nutritionists, and diabetes experts
Certain pregnant patients with a high-risk heart condition may plan for labor and delivery at a Penn Medicine hospital. Others may be able to deliver at an institution closer to home. “People in our program don’t necessarily need to deliver at Penn. Our goal is to identify the people who can safely deliver in their own community because everyone will be more comfortable delivering closer to home if that is a safe possibility. We can help make sure that everyone (the patient, the obstetrician, the local cardiologist, etc.) is comfortable with the monitoring and treatment plan,” says Dr. Lewey.
A specialist might recommend that some patients with high-risk heart conditions deliver at a Penn Medicine hospital. This provides access to more advanced heart monitoring systems than can be found at local hospitals. In addition, cardiothoracic surgeons and advanced heart failure teams can be prepared in advance for the individual patient’s condition and be available during delivery.
Peripartum cardiomyopathy or newly identified heart conditions
Even pregnant patients who didn’t have a heart problem before or during pregnancy can develop one after delivery. One of particular concern is peripartum cardiomyopathy, a rare form of pregnancy-related heart failure that can occur late in pregnancy or in the postpartum time period.
If you notice shortness of breath or swelling in the legs that isn’t getting better after pregnancy, it is important to seek immediate medical care. There are essential tests that can identify heart issues early so that doctors can begin treatments quickly and save the pregnant patient’s life. These tests may include an echocardiogram to assess heart function, and a blood test called B-type natriuretic peptide (BNP). BNP is a hormone produced by the heart and blood vessels. Levels of the hormone can help your team determine the severity of a heart condition.
The Penn Medicine Pregnancy and Heart Disease Program offers expert heart assessment and treatment to help the heart recover. Heart recovery is important for long-term health and potential future pregnancy.
“The time after birth is actually one of the most vulnerable times in a patient’s health. Unfortunately, it’s at the same time that we often see a lack of follow-up because parents are focusing on taking care of their babies,” Dr. Lewey says. The Penn Medicine Pregnancy and Heart Disease Program offers in-person consultations as well as telehealth visits to accommodate parents who are busy taking care of their families. Many times, patients can see a maternal fetal medicine specialist and a cardiologist in the same visit. “We’re bringing care to where the patients are, rather than having the patient travel all over the place to get the care that they need,” says Dr. Lewey.
Offering this kind of expanded access to specialists is part of Penn Medicine’s commitment to reducing disparities in maternal health. Black women are more likely to die from pregnancy-related complications than White women. Care coordination, virtual visits, and patient and provider education are some ways to help people access care and improve outcomes.
Additional services for heart disease and pregnancy
The Penn Medicine Pregnancy and Heart Disease Program also offers additional services to patients with pregnancy-related heart conditions:
- Enrollment in research studies, including clinical trials, which may offer treatment and support not available elsewhere
- Specialized programs to care for patients with certain heart conditions in pregnancy, including peripartum cardiomyopathy
- Support groups for patients to connect with others having similar experiences during motherhood
- Research registries to track outcomes and improve care of pregnant patients in the future
Talk to a specialist in maternal heart health
Learn more about the Penn Medicine Pregnancy and Heart Disease Program.