Clinic Brings Heart Care Focus to Maternal-Fetal Medicine

Congenital specialist helps identify, treat patients who may be at risk

Close up of a pregnant woman's belly

A specialized clinic created to treat cardiovascular conditions during pregnancy has become a fast-growing partner of Duke Maternal-Fetal Medicine Division and the Pregnancy Heart Center.

Cary C. Ward, MD, an adult congenital heart disease specialist, occasionally treated pregnant patients as a part of her practice. Those patients often presented with complex, challenging conditions, Ward says, which nurtured her personal interest in addressing cardiovascular risk factors in a more organized, effective way.

“Some patients in my congenital practice would be women with mechanical heart valves, for example, who were pregnant or wanted to become pregnant,” says Ward. “These individuals required very specialized care.”

Ward began to work more closely with physicians in the Maternal-Fetal Medicine Division early in 2019 by offering cardiovascular care recommendations for patients when consulted by maternal-fetal specialists. “When we started, they had my pager and contacted me when I could help,” she remembers.

Comprehensive clinical collaboration

By the end of 2019, a half-day clinic was created as part of a comprehensive clinical collaboration. Ward now joins a monthly multidisciplinary maternal-fetal medicine planning conference led by Jerome J. Federspiel, MD, PhD, that brings together cardiology, anesthesia, and maternal-fetal medicine. Anesthesiologist Marie-Louise Meng, MD, represents the anesthesiology team in the conference.

The case reviews help establish collaborative clinical plans for the highest-risk patients. Looking ahead, participants in the monthly planning sessions develop care guidelines and standardized documentation of delivery plans for their patients. This specialized, proactive approach to their care has resulted in more referrals and a fast-growing patient panel as more women from across North Carolina and adjoining states are referred to the clinic.

“One contributor to our fast growth is that the multidisciplinary approach creates an environment in which we are able to help patients with immediate health risks,” Ward says. The number of active patients cared for by the interdisciplinary team has tripled over the past year, Ward says.

But the demand for comprehensive cardiac care before and during pregnancy remains high, Ward says. She has personally witnessed the medical challenges facing pregnant individuals in the United States. “Among nations of the same socioeconomic profile, the statistical risks associated with pregnancy are significantly higher in the U.S. than in other countries,” Ward says.

These risks have  continued to rise in recent years. Since the creation of the CDC’s Pregnancy Mortality Surveillance System, the number of reported pregnancy-related deaths in the United States increased from 7.2 deaths per 100,000 live births in 1987 to 32.9  deaths per 100,000 live births in 2021. Among African American women who are pregnant, the maternal mortality rate is twice as high, a statistic that highlights the health care disparities in this field.

The reasons for the increase in overall maternal mortality are multifactorial, but the experience at Duke has convinced Ward and her colleagues that pregnant women need proactive care as soon as possible.

“Women are becoming pregnant later in life, and have higher rates of diabetes, obesity and elevated blood pressure,” Ward adds. “These risk factors can contribute to hypertensive disorders of pregnancy such as preeclampsia, all of which are associated with a higher risk of maternal death.”

When to Refer

You can refer your patients to the Duke Pregnancy Heart Center when they have severe maternal cardiac disease or abnormalities, including:

  • Complications with maternal heart valves or function of the heart.
  • Heart failure and congenital heart disease.
  • Myocardial infarction in previous valve replacements.
  • Peripartum cardiomyopathy. Patients can develop a cardiomyopathy during pregnancy and/or following pregnancy, as subsequent pregnancies may have 25 to 50% risk of mortality.

To refer a patient, call 919-684-6327.

High-risk pregnancies benefit from maternal care navigators

One key step to providing proactive, efficient care to patients with high-risk pregnancies is the increasingly significant role played by maternal care navigators. These individuals are trained to develop outreach plans, help coordinate visits and check-ups, and create a proactive approach to maternal care. The trainees specializing in working with the patients and managing care.

Maternal care navigators represent an important part of the effort by Maternal-Fetal Medicine to provide outreach to individuals with the highest-risk pregnancies to proactively to ensure that the individuals receive care and can be directed to the correct providers efficiently and quickly. Pregnancy heart centers like the one at Duke are being created at many medical institutions to help address the gaps in care for patients who are pregnant.

Sarah Snow, MD, and Toi Spates, MD, from the Duke Cardiovascular Disease Fellowship Program assist Ward. Both are training to expand the number of providers who can participate in the care of pregnant women with cardiovascular disease, Ward says.

Duke’s approach sets the stage for future growth, Ward says. “We want to expand the clinic to a full day and add more providers.” In the future, she hopes the multidisciplinary approach can be offered in satellite clinics beyond Durham. The clinic is located at Pavilion East at Lakeview, 2608 Erwin Road #200 in Durham.