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CME / ABIM MOC / CE

Cardiovascular Symptoms and COVID-19 in Pregnancy Requires a Team Approach

  • Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 9/23/2022
  • Valid for credit through: 9/23/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for cardiologists, family medicine/primary care clinicians, internists, pulmonologists, cardiologists, critical care clinicians, obstetricians/gynecologists/women’s health clinicians, nurses, pharmacists, public health and prevention officials, physician assistants, and other members of the healthcare team for pregnant women with cardiovascular (CV) symptoms and COVID-19.

The goal of this activity is for learners to be better able to describe CV complications and interprofessional approaches to diagnosis in women with pregnancy-associated COVID-19, according to a review by the American College of Cardiology (ACC) Cardiovascular Disease (CVD) in Women Committee.

Upon completion of this activity, participants will:

  • Describe CV complications in women with pregnancy-associated COVID-19, according to an ACC review by the CVD in Women Committee
  • Determine interprofessional approaches to diagnosis of CV complications in women with pregnancy-associated COVID-19, according to an ACC review by the CVD in Women Committee
  • Outline implications for the healthcare team


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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Megan Brooks has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie Inc.

Editor/Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.


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In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

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CME / ABIM MOC / CE

Cardiovascular Symptoms and COVID-19 in Pregnancy Requires a Team Approach

Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 9/23/2022

Valid for credit through: 9/23/2023

processing....

Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to the approved COVID-19 vaccines are provided in this activity in an effort to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

COVID-19 often has cardiovascular (CV) complications, including microvascular and macrovascular thrombotic complications of arterial and venous thromboembolism, myocardial injury, or inflammation causing myocardial infarction (MI), heart failure (HF), and arrhythmias. Evidence suggests greater risk for adverse COVID-19 outcomes in pregnant vs nonpregnant women of reproductive age, including intensive care unit (ICU) admission, mechanical ventilation, and extracorporeal membrane oxygenation (ECMO).

Case series of pregnancy-associated COVID-19 have shown MI, ventricular dysfunction, arrhythmias, thrombotic complications, higher preeclampsia risk, and “long haul” symptoms. As prevalence of vaccinated women is lower than in other population groups, the potential for CV complications may remain high during pregnancy.

Study Synopsis and Perspective

Management of the cardiac complications of COVID-19 during pregnancy requires a "pregnancy heart team" to optimize patient care, the American College of Cardiology (ACC) Cardiovascular Disease (CVD) in Women Committee wrote in a new report.

This interprofessional team can include clinicians comfortable with high-risk pregnancy, obstetric anesthesia, cardiology, critical care, and neonatal care, depending on the nature of the complication, stage of pregnancy, and severity of disease, suggested Joan E. Briller, MD, from the University of Illinois, Chicago, and colleagues.

The group summarized what is known about pregnancy-associated COVID-19 CV complications in a "state-of-the-art" review, published in the August issue of JACC: Advances.

Challenging Group

Pregnant women can be more apt to develop severe COVID-19 and require ICU care, mechanical ventilation, and ECMO, they pointed out.

Pregnant women are also at elevated risk for the cardiac complications of COVID-19, including myocardial injury, arrhythmias, and heart failure compared with nonpregnant women of reproductive age.

Factors associated with a higher risk for cardiac complications in pregnancy include maternal age over 35 years; higher body mass index (BMI); preexisting comorbidities, such as chronic hypertension, diabetes, CVD, and preeclampsia; racial/ethnic minority; and unvaccinated status.

In terms of management considerations, Briller and colleagues said it is important to distinguish unique complications of pregnancy -- such as preeclampsia, peripartum cardiomyopathy, and spontaneous coronary dissection (SCAD) -- from other COVID-19-associated cardiac complications; however, current statements addressing COVID-19-associated cardiac complications do not include pregnancy complications that can mimic COVID-19 complications, they pointed out.

One challenge, they said, is that some of the prothrombotic changes of pregnancy, such as complement activation, release of proinflammatory cytokines, antigen-antibody abnormal responses, prothrombotic phenomena, and endothelial-vascular dysregulation, are similar to the immune-mediated severe forms of COVID-19 thought to be responsible for myocardial injury with infection.

Pregnant women with severe COVID-19 or with multiple risk factors -- such as diabetes, hypertension, older age, smoking, obesity, and previous CVD -- should be assumed to be at the highest risk for myocardial injury.

Although there currently is no standard recommendation for when cardiac biomarkers should be checked, the writing group suggests considering it in pregnant women with moderate or severe COVID.

Chest discomfort thought to be of cardiac origin, whether acute or persistent, warrants evaluation with biomarkers. Levels more than 20% above baseline warrant further evaluation, they said.

In the setting of chest discomfort with abnormal biomarkers, differential diagnosis includes demand ischemia, myocarditis, stress cardiomyopathy, and acute coronary syndrome (ACS).

Overall, the group noted that approaches to the diagnosis of suspected myocardial injury are similar to those in nonpregnant patients. Initial assessment is based on history and physical exam findings, chest x-ray, electrocardiogram (ECG), cardiac biomarkers, and frequently echocardiography.

Urgent angiography is "reasonable" when the ECG suggests ST-segment elevation myocardial infarction (STEMI), especially with classic symptoms. Equivocal symptoms or ECG findings can prompt evaluation with a focused or full transthoracic echocardiography (TTE).

The presence of wall motion abnormalities will help guide the decision to proceed to coronary angiography, computed tomography angiography (CTA), or medical therapy.

Computed tomography angiography (CTA) is an option for stable patients or patients with divergent findings to rule out ACS or point to an alternative diagnosis.

"Be Vigilant" for Heart Problems

Heart failure can be particularly challenging in the setting of pregnancy. Symptoms of HF can mimic those of normal pregnancy, and the signs and symptoms of COVID-19 can further obscure the clinical picture. Members of the interprofessional team play a vital role in evaluation, diagnosis, and management of these patients.

"Therefore, when managing pregnant women with COVID-19, particularly those with moderate-severe illness or those with evidence of myocardial injury, care should be taken to evaluate for [HF] and cardiomyopathy," the group advised.

They said COVID-related cardiomyopathy needs to be differentiated from peripartum cardiomyopathy (PPCM), owing to implications for long-term follow-up and counseling about the risks with future pregnancies.

The timing of HF presentation can help distinguish PPCM from pregnancy-associated COVID-related cardiomyopathy.

Heart failure related to COVID-19 can occur throughout pregnancy, whereas PPCM usually presents toward the end of pregnancy or in the months after delivery.

Still, the 2 conditions can be challenging to differentiate in patients with COVID-19 during the third trimester or the early postpartum period and among patients with risk factors common to both conditions.

Summing up, the authors said it is important for physicians to know that most cardiac complications described outside of pregnancy, such as arrhythmias, myocardial injury, thromboembolic complications, and long-haul symptoms, women also report during pregnancy. Additional concerns include increased risk for preterm labor and delivery and development of preeclampsia.

The group encouraged cardiologists and members of the interprofessional team to be "vigilant" in assessing women with COVID-19 for cardiac complications.

Members of the care team should also encourage and provide education on COVID-19 vaccination of pregnant women, as recommended in guidelines from the Centers for Disease Control and Prevention (CDC), American College of Obstetrics and Gynecology, and the Society of Maternal Fetal Medicine.

This research had no specific funding. Briller is on the steering committee and a site investigator for the REBIRTH trial.

JACC Adv. 2022;1:100057.[1]

Study Highlights

  • CV complications of COVID-19 include microvascular and macrovascular thrombotic complications (eg, arterial and venous thromboembolism, myocardial injury, or inflammation causing MI, HF, and arrhythmias).
  • Pregnant women also report most of these, as well as long-haul symptoms.
  • Risk for adverse COVID-19 outcomes, including ICU admission (4%), mechanical ventilation (3%), and ECMO use (0.2%) is greater in pregnant vs nonpregnant women of reproductive age.
  • Pregnant women at highest risk for myocardial injury are individuals with severe COVID-19 or with multiple risk factors, including age > 35 years; higher BMI; preexisting comorbidities, such as chronic hypertension, diabetes, CVD, and preeclampsia; racial/ethnic minority; and unvaccinated status.
  • Pregnancy complications that may mimic and must be distinguished from other COVID-19 complications include PPCM, SCAD, and preeclampsia.
  • Differentiating these is hindered by overlap of prothrombotic changes of pregnancy (eg, complement activation, proinflammatory cytokine release, antigen-antibody abnormal responses, prothrombotic phenomena, and endothelial-vascular dysregulation) with those seen in severe immune-mediated COVID-19.
  • COVID-19 complications can modify pregnancy management, as infected women are at higher risk for preterm birth (odds ratio [OR] 1.47 [95% CI: 1.14, 1.91]) and stillbirth (2.84 [95% CI: 1.25, 6.45]), and 25% [95% CI: 14, 37] of their infants require neonatal ICU admission.
  • Mechanisms for adverse outcomes of viral infection in pregnancy may include immune system changes, increased clotting risk, older age, underlying comorbidities (eg, diabetes, hypertension, and obesity), and racial and social disparities.
  • Management of cardiac complications of COVID-19 during pregnancy requires a "pregnancy heart team," or an interprofessional healthcare team, including clinicians who are experienced in high-risk pregnancy, obstetric anesthesia, cardiology, critical care, and neonatal care, depending on specific patient needs.
  • Members of the healthcare team should be vigilant in evaluating pregnant women with COVID-19 for cardiac complications and should encourage COVID-19 vaccination of pregnant women, as recommended by professional society guidelines.
  • Physicians should consider checking cardiac biomarkers in pregnant women with moderate or severe COVID.
  • Acute or persistent chest discomfort thought to be cardiac warrants biomarker testing.
  • Biomarkers > 20% above baseline warrant further workup, with differential including demand ischemia, myocarditis, stress cardiomyopathy, and ACS.
  • Workup of suspected myocardial injury resembles that for nonpregnant patients, based on history, physical exam, chest x-ray, ECG, cardiac biomarkers, and often echocardiography.
  • ECG and classic symptoms suggesting STEMI warrants urgent angiography, whereas focused or full TTE may suffice for equivocal findings.
  • Wall motion abnormalities merit further workup with coronary angiography, CTA, or medical therapy.
  • CTA is suitable for stable patients or patients with divergent findings to rule out ACS or suggest an alternative diagnosis.
  • Given implications for long-term follow-up and counseling regarding risks for future pregnancies, COVID-related cardiomyopathy and PPCM need to be differentiated.
  • HF from COVID-19 may occur throughout pregnancy, whereas PPCM usually occurs in late pregnancy or within a few months postpartum.
  • Distinguishing these conditions is difficult in patients with COVID in late pregnancy or early postpartum and in patients with risk factors shared by both conditions.

Clinical Implications

  • Pregnant women at highest risk for myocardial injury are those individuals with severe COVID-19 or with multiple risk factors.
  • Pregnancy complications that may mimic and must be distinguished from other COVID-19 complications include PPCM, SCAD, and preeclampsia.
  • Implications for the Healthcare Team: Diagnosis and management of cardiac complications of COVID-19 during pregnancy requires an interprofessional healthcare team to improve patient outcomes.

 

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