CARDIOVASCULAR DISEASE SCREENING IN PREGNANCY- …

CARDIOVASCULAR DISEASE SCREENING IN

PREGNANCY-

ROLE OF THE CMQCC TOOLKIT

AFSHAN HAMEED, MD, FACOG, FACC

HS Professor, Maternal Fetal Medicine & Cardiology

University of California, Irvine

AWHONN California Section Conference, February 21st 2020, Long Beach CA

WHY?Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit

Maternal MortalityChild Health USA 2013

0

5

10

15

20

25

Mat

ern

al M

ort

alit

y R

atio

(per

10

0,0

00

bir

ths)

1980 1990

2000 2008

Maternal Mortality Ratios in Selected Countries over the Past 30

Years

Hogan et al, Lancet 2010; 375: 1609–23

July 17, 2015

The US has the highest Maternal Mortality rate of any high resource country and the only country outside

of Afghanistan and Sudan where the rate is rising

Significant reductions in maternal mortality and morbidity can not be accomplished without addressing the

gaps in maternity care for black women

July 17, 2015

3-4 X

cdc.gov 8

1.6%

2X

350-400xSerious

Morbidity:

(prolonged

length of stay)

Maternal Morbidity andMortality: CVD

15-20x

Severe Maternal

Morbidity - ICU

13

13 Cardiovascular Related Mortalities/2007 in CA

LESSONS LEARNED FROM

MATERNAL MORTALITY REVIEWSCardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit

Cardiovascular Disease isthe leading cause of maternal mortality in CA and U.S.

under-recognized in pregnant or postpartum women

higher among African-American women

▪ 25% of deaths attributed to cardiovascular disease may have been prevented if the

woman’s heart disease had been diagnosed earlier

▪ Pregnancy is a period of frequent interaction with health care providers and offers an

opportunity to detect and treat heart disease, improve pregnancy outcomes, and affect

future cardiovascular health.

Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI:

10.1016/j.ajog.2015.05.008

CA-PAMR FindingsIdentification and Confirmation of CVD Pregnancy-Related Deaths 2002-2006

California Birth Cohort, 2002-2006

N=2,741,220

Pregnancy-Associated Cohort

N=864

Pregnancy-Related Deaths

N=257

Cardiovascular Pregnancy-Related Deaths

N=64

Cardiomyopathy

N=42

Other Cardiovascular

N=22


10.1016/j.ajog.2015.05.008

Top 5 Causes of Death

2002-2005

Grouped Cause of Death,

per CA-PAMR Committee

Pregnancy-Related

Deaths

N (%)

Cardiovascular disease 49 (24)

Cardiomyopathy 30 (15)

Other cardiovascular 19 (9)

Preeclampsia/eclampsia 36 (17)

Obstetric hemorrhage 10 (10)

DVT/ PE 20 (10)

AFE 18 (9)

All other causes 64 (31)

TOTAL 207

CVD Pregnancy-Related Mortality Rate: 2.3 deaths /100,000 live births

23.7

17.4

9.7 9.78.7

0

5

10

15

20

25

CVD PreE/E OB Hem VTE AFE

% o

f P

reg

nan

cy-r

ela

ted

Mo

rtality

5 Leading Causes of Pregnancy-related Deaths

Main et al. Pregnancy-Related Mortality in California. Obstet Gynecol April 2015

Note: approx 30% of pregnancy-related deaths were from a variety of “other”

causes (each below 8% including sepsis, ICH, other hemorrhages)

Proportions for Each of the Leading 5 Causes of California Pregnancy-related

Mortality

3% 8% 6% 34% 48%

Preexisting (prior to pregnancy) Prenatal period At labor and delivery Postpartum period Postmortem

CA-PAMR Findings 2002-2006

Timing of Diagnosis and Death

▪ Timing of CVD Diagnosis (n=64)

▪ Timing of Death ▪ 30% of all CVD deaths were >42 days from birth/fetal demise vs. 7.3% of non CVD

pregnancy-related deaths

▪ Driven by Cardiomyopathy deaths, with 42.9% deaths >42 days


10.1016/j.ajog.2015.05.008


Presentation of Women with CVD

▪ Abnormal physical exam findings

▪ HTN >140/90 (64%)

▪ HR >120 (59%)

▪ Crackles, S3 or gallop rhythm etc. (44%)

▪ O2 <90% (39%)


10.1016/j.ajog.2015.05.008

CA-PAMR Findings

Contributing Factors & Quality Improvement Opportunities (2002-2006) for CVD

HEALTH CARE PROVIDER RELATED

• Contributing Factors: (69% of all cases)▪ Delayed or inadequate response to clinical warning signs (61%) ▪ Ineffective or inappropriate treatment (39%)▪ Misdiagnosis (37.5%)▪ Failure to refer or consult (30%)

▪ Quality Improvement Opportunities

▪ Better recognition of signs and symptoms of CVD in pregnancy

▪ Shortness of breath, fatigue

▪ Tachycardia, blood pressure change, or low oxygen saturation

▪ Improved management of hypertension

Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008

▪ Contributing factors: (70% of all cases)

▪Presence of underlying medical conditions (64%)

▪Obesity (31%)

▪Delays in seeking care (31%)

▪ Lack of recognition of CVD symptoms (22%)

▪ Quality improvement opportunities

▪ Education around when to seek care for worrisome symptoms

▪ Support for improving modifiable risk factors, such as attaining healthier weight and

discontinuing drug use

Hameed A, Lawton E, McCain CL, et al. Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy. American Journal of Obstetrics and Gynecology 2015; DOI: 10.1016/j.ajog.2015.05.008

CA-PAMR Findings

Contributing Factors & Quality Improvement Opportunities (2002-2006) for CVD

PATIENT RELATED

PREGNANCY SYMPTOMS VS.

CARDIOVASCULARCardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit

SYMPTOMS SIGNS

• Reduction of exercise

tolerance

• Hyperventilation -

shortness of breath

• Orthopnea

• Palpitations

• Light headedness

• Dizziness/Syncope

• Edema

• JVD

• Murmurs

• AUSCULTATION

• 96% have a “functional murmur”

• Mid-systolic and low intensity

• Third heart sound is common

Pregnancy Mimics

Plasma Volume in Pregnancy

Pitkin RM Clin Obstet Gyn 1976;19:489

Physiologic changes

Signs and Symptoms of Pregnancy that mimic heart

disease

Affect diagnostic tests

•Heart failure

•Arrhythmia

DEATH

History

SymptomsPhysical

Examination

CMQCC CARDIOVASCULAR

DISEASE TOOLKITCardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit

California Pregnancy-Associated Mortality Review

(CA-PAMR) Quality Improvement Review Cycle

1. Identification of cases

2. Information collection, review by multidisciplinary

committee

3. Cause of Death, Contributing Factors and Quality Improvement (QI) Opportunities identified

4. Strategies to improve care and

reduce morbidity and mortality

5. Evaluation and Implementation of QI strategies and tools

ToolkitsCVD

Venous Thromboembolism

HemorrhagePreeclampsia

IMPROVING HEALTH CARE RESPONSE TO

CARDIOVASCULAR DISEASE

IN PREGNANCY AND POSTPARTUM:

A CALIFORNIA QUALITY IMPROVEMENT

TOOLKIT

The CVD Toolkit was developed by CMQCC at Stanford University under contract with CDPH with funding from federal Title V MCH Block grant

© California Department of Public Health, 2017

Cardiovascular Disease in Pregnancy and Postpartum Task Force

Chair: Afshan Hameed MD—UC Irvine

Co-Chair: Christine H. Morton PhD—CMQCC

WRITING GROUP

◼ Deirdre Anglin MD, MPH—USC

◼ Julie Arafeh MSN, RN—Stanford

◼ Alisa Becket—WomenHeart

◼ Leona Dang-Kilduff, RN, MS, CDE—RPPC

◼ Elyse Foster, MD—UC San Francisco

◼ Abha Khandelwal, MD—Stanford

◼ Elizabeth Lawton, MHS—CDPH/MCAH

◼ Elliott Main, MD—CMQCC

◼ Barbara Murphy, MSN, RN—CMQCC

◼ Monica Sood, MD—Kaiser Walnut Creek

◼ Maryam Tarsa MD, MAS—UC San Diego

◼ Lisa Townsend—Sister to Sister

◼ Jan Trial, EdD, RN, CNM—Memorial Care

◼ Julie Vasher, DNP, MSN, RNC-OB, CNS-BC—CMQCC

REVIEWER GROUP

◼ Kathleen Belzer, CNM, NP—East Bay Perinatal

◼ Chloe Bird, PhD—RAND

◼ Susan Bogar, MSN, CNM—UCLA

◼ Elisabeth Chicoine, MS, RN, PNP—Sonoma County Department of

Health Services

◼ Karen Clemmer, MN, PHN—Sonoma County Department of Health

Services

◼ Uri Elkayam, MD—USC

◼ William (Bill) Gilbert, MD—Sutter Health System Sacramento

◼ Tipu Khan, MD—California Academy of Family Physicians

◼ Nathana Lurvey, MD—ACOG IX

◼ Karen Ramstrom, DO, MSPH—CDPH/ Center for Family Health

◼ Mari-Paule Thiet, MD—UCSF

CVD Case Presentation

▪25 year old obese (BMI 38) African-American G2P2 presents 10

days after an uncomplicated vaginal delivery with fatigue and

persistent cough since delivery.

▪BP 110/80, HR 110, RR 28, afebrile, with O2 sat 94% on room

air.

▪She gets diagnosed with respiratory infection and is prescribed

an antibiotic. Fatigue is attributed to lack of sleep.

CVD Case Presentation (CONTINUED)

▪One week later, she presents again with continued symptoms.

Antibiotics are switched and beta-agonists are added for presumptive

“new-onset asthma.”

▪Two days later, the patient experiences cardiac arrest at home and

resuscitation attempts are unsuccessful.

▪Autopsy findings were indicative of cardiomyopathy.

CVD Assessment Algorithm

for Pregnant and Postpartum Women

Suggestive of Heart Failure: • Dyspnea• Mild orthopnea• Tachypnea• Asthma unresponsive

to therapySuggestive of Arrhythmia:• Palpitations• Dizziness/syncopeSuggestive of Coronary Artery

Disease: • Chest pain• Dyspnea

SYMPTOMS *NYHA class > II

• Resting HR ≥110 bpm• Systolic BP ≥140 mm Hg• RR ≥24• Oxygen sat ≤96%

• Age ≥40 years• African American• Pre-pregnancy obesity

(BMI ≥35)• Pre-existing diabetes • Hypertension• Substance use (cocaine,

alcohol, methamphetamines)

• History of cardiotoxicchemotherapy

Heart: Loud murmur orLung: Basilar crackles

VITAL SIGNS ABNORMAL PHYSICAL EXAMINATION

RISK FACTORS

Modified from: ©California Department of Public Health, 2017; supported by Title V funds. Developed in

partnership with California Maternal Quality Care Collaborative Cardiovascular Disease in Pregnancy

and Postpartum Taskforce.

≥ 1 Symptom + ≥ 1 Vital Signs Abnormal + ≥ 1 Risk Factor orANY COMBINATION ADDING TO ≥ 4

Obtain: EKG, Echocardiogram, BNP +/- CXR; arrhythmia monitor

Consider: CBC, Comprehensive metabolic profile, Arterial blood gas, Drug screen, TSH, etc.

Follow-up within one week

NOYES

Consultation with

Pregnancy Heart Team

Results abnormalResults negative

Signs and symptoms resolved

Reassurance and routine follow-up

CVD Algorithm Validation

▪We applied the algorithm to 64 CVD deaths from 2002-2006 CA-

PAMR.

▪56 out of 64 (88%) cases of maternal mortality would have been

identified.

▪Detection increased to 93% when comparison was restricted to 60

cases that were symptomatic.

Hameed, AB, Morton, CH and A Moore. Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum Developed under contract #11-10006 with the California Department of

Public Health, Maternal, Child and Adolescent Health Division. Published by the California Department of Public Health, 2017.

11.1

7.7

10.0

14.6

11.8 11.7

14.0

7.4

7.3

10.9

9.7

11.6

9.2

6.2

16.9

8.9

15.1

13.1

12.19.9

9.9

9.8

13.3

12.7

15.5 16.916.6

19.3

19.9

22.0

0.0

3.0

6.0

9.0

12.0

15.0

18.0

21.0

24.0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

California Rate

United States Rate

Maternal Mortality Rate,

California and United States; 1999-2013

Ma

tern

al D

ea

ths

pe

r 1

00

,000

Liv

e B

irth

s

HP 2020 Objective – 11.4 Deaths per 100,000 Live Births

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for

California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data

and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007

only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon

March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March,

2015.

OB

Hemorrhage

QI Toolkit,

Collaboratives

Preeclampsia

QI Toolkit,

Collaboratives

http://wonder.cdc.govon/

Maternal Mortality Rate (early and late deaths),

California Residents; 1999-2013

11.1

7.7

10.014.6

11.8 11.7

14.0

7.4

7.3

10.9

9.7

11.6

9.2

6.2

16.9

10.2

19.1

13.4

15.2

9.9

7.7 10.9

19.0

13.8

16.315.7

18.017.1

15.5

15.2

0.0

5.0

10.0

15.0

20.0

25.0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

(standard MMR calculation)Early Maternal Deaths <=42 days postpartum

Early and Late Maternal Deaths up to one year postpartum

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for

California (Early maternal deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) and

code O96 is also included when calculating Early and Late Maternal Deaths up to one year postpartum. Produced by California Department of Public

Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March, 2015.

HP 2020 Objective – 11.4 Deaths per 100,000 Live Births

Ma

tern

al D

ea

ths

pe

r 1

00

,000

Liv

e B

irth

s

3% 8% 6% 34% 48%

Preexisting (prior to pregnancy)

Prenatal period

At labor and delivery

Postpartum period

Postmortem


Timing of Diagnosis and Death

▪ Timing of CVD Diagnosis (n=64)

▪ Timing of Death ▪ 30% of all CVD deaths were >42 days from birth/fetal demise vs. 7.3% of non CVD

pregnancy-related deaths

▪ Driven by Cardiomyopathy deaths, with 42.9% deaths >42 days


10.1016/j.ajog.2015.05.008

Timing of Diagnosis of Peripartum CardiomyopathyElkayam et al. Circulation 2005;111:2050

0

25

50

75

<27 28-32 33-36 37-40 1 2 3 4 5

Nu

mb

er

of

pati

en

ts

Early

Traditional

Weeks Months PPDELIVERY

N=123

BNP levels in Normal Pregnancy

B-Type Natriuretic Peptide

Increases natriuresis

and diuresis

Relaxes vascular

smooth muscle

Inhibits renin-angiotensin

aldosterone system

IMPLEMENTATION AT THE

HOSPITAL LEVELCardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit

UCI – QI Study Protocol

• Descriptive study of algorithm implementation

• Goals:

• Clinical burden of CVD screening

• Outcomes for women designated “at risk” based on the

algorithm

• Numbers

• Percentage of women with CVD

UCI – QI Study Protocol

• Applying algorithm to all patients:

• First prenatal visit

• Postpartum visit

• Anytime with symptoms and/or vital sign abnormalities with no

known cardiovascular disease

SMFM 2019

846 women screened

8% screen +

True + 1.5%

CVD confirmed in 30% of screen +

SMFM 2020

SMFM 2020

THE FUTURE: BROADER DISSEMINATION OF CVD SCREENING

Cardiovascular Disease Screening in Pregnancy – Role of the CMQCC Toolkit

DEVELOPING CARDIOVASULAR SCREENING MEASURES

FOR PREGNANT & POSTPARTUM WOMEN

KICK-OFF MEETING, SEATTLE, JAN. 10, 2020

Improving Diagnostic Excellence: Gordon and Betty Moore

Foundation

University of California, Irvine, Medical Center Health SystemsUCI Health 1,500 births a year, 3% black

Hameed/Thiel de Bocanegra/Crosland

University of California, San Diego, Medical Center Health SystemsUCSD Jacobs & Hillcrest 3,000 births a year, 5-6% black

Tarsa

University of Tennessee, St Thomas Health SystemsSt Thomas Health Systems 12,000 deliveries in 2018, 25% black

Graves

APPROACH

Integrate CVD algorithm into the EMR by placing and dot phrase with drop down menu

• Fill in the blanks in the dot phrase

• CVD screening added to problem list

Clinicians receive immediate score SCREEN POSITIVE

• Follow up imaging

• Follow up laboratory test

• Follow up consultations

Follow up monitored through EMR

Upload data to UCI RedCap

• Elicit feedback

• Review measures with the work group

Measures

1. CVD Risk Assessment =

Pregnant + postpartum women screened for CVD using algorithm

______________________________________________________

All pregnant + postpartum women seen at facility

2. CVD Risk Follow-up =

Women who received follow up for CVD risk

_____________________________________

Women who screened positive for CVD risk

Feasibility EvaluationAim of current study:

1. Demonstrate the feasibility to calculate meaningful and actionable

measures using data from the hospital wide network

- Potential to scale from pilot to system wide implementation

2. Explore whether the system wide administration of the measure will

produce a similar yield to that of the pilot studies

- Clinical and epidemiological value; important for business case

Summary

• Cardiovascular deaths are preventable

• 25% to 68%

• A large proportion of CVD deaths are beyond the 42 day

postpartum

• Most of the women who died of CVD have underlying risk

factors

• There is a need for universal screening for CVD to improve

maternal outcomes

[email protected]

For More Information and to

Download the

Toolkit

• Visit • www.cmqcc.org

• https://www.cdph.ca.gov

• Contact:[email protected]

http://www.cmqcc.org/

https://www.cdph.ca.gov/

mailto:[email protected]

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