Leads: 

• Diana Wolfe, MD, MPH, Co-Lead, Cardio-Obstetrics Program
• Anna Bortnick, MD, PhD, Cardiologist and Co-Lead, Cardio-Obstetrics Program 
• Pe’er Dar, MD, Vice Chair, Obstetrical Ultrasound & Fetal Medicine
• Mark H. Einstein, MD, Chair, Obstetrics & Gynecology and Women’s Health  

Cardiovascular (CV) conditions are one of the most common causes of death associated with pregnancy in New York City (NYC 2016 –20). The Bronx carries the largest burden of cases, with 30.9 deaths per 100,000 live births, triple the national average. The largest contributing factors among preventable deaths due to CV conditions included lack of continuity of care and lack of care coordination. Montefiore Einstein, as the regional perinatal referral center, is where many mothers with unknown or undiagnosed CV issues are sent for care. In fact, many times we diagnose their severe CV issues for the first time in pregnancy. Figure 1 illustrates the state data of our New York State (NYS) reported CV rates compared to peers. 

If we know that patients have CVD prior to pregnancy, it allows for multidisciplinary care and careful delivery planning; however, the larger low-risk population are the mothers who deliver without a diagnosis.  Labor is the ultimate stress test. Thus, undiagnosed CVD can lead to severe complications and even deaths in mothers who are referred to us or who are from the Bronx community. 

Signs and symptoms of pregnancy mimic heart disease. Furthermore, pregnancy modifies electrocardiogram (ECG) and echocardiogram (ECHO) findings. Our challenge is to determine the best way to screen this large population of potentially high-risk pregnant patients in order to identify those who have true CVD.   

We are an active site for a National Heart, Lung and Blood Institute (NHLBI)–funded program, Heart Outcomes in Pregnancy Expectations (HOPE), which targets mothers who have known high-risk factors for severe CVD in pregnancy (e.g. obesity, advanced maternal age, family risk factors). Building on the success of these strategies that focus on screening for CVD, we have been developing a Program to offer universal CV screening using POCUS to all comers, focusing initially on Healthfirst patients.   

Within this Program, we are attempting to identify women who may be seen as experiencing normal physiologic changes of pregnancy but are in fact suffering from potentially life-threatening CVD, using POCUS. These are pregnant patients who have screened negative in our funded trial (using the California Maternal Quality Care—CMQCC CVD algorithm—see Figure 4). We will be performing a maternal lung and heart ultrasound that will be scheduled at the same time as their fetal ultrasound exams (see Figure 3 for screening workflow). They will be performed by our trained obstetrics/gynecology (OB/GYN) technicians and reviewed by our high-risk OB (maternal- fetal medicine) clinicians. Quality assurance (QA) will be performed by cardiologists to improve performance and clarity of images. Abnormal findings will result in consultation with our Cardio-Obstetrics Program and diagnostic testing. We aim to identify diseases prior to delivery and therefore prevent morbidity and mortality on labor and delivery in our known high-incident undiagnosed CVD patients in the Bronx community.