Incorporating Echocardiographic Assessment in High-risk Pregnancies for Risk Stratification and Better Pregnancy Outcomes

Dear Editor, Maternal mortality has been recognized as one of the major public health concerns, with 0.28 million maternal deaths being reported worldwide in 2020, of which 95% are recorded in low-and middle-income nations.[1] Cardiovascular diseases have been ranked as the single largest (>33%) indirect cause of maternal deaths globally.[2] Moreover, the findings of a review revealed that in high-income nations, cardiovascular diseases account for almost one-third of reported maternal deaths.[3] In low- and middle-income nations, rheumatic heart diseases have been identified as the leading cause of pregnancy-related deaths.[3] Further, the systematic analysis of these reported deaths showed that hypertensive disorders (pre-eclampsia and eclampsia) together contribute to 16% of pregnancy-related deaths worldwide.[1] Despite cardiovascular diseases being the major contributor to maternal deaths, it is quite alarming that most women with underlying cardiomyopathy or valvular heart diseases either remain asymptomatic or experience mild symptoms that mimic normal pregnancy, resulting in late diagnoses and poor pregnancy outcomes.[4] Women with congenital or rheumatic heart diseases who become pregnant without prior cardiac evaluation are at high risk of developing complications that are completely preventable and often require interdisciplinary management.[5] Condition like peripartum cardiomyopathy is associated with an average of 11% of maternal deaths, long-term heart failure, and recurrent risk in future pregnancies.[4] At the same time, infants born to affected mothers possess four times the risk of developing cardiovascular diseases in childhood.[4] Further, the findings of a study revealed that preeclampsia can increase the risk of peripartum cardiomyopathy by 19 times and complicate the entire management.[6] Echocardiography has shown extensive clinical utility, as it is safe, noninvasive, and feasible during pregnancy compared to other radiological investigations.[4,7-10] The findings of a retrospective cohort study indicated that upon subjecting first-trimester class III obese women to transthoracic echocardiography, 40% were diagnosed with structural and functional abnormalities.[7] As reported earlier, speckled echocardiography can identify women at risk of developing peripartum cardiomyopathy, including tracking progression or recovery from the condition.[4] Echocardiography proved to be of immense utility in the quantification of the extent of damage to the mitral valve in pregnant patients with rheumatic mitral stenosis, and when correlated with clinical data, it can also predict the risk of peripartum cardiac events.[8] Transthoracic or trans-oesophageal echo can aid in the detection of ventricular failure or aortic complications in pregnant women, thereby enabling anesthetic and obstetric adjustments in real-time.[9] Echocardiography can also aid in the detection of congenital heart disease among fetuses during pregnancy and mentally prepare couples for anticipatory neonatal management, reducing perinatal morbidities and mortality.[10] In the Obstetrics and Gynecology outpatient department of Shalinitai Meghe Hospital and Research Centre, Datta Meghe Institute of Higher Education and Research, high risk pregnancies are screened through echocardiography for risk stratification and better pregnancy outcomes. Acknowledging the role of cardiovascular diseases in maternal deaths and the utility of echocardiography in improving clinical outcomes among high-risk pregnant women, there is an urgent need to incorporate echocardiographic assessment of these women.[11-13] There is a definite financial implication involved in this, as money will be required for equipment, training of personnel, and support of information technology.[6,7] Keeping this financial angle and feasibility in mind, we do not propose universal echocardiography for all pregnancies, rather advocate for implementation of a risk-based approach (viz. screen pregnant women through a validated checklist and perform baseline transthoracic echo only for those who screen positive or carry known high-risk conditions [such as rheumatic/valvular disease, congenital disease, prior cardiomyopathy, severe preeclampsia, etc.]).[7-9,11] In addition, it is recommended to equip district sites with handheld devices for triage and establish tele-echocardiography at only these locations rather than using it in remote facilities. The results of a systematic review advocate that existing antenatal care guidelines should be revised to ensure that all high-risk women must be subjected to a baseline transthoracic echocardiography to enable the detection of valvular diseases and other lesions, especially in areas endemic for rheumatic heart diseases.[12] This will essentially require that healthcare professionals should be trained in echocardiography to deal with the rising complexity of obstetric critical care. In continuation, multidisciplinary teams comprising obstetricians, cardiologists, anaesthetists, and neonatologists should be constituted to interpret echoes together and decide about the line of management to improve pregnancy outcomes.[13] In resource-constrained settings, noncardiologist staff can be trained to use handheld scanners, while portable handheld units can be made available in district hospitals to bridge the existing gaps. Finally, tele-echocardiography has shown immense utility in the detection of congenital heart diseases in the antenatal period, as reported in a study done in the United States.[14] In conclusion, maternal deaths continue to be high in low-income nations, with cardio-obstetric disease being the prominent and preventable killer. The need of the hour is to integrate cardiac evaluation into antenatal care among high-risk pregnancies to detect these diseases early, guide risk stratification, improve pregnancy outcomes, and minimize maternal deaths eventually. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.