Multidisciplinary Pilot Program Aims to Improve Cardiovascular Health in Women with Adverse Pregnancy Outcomes

AdventHealth Central Florida conducted a pilot program called Mother’s Heart Wise to identify women with adverse pregnancy outcomes that increase their lifetime risk of developing cardiovascular (CV) disease and connect them to an ongoing, preventive care plan that reduces that risk.

Hypertensive disorders of pregnancy (gestational hypertension, preeclampsia, eclampsia), gestational diabetes mellitus (DM), intrauterine growth restriction/small for gestational age (IUGR/SGA), and pre-term delivery have all been identified as atherosclerotic cardiovascular disease (ASCVD) risk factors for women. Specific findings include the following:

• A history of preeclampsia or gestational hypertension doubles a woman’s lifetime risk of ischemic cardiac disease or stroke.
• Women with gestational diabetes mellitus have a twofold higher risk of cardiovascular events. This risk is not dependent upon the development of type 2 diabetes and is apparent within the first decade postpartum.

The American Heart Association and the American College of Obstetricians and Gynecologists issued a joint advisory in 2018 that focused on how obstetricians can help optimize women’s CV health through early identification and modification of risk factors. The report emphasized that despite heart disease being the number one killer of women, only 45% of women identify it as such. In addition, a multinational cohort study published earlier this year in the American Journal of Obstetrics & Gynecology found that better CV health at 24-32 weeks gestation was associated with lower risks for severe adverse maternal and newborn outcomes.

Under the leadership of Cardiologist Patricia Guerrero, MD, and OB/GYN D. Ashley Hill, MD, and in collaboration with Family Physician Christopher Buelvas, MD, AdventHealth has developed and is piloting Mother’s Heart Wise to achieve the following:

• Proactively identify patients within the health system who have adverse pregnancy disorders and outcomes
• Educate them about their risk factors
• Get them into a proactive care plan
• Improve their long-term CV health

“Each year, our Central Florida Division performs over 16,000 deliveries and sees approximately 6,500 women with one or more adverse pregnancy outcomes that increase their risk for cardiovascular disease,” explains Dr. Hill. “This doesn’t even include women identified during annual well women visits. Because of the size and integration of our system, we saw this as a tremendous opportunity to work in a coordinated, multidisciplinary fashion to intervene early and positively impact the life-long cardiovascular health of our patients.”

Care Coordination — Women’s Health Nurse Navigator

Through this pilot project, AdventHealth OB/GYN teams have initially identified 40 at-risk women who have been referred to a women’s health nurse navigator at 6 weeks postpartum to coordinate their long-term follow-up care. This includes assistance with the following:

• Finding a primary care provider (PCP)
• Answering health care questions
• Assisting with scheduling office visits and screenings
• Providing resources and support to help with adopting healthy habits, such as exercising daily, eating a heart healthy diet and maintaining a healthy weight

Physician Care Pathways

In addition, to coordinate patient care amongst the OB/GYNs and primary care providers, the following two initial physician care pathways have been established:

Hypertensive Disorders of Pregnancy

• Pregnancy and Early Postpartum Management:
• OB/GYN addresses patient education and home blood pressure (BP) monitoring
• Referral at 6 weeks postpartum to PCP for Cardiovascular Risk Reduction (via women’s health nurse navigator)
• Inter-pregnancy Management:
• PCP visit timing based on BP at 6-week visit
• Within 1-2 months if the patient is normotensive at 6 week postpartum
• Accelerated PCP visit within 1-2 weeks if persistent hypertension or additional CV risks
• PCP Visit:
• Documentation of gestational hypertension (HTN)
• Patient education regarding increased risk (lifetime risk)
• Screen for CV risk factors
• Additional testing, including creatinine, metabolic panel and ECG
• Counsel and refer to ancillary services
• Home BP monitoring
• Manage CV risks
• Reevaluate at regular intervals

Gestational Diabetes Mellitus

• Pregnancy and Early Postpartum Management:
• OB/GYN tests for undiagnosed DM or pre-DM during pregnancy
• Oral glucose tolerance test (OGTT) or fasting glucose performed at 6 weeks postpartum.
• Referral at 6 weeks postpartum to PCP for cardiovascular risk reduction (via women’s health nurse navigator)
• Inter-pregnancy and Long-term Management:
• Primary care physician
• PCP Visit:
• Documentation of gestational DM
• Patient education regarding increased risk of CV events (lifetime risk) and development of DM
• Additional testing, including OGTT or fasting blood sugar at 4-12 weeks postpartum if not already performed
• Life-long screening with OGTT or HbA1c for those without manifest diabetes every 1-3 years
• Screen and manage CV risk factors
• Intensive lifestyle intervention and/or metformin to prevent DM

The Mother’s Heart Wise team has also developed an intake questionnaire that physicians can use to identify women within their practices who are at increased CV risk due to adverse pregnancy outcomes.

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Patient Intake Questionnaire to Identify Women at Higher Risk for Cardiovascular Disease Due to Adverse Pregnancy Outcomes

1. How many pregnancies have you had?
2. Were any of your babies born early (more than three weeks before your due date)?
   • How many?
   • Did this occur spontaneously or were you delivered early because you were ill?
3. Did you have preeclampsia in any of your pregnancies?
   • Which pregnancy?
   • How many times?
   • Were you delivered early because you had preeclampsia?
   • How many weeks before your due date were you delivered?
4. Did you have high blood pressure in any pregnancy?
   • Did you have protein in your urine that pregnancy?
   • Did you have hypertension after that pregnancy?
5. What was the weight of your babies and how many weeks before your due date were they delivered?
6. Did you have gestational diabetes during your pregnancies?

Looking Ahead

Drs. Hill, Guerrero and their team hope to complete the initial phase of the pilot project this summer and then make adjustments to the Mother’s Heart Wise program as needed based on any barriers identified as well as feedback from the patients and providers. Anticipated benefits of the program include improved CV outcomes in women with adverse outcomes of pregnancy, reduced lifelong healthcare costs and improved patient satisfaction.

“As physicians, our ultimate goal is to positively impact the health of our patients,” he said. “We believe by better identifying, educating and addressing the long-term risks posed by adverse pregnancy outcomes, we can do just that.”

For more information about the Mother’s Heart Wise project, contact the AdventHealth Women’s Health Nurse Navigator at Call407-720-5191.

About D. Ashley Hill, MD:
Ashley Hill, MD, is a Medical Director of obstetrics and gynecology at AdventHealth Medical Group and Associate Director of the AdventHealth Graduate Medical Education Program’s Department of Obstetrics and Gynecology. Additionally, Dr. Hill is a Professor of Obstetrics and Gynecology at the UCF College of Medicine. He received his medical degree from the University of South Florida College of Medicine, where he also completed his residency. Dr. Hill specializes in abnormal uterine bleeding, treatment of uterine fibroids, minimally invasive gynecologic surgery, normal and high-risk pregnancies, and ultrasonography. He has published numerous papers in medical journals, serves as an expert reviewer for several journals, and is the Medical Director of the Multiprofessional Obstetric Simulation Training (MOST®) program and the Women’s and Children’s Quality Improvement Committee. Dr. Hill is board certified by The American Board of Obstetrics and Gynecology.