Indications for Maternal Echocardiography in Detecting Disease and the Impact on Pregnancy Management

Abstract

Objective Few obstetric-specific guidelines detail the indications for screening echocardiography in pregnancy. The objective of the study is to examine the association of common indications for maternal echocardiography with the likelihood of abnormality identification, pregnancy management alteration, and conformity with current American College of Cardiology Foundation (ACCF) guidelines.

Study Design This retrospective cohort analysis categorized all echocardiograms performed within pregnancy and the first month postpartum within a tertiary health system to correlate indications with abnormal findings.

Results Data from 226 echocardiograms were analyzed from 205 women. The most common indication for initial echocardiography was cardiac symptoms (34.6%). History of cardiac disease was the only indication demonstrating a significant association with an abnormal finding on initial echocardiography (odds ratio [OR]: 2.6; p = 0.006). Postpartum status (OR: 4.9; p < 0.001), multiparity (p < 0.001), and tobacco use (OR: 2.2; p = 0.011) were demographic characteristics associated with the identification of abnormal findings on initial echocardiography. Abnormal echocardiographic findings were associated with changes in clinical management but did not correlate with adverse obstetric or neonatal outcomes, which may support the impact of a multidisciplinary programmatic approach. ACCF appropriateness criteria correlated well with identification of abnormal echocardiographic results (p = 0.034).

Conclusion Although the presence of cardiac symptoms or history of diabetes failed to demonstrate association with abnormal echocardiographic findings, a history of prior cardiac disease, tobacco use, multiparity, and postpartum status were factors associated with identification of abnormal findings on initial maternal echocardiography. The ACCF appropriateness criteria for obtaining echocardiography can be applied to pregnant women with consideration for these additional risk factors.

Key Points

• The ACCF criteria are applicable in pregnancy for appropriateness of echocardiography indications.

• Several clinical factors often prompt performance of echocardiography in pregnancy without merit.

• Consideration for multiparty, tobacco abuse, and postpartum state should coincide with ACCF criteria.

Keywords

echocardiography - pregnancy - guidelines - outcomes - echocardiogram - cardiac disease

Note

ACCF guidelines for echocardiography indications are appropriate in pregnancy but should emphasize tobacco use, multiparity, and postpartum concerns.

Publication History

Received: 10 August 2020

Accepted: 02 March 2021

Article published online:
04 May 2021

• References

• 1 Cunningham FG, Leveno KJ, Bloom SL. et al. Williams Obstetrics. 24th ed.. New York, NY: McGraw-Hill Education; 2014
• 2 Sanghavi M, Rutherford JD. Cardiovascular physiology of pregnancy. Circulation 2014; 130 (12) 1003-1008
• 3 Siu SC, Sermer M, Colman JM. et al; Cardiac Disease in Pregnancy (CARPREG) Investigators. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001; 104 (05) 515-521
• 4 Jastrow N, Meyer P, Khairy P. et al. Prediction of complications in pregnant women with cardiac diseases referred to a tertiary center. Int J Cardiol 2011; 151 (02) 209-213
• 5 Tsiaras S, Poppas A. Cardiac disease in pregnancy: value of echocardiography. Curr Cardiol Rep 2010; 12 (03) 250-256
• 6 Drenthen W, Pieper PG, Roos-Hesselink JW. et al; ZAHARA Investigators. Outcome of pregnancy in women with congenital heart disease: a literature review. J Am Coll Cardiol 2007; 49 (24) 2303-2311
• 7 Small MJ, James AH, Kershaw T, Thames B, Gunatilake R, Brown H. Near-miss maternal mortality: cardiac dysfunction as the principal cause of obstetric intensive care unit admissions. Obstet Gynecol 2012; 119 (2, Pt 1): 250-255
• 8 Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010; 116 (06) 1302-1309
• 9 Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015; 125 (01) 5-12
• 10 Cutforth R, MacDonald CB. Heart sounds and murmurs in pregnancy. Am Heart J 1966; 71 (06) 741-747
• 11 Gillam LD. Reflections of an echocardiologist of the many uses and possible abuses of echocardiography. Accessed March 15, 2018 at: www.medscape.com/viewarticle/452292
• 12 Douglas PS, Garcia MJ, Haines DE. et al; American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American College of Chest Physicians. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate use criteria for echocardiography. J Am Soc Echocardiogr 2011; 24 (03) 229-267
• 13 Kim MJ, Seo J, Cho KI, Yoon SJ, Choi JH, Shin MS. Echocardiographic assessment of structural and hemodynamic changes in hypertension-related pregnancy. J Cardiovasc Ultrasound 2016; 24 (01) 28-34
• 14 Savu O, Jurcuţ R, Giuşcă S. et al. Morphological and functional adaptation of the maternal heart during pregnancy. Circ Cardiovasc Imaging 2012; 5 (03) 289-297
• 15 Dharmarajan L, Hale TM, Velastegui Z, Castillo E, Kanna B. Utility of two-dimensional echocardiography in pregnancy and post-partum period and impact on management in an inner city hospital. J Perinat Med 2009; 37 (06) 663-668