Quality standard

Quality statement 3: Heart disease – risk assessment

Quality statement

Pregnant women with heart disease have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.

Rationale

Changes to the heart and circulation occur during pregnancy. Regular risk assessment allows planning for any additional management needed for women with heart disease who are at risk of adverse cardiovascular outcomes during labour and birth. Cardiovascular risk assessment is based on a combination of clinical, diagnostic and functional assessment. It is carried out by a multidisciplinary team that includes a cardiologist with expertise in managing the condition in pregnancy. The content and timing of risk assessment are tailored to the severity of the condition and the findings of previous assessment.

Quality measures

Structure

a) Evidence of local arrangements for pregnant women with heart disease to have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period by a multidisciplinary team that includes a cardiologist with expertise in managing heart disease in pregnant women.

Data source: Local data collection, for example, service protocols, local network agreements for referral and core multidisciplinary team membership records.

b) Evidence of local arrangements for pregnant women with heart disease to have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.

Data source: Local data collection, for example, service protocols and local network agreements for referral.

Process

Proportion of pregnant women with heart disease who have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.

Numerator – the number in the denominator who have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.

Denominator – the number of pregnant women with heart disease.

Data source: Local data collection, for example, an audit of maternity records.

Outcomes

Rates of mortality during labour, birth and the early postnatal period for women with heart disease.

Data source: Local data collection. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on the number of maternal deaths attributed to heart disease.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that local protocols and referral pathways are in place so that pregnant women with heart disease have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period by a multidisciplinary team that includes a cardiologist with expertise in managing heart disease in pregnancy. They ensure that staff have capacity to perform the assessments regularly and that there are rotas and systems in place for a cardiologist to be available to take part in team discussions.

Healthcare professionals (such as midwives, obstetricians, obstetric anaesthetists and cardiologists with experience of managing heart disease in pregnancy) regularly assess cardiovascular risk for pregnant women with heart disease during pregnancy and the intrapartum period through clinical, diagnostic and functional assessment. Cardiologists use their knowledge and experience to advise the multidisciplinary team on specialist aspects of intrapartum care for pregnant women with heart disease that is tailored to the woman's individual level of risk.

Commissioners (clinical commissioning groups) ensure that they commission services that have local protocols and referral pathways in place, and the capacity for pregnant women with heart disease to have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period by a multidisciplinary team that includes a cardiologist with expertise in managing heart disease in pregnancy. They ensure that services have rotas and systems in place for the cardiologist to be involved in team discussions.

Pregnant women with heart disease have regular tests to check their heart condition during pregnancy and up to 24 hours after birth by a team that includes a specialist in managing heart disease in pregnancy. This will help them and the team to plan the care needed during labour and birth.

Definitions of terms used in this quality statement

Pregnant women with heart disease

Relevant populations and heart conditions within the scope of this quality standard include:

  • women with mechanical heart valves

  • disease of the aorta

  • pulmonary arterial hypertension

  • heart failure

  • severe left-sided stenotic lesions (for example, aortic stenosis and mitral stenosis)

  • hypertrophic cardiomyopathy

  • cardiomyopathy with systolic ventricular dysfunction

  • Fontan circulation and other univentricular circulations

  • moderately severe and severe cardiovascular disease, as classified by New York Heart Association (NYHA) functional class.

[Adapted from NICE's guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies, section 1.3 and evidence review C]

Some women with heart disease are at low riskof complications and their care should be in line with NICE's guideline on intrapartum care for healthy women and babies, whereas others need individualised specialist care.

Cardiovascular risk regularly assessed

The timing of risk assessment is tailored to the severity of the condition and the findings of previous assessment. The following should be used for the initial and ongoing assessments:

[Adapted from NICE's guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies, recommendation 1.3.4 and evidence review C]

Equality and diversity considerations

Pregnant women with heart disease should be able to communicate effectively with the multidisciplinary team as part of their risk assessments. Women should have access to an interpreter, link worker or advocate if needed. The interpreter, link worker or advocate should not be a member of the woman's family, her legal guardian or her partner, and they should communicate with the woman in her preferred language.