Abstract
Background:
Obstetrical complications including indicated preterm birth (PTB), hypertension (HTN), IUGR, and GDM are risk factors for future cardiovascular disease. To identify patients at risk the American Heart Association recommends obtaining a detailed obstetric history.
Objective:
Our objective was to determine if non OB-GYN physicians-in-training obtain an obstetric history when assessing a risk profile for cardiovascular disease and to identify differences based on level of training.
Methods:
In 2019 an anonymous survey was distributed to trainees in internal medicine, cardiology, endocrinology, nephrology, and neurology. Subjects were queried about frequency of asking a history of PTB, IUGR, GDM, and HTN in pregnancy. Survey options were Always/Frequently/Sometimes/Rarely/Never and were categorized into two groups: “Ask” (Always/Frequently/Sometimes) vs. “Don’t Ask” (Rarely/Never). Comparisons between specialties and levels of training were made using chi-square and Fisher’s exact test. Comparisons within subjects were made using McNemar’s test.
Results:
The response rate was 64% (210 total possible participants); including 98 internal medicine residents and 37 fellows in cardiology (21), endocrinology (3), nephrology (8), and neurology (5). Asking about medical complications (HTN + GDM) was significantly more common than asking about OB complications (PTB + IUGR) (p<0.001). Internal medicine residents were less likely than subspecialty fellows to ask about HTN (31% vs. 70%; p<0.001). There were no differences in likelihood of eliciting OB history based on PGY-level.
Conclusions:
An OB history can identify risk factors for cardiovascular morbidity. Our data demonstrates that physicians caring for women lack awareness on the association between complications in pregnancy and cardiovascular health.
Keywords: pregnancy, medical education, cardiovascular health
Introduction:
Obstetrical complications are associated with future cardiovascular health risks for women. For example, preterm birth (PTB) is associated with a two-fold increase of future cardiovascular disease and the highest risk is associated with delivery < 32 weeks gestation or an indicated preterm delivery. A history of recurrent preeclampsia or fetal growth restriction (IUGR) is associated with a cardiovascular risk rate that is similar to women with a history of obesity or tobacco abuse [1]. Compared to women with no history of preeclampsia, women with recurrent preeclampsia have a two times increased risk of heart disease and three times the risk of cerebrovascular disease later in life [2,3]. In a U.S. study of the Kaiser Permanente population, 14,000 women who had preeclampsia before 34 weeks gestation were followed for a median of 37 years and there was an almost ten-fold increased risk for later life cardiovascular death [4].
Gestational diabetes mellitus (GDM) is another common obstetric complication that serves as a predictor for future cardiovascular health. It is estimated that up to 70% of women with GDM will develop Type 2 Diabetes within 22–28 years after pregnancy [5]. The progression to Type 2 Diabetes is also influenced by race, ethnicity, and obesity. In this regard, 60% of Latin American women with GDM may develop Type 2 diabetes within five years of their index pregnancy [5].
Importantly, as of 2011 the American Heart Association (AHA) guidelines recommend clinicians obtain an obstetrical history and consider preeclampsia and GDM as risk factors for future cardiovascular disease [6]. Despite these well-established associations and AHA recommendations, our hypothesis is that clinicians are not as vigilant in eliciting an obstetrical history while assessing a woman’s risk profile for cardiovascular disease.
Our objective was to determine via survey how often non OB-GYN physicians-in-training obtain an obstetric (OB) history when assessing a risk profile for cardiovascular disease. We also aimed to identify differences in the frequency of obtaining an OB history and the likelihood of obtaining a history of medical or obstetrical complications of pregnancy based on specialty and level of training.
Methods:
In 2019 an electronic, voluntary, anonymous survey was distributed to internal medicine residents and cardiology, endocrinology, nephrology, and vascular neurology fellows at a single tertiary-care academic institution. In addition to demographic questions, subjects were queried about how frequently they asked women about a history of pregnancy, PTB, intrauterine growth restriction (IUGR), GDM, and the hypertension (HTN) disease spectrum in pregnancy (Figure 1). HTN and GDM were considered medical complications in pregnancy. PTB and IUGR were considered obstetrical complications. Survey answer options included: Always, Frequently, Sometimes, Rarely, and Never. Theses answers were then consolidated into two categories: “Ask” (Always/Frequently/Sometimes) versus “Don’t Ask” (Rarely/Never). This internal survey was created by the research team and thus there is no evidence of validity.
Figure 1.
Survey questions distributed to non OB-GYN physicians in training.
The primary outcome was to determine how often non OB-GYN physicians-in-training obtain an obstetric history when assessing a risk profile for cardiovascular disease. The secondary outcome was to identify differences based on specialty and level of training. In univariate analyses, distributions of categorical variables were compared using Chi square or Fisher’s exact test. Paired comparisons within individual subjects were made using McNemar’s test. A p-value of <0.05 was considered statistically significant. This study was deemed exempt by the Weill Cornell College of Medicine Institutional Review Board (protocol #19–04020247), with a waiver of informed consent.
Results:
The survey response rate was 64% (210 total possible participants). The 135 respondents included 98 internal medicine residents and 37 fellows in cardiology (n =21), endocrinology (n =3), nephrology (n =8), and vascular neurology (n =5). Survey responses are summarized in Figure 2. Of the 135 respondents, 48 (35.6%) reported that they rarely or never ask women if they have been pregnant and 60 (44.4%) rarely or never ask about a history of any specific obstetric complication. Internal medicine residents were more likely to report rarely or never asking about any specific complication compared to fellows (54.1% vs. 18.9%; p<.001). The frequency of obtaining an OB history did not increase as internal medicine residents advanced in PGY level.
Figure 2.
Resident survey responses regarding the frequency of obtaining a history about pregnancy and obstetrical complications. The numbers above each column correspond to the individual question in the legend.
In the entire cohort, only 41.5% (n=56) “always,” “frequently,” or “sometimes” asked if a woman had any HTN complications in pregnancy. Internal medicine residents were less likely to ask about HTN in pregnancy compared to subspecialty fellows (31% vs. 70%; p<0.001). There were no differences in likelihood of asking about a history of other obstetrical complications based on resident versus fellowship training (Table 1).
Table 1.
Frequency of obtaining an obstetrical history in relation to PGY level of training.
| Internal Medicine Residents | Sub Specialty Fellows | p-Value | |
|---|---|---|---|
| HTN | 30/98 (30.6%) | 26/37 (70.3%) | <0.001 |
| GDM | 37/98 (37.8%) | 19/37 (51.4%) | 0.17 |
| IUGR | 2/98 (2.0%) | 3/36 (8.3%) | 0.12 |
| PTB | 10/97 (10.3%) | 2/37 (5.4%) | 0.51 |
Individual respondents were significantly more likely to ask about a history of medical complications in pregnancy (HTN and/or GDM) than about OB complications (PTB and/or IUGR). This was true for the entire cohort and the subgroups of internal medicine residents and subspecialty trainees (all paired comparisons p<0.001). Subspecialty fellows were nearly twice as likely to ask about medical complications compared to internal medicine residents (81% vs. 42%, p<.001) (Table 2).
Table 2.
Frequency of obtaining medical and obstetrical history by PGY level of training.
| Internal Medicine Residents | Sub Specialty Fellows | p-Value | |
|---|---|---|---|
| Medical Complications (GDM and/or HTN) | 41/98 (41.8%) | 30/37 (81.1%) | <0.001 |
| OB Complications (IUGR and/or PTB) | 11/98 (11.2%) | 4/37 (10.8%) | 1.0 |
Discussion:
Recent literature has highlighted the link between obstetrical outcomes and the future risk of cardiovascular disease [7,8]. Only a thorough OB history can identify these sex specific cardiovascular risk factors and without this history healthcare clinicians cannot fully estimate a patient’s cardiovascular risk or implement preventive strategies.
Women’s health care is currently fragmented and divided among many fields of primary and specialty care. This healthcare landscape has been described as a “patchwork quilt with gaps” [9]. Findings from the National Health Interview Survey reported that 15% of women between ages of 18 and 64 were seen by general medical physicians, 62% by gynecologists alone, and 23% by both [10,11].
If a primary care physician or medical subspecialist does not consider a patient’s obstetrical history in relation to her cardiovascular risk, this responsibility falls to the obstetrician/gynecologist. However, an annual well-woman exam with an OB-GYN may not be focused on the management or surveillance of cardiovascular disease. Furthermore, after childbearing, some women do not return to the gynecologist for preventive medicine. If a gynecologist does not include cardiovascular care in an annual exam and a physician assessing cardiovascular health does not consider a women’s obstetrical history, this creates discernable gaps in care. These gaps include low rates of treatment initiation for hypertension and the failure to follow guidelines for diabetes surveillance [11].
Our data demonstrates that physicians-in-training who will care for women in the future lack awareness of the association between complications in pregnancy and cardiovascular health. This is true regarding preterm birth and fetal growth restriction, which do not have obvious correlates outside of pregnancy like diabetes or hypertension. Improving the education of trainees, particularly in primary care, may lead to increased awareness about the consequences of obstetric complications and lead to improved screening and risk assessment for future women.
Our study highlights the evaluation of practice habits in relation to obstetric history and the impact on a cardiovascular risk assessment profile. The strengths of our study include an adequate survey response rate, with a variety of physicians in different specialties at different levels of training. However, the data are limited to a single training institution in an urban setting and we cannot verify that the responses in this survey correlate with actual practice.
This survey highlights the gaps in providing complete and contextualized medical care to women and offers opportunities for improvement. At our training institution, the maternal-fetal medicine fellows, in collaboration with the internal medicine chief residents, have developed a didactic curriculum focused on obstetric complications and women’s health. This once monthly curriculum is outlined in Table 3. Future directions include implementation of this curriculum and distribution of the survey to a more geographically diverse group of trainees. Our goal is to increase awareness of the importance of obstetrical complications in long-term cardiovascular health for non OB-GYN physicians-in-training.
Table 3.
Women’s health and obstetrics curriculum topics for internal medicine residents.
| Topic Source: American College of Obstetrics & Gynecology, Practice Bulletins (PB) and Committee Opinions (CO) |
|---|
| 1. Pregnancy and Heart Disease (PB# 212) |
| 2. Gestational Hypertension and Preeclampsia (PB #202) |
| 3. Chronic Hypertension in Pregnancy (PB # 203) |
| 4. Fetal Growth Restriction (PB# 204) |
| 5. Medically Indicated Late-Preterm and Early Term Deliveries (CO # 764) |
| 6. Pregestational Diabetes Mellitus (PB # 201) |
| 7. Gestational Diabetes Mellitus (PB # 190) |
| 8. Use of Hormonal Contraception in Women With Coexisting Medical Conditions (PB # 206) |
| 9. Long Acting Reversible Contraception: Implants and Intrauterine Devices (PB # 186) |
| 10. Antiphospholipid Syndrome (PB # 132) |
| 11. Pre-pregnancy Counseling (CO #762) |
| 12. Well-Woman Visit (CO #756) |
Conclusions:
A thorough OB history can identify risk factors for cardiovascular morbidity. Our data demonstrates that physicians caring for women in the future may lack awareness of the association between complications in pregnancy and cardiovascular health. This is especially true regarding preterm birth and fetal growth restriction. Improving the education of trainees could lead to increased awareness about the impact of a woman’s obstetrical history on her future health.
Acknowledgments
Ethical Standards:
This study was deemed exempt by the Weill Cornell College of Medicine Institutional Review Board (protocol #19–04020247), with a waiver of informed consent.
Funding: Not applicable
List of Abbreviations:
- AHA
American Heart Association
- GDM
Gestational diabetes mellitus
- HTN
Hypertension
- IUGR
Intrauterine growth restriction
- OB
Obstetric
- OB-GYN
Obstetrics & Gynecology
- PTB
Preterm birth
Footnotes
Declarations:
Conflicts of interest/Competing interests: Not applicable
Availability of data and material: Not applicable
Code availability: Not applicable
Contributor Information
Megan Savage, Department of Obstetrics & Gynecology, Division of MFM, Weill Cornell Medicine, New York, NY.
Diala Steitieh, Department of Medicine, Weill Cornell Medicine, New York, NY.
Nivee Amin, Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, NY.
Line Malha, Department of Medicine, Division of Nephrology & HTN, Weill Cornell Medicine, New York, NY.
Stephen Chasen, Department of Obstetrics & Gynecology, Division of MFM, Weill Cornell Medicine, New York, NY.
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