For Sarah Goldstein, MD, pursuing a career in cardiovascular medicine was a natural decision.
“I fell in love with cardiology in medical school. The hemodynamics and disease physiology of cardiology was challenging to understand but doing so gave me an appreciation for how the heart develops and changes throughout the lifespan,” she said.
Goldstein was initially drawn to adult congenital heart disease. “Each patient is unique and inspiring; they have been through so much during their childhood.”
While training at Duke University, Goldstein additionally discovered her love of cardio-obstetrics and found that the field fit together seamlessly with her interest in adult congenital heart disease. More than that, she learned that there is much more to cardio-obstetrics than just the management of adult congenital heart disease during pregnancy. Goldstein developed her own training pathway at Duke and established a multidisciplinary cardio-obstetrics clinic with her mentor.
Heart disease is the leading cause of maternal mortality in the United States. Additionally, the United States is the only developed country in the world where maternal mortality has worsened over the last two decades. Goldstein is part of the multidisciplinary Maternal Cardiac Program at Yale New Haven Hospital that aims to improve the outcomes of women with heart disease complicating pregnancy.
There are three types of patients who benefit from cardio-obstetrics care. The first group is women with known heart disease, including congenital heart disease as well as acquired heart diseases, such as cardiomyopathy, which can lead to heart failure, abnormal heart rhythms (arrhythmias), and ischemic heart disease, also known as coronary artery disease.
Goldstein works with maternal-fetal medicine, obstetrics and gynecology, anesthesiologists, and pharmacists to support women with pre-existing heart disease.
“We offer preconception counseling to assess the risk for both cardiovascular and pregnancy complications related to underlying cardiovascular disease. The most common cardiac complications seen during pregnancy in women with heart disease are abnormal heart rhythms and heart failure. Pregnant women with heart disease may also be at risk for pregnancy complications such as early delivery, hemorrhage, and problems with the growth of their baby. We aim to meet with patients before pregnancy to ensure that they know about these risks and to formulate a comprehensive monitoring plan that will be followed during pregnancy. During pregnancy, we coordinate cardiology and maternal fetal medicine clinic appointments so that patients can see both teams on the same day and thus can be provided with a unified plan for their ongoing pregnancy care.”
The most common cardiac complications seen during pregnancy in women with heart disease are abnormal heart rhythms and heart failure.
Sarah Goldstein, MD
The second category of patients who benefit from cardio-obstetrics care are those who develop new cardiovascular disease during pregnancy.
“Pregnancy is a nine-month stress test for the cardiovascular system,” added Goldstein. “In uncomplicated pregnancies, the cardiovascular system undergoes huge changes that continue throughout pregnancy and following delivery. Patients who are susceptible to cardiac disease or who have previously undiagnosed congenital or valvular heart disease can experience symptoms for the first time during pregnancy. I work with women who are experiencing new symptoms during pregnancy that are potentially due to cardiac disease to further assess whether they may have a previously unknown underlying cardiac condition. I also care for women during pregnancy, their delivery admission, and postpartum if they're diagnosed with an uncommon condition that may be triggered during pregnancy, such as peripartum cardiomyopathy. Women who develop pre-eclampsia or hypertension disorders of pregnancy are also at an increased risk.”
The third category of patients seen by the cardio-obstetrics team are those who develop pregnancy-specific complications such as preeclampsia.
“We know that certain pregnancy complications are associated with future risk for cardiovascular disease. For example, it is now understood that women who develop preeclampsia or other associated hypertensive disorders of pregnancy are at increased risk for future cardiovascular complications such as chronic hypertension, heart attacks, strokes and heart failure and that these complications can occur earlier in life than would normally be expected.”
In collaboration with the maternal fetal medicine and pharmacy teams, Goldstein helps care for women who developed preeclampsia to ensure that they receive appropriate care throughout the first postpartum year. During that time, the care team will determine if a patient has high blood pressure, high cholesterol, diabetes, or other modifiable risk factors for future cardiovascular disease, and will provide educational tools with a custom nutrition and exercise plan.
Future Directions in Cardio-Obstetrics
Research is a vital component of the growing field of cardio-obstetrics.
“There's been rapid growth in research and publications focused on this field. Additionally, within the past five years we’ve seen a growing emphasis on forming a multi-disciplinary Pregnancy Heart Teams to improve patient outcomes,” said Goldstein.
Goldstein has been collaborating with Annalies Denoble, MD, MSc, and colleagues at Duke to create a multi-center retrospective registry to understand cardiac disease outcomes and appropriate interventions during pregnancy. She recently published a study in the journal JACC: Advances that identified the prevalence of and risk factors for hypertensive disorders among pregnant women with and without congenital heart disease. A second recent study published in collaboration with Denoble focused on women with preexisting ischemic heart disease complicating pregnancy.
“Ultimately, we're hoping to learn how to better harness the electronic medical record to prospectively and efficiently study pregnant patients with heart disease because currently the field lacks national and large-scale registries and databases to study these patients,” she said.
Currently the field lacks national and large-scale registries and databases to study these patients.
Sarah Goldstein, MD
As the field of cardio-obstetrics has grown, there has been an increasing focus on formalized training so that cardiologists can develop specific expertise in caring for cardiac conditions during pregnancy. For trainees interested in pursuing a career in cardio-obstetrics, Goldstein recommends seeking a flexible fellowship program that allows trainees to spend time with other subspecialties within the cardio-obstetrics team.
“Learn from your OB/GYN colleagues about their unique concerns. One of the challenges is understanding how different sub-specialties speak and think about patient management strategies and risk factors.”
Goldstein joins the Yale community with her husband Marc Samsky, MD, who specializes in heart failure. They enjoy exploring Connecticut State Parks with their three children.