testing in pregnancy -

[SerenaWelsh]

Dr. Fett,

KellyDL posted in another forum about why there isn't routine heart testing done during pregnancy - and I know it's been VERY discussed on this board and others...cost effectiveness and low occurance of PPCM being the biggest reasons for NOT doing an ECHO on every pregnant woman...

But, in your opinion, would blood tests, looking at the BNP and CRP in EVERY pregnant woman be enough to catch the onset of any heart problems - then decide the need for further testing with echo, etc...?

Even without insurance, those are relatively inexpensive tests, correct?

[SarahsMom]

Serena,

EXCELLENT questions? Why wouldn't they run a BNP test on all women who have just given birth before discharge? If the results of that test come back abnormal, more diagnostic tests can be ordered - i.e. echocargiograms. I think Dr. Fett once posted that the BNP tests were $30...small price to pay for Mom's to see their children grow up.

Kari

[JAMESFETT]

It depends upon where you live. In Haiti, high-incidence area for PPCM, it is economically sound to do an echo on every term pregnancy or shortly postpartum mother. [See Fett JD, Christie LG, Carraway RD, Sundstrom JB, Ansari AA, Murphy JG. Unrecognized peripartum cardiomyopathy in Haitian women. Int J Gynaecol Obstet 2005;90:161-6.](do an Entrez PubMed search for abstract) There are other African countries where the same is true.

In most places in the USA, Canada and Europe it is deemed too expensive with too few cases to justify doing an echo in that fashion. So far, medical economists, obstetricians, and epidemiologists feel that not even a blood BNP (around $30 per test) in every term pregnancy patient is economically feasible, so far as insurance companies paying.

Persons with higher risk, such as family history of PPCM or familial DCM make it necessary to do screening tests for same during pregnancy. Otherwise, symptoms of heart failure justify doing the tests (echocardiogram, BNP) and having them paid for by insurance companies.

Even so, in the USA doctors who care for pregnant patients should have a very high index of suspicion for heart failure symptoms, and at the very least do the blood BNP---that's a test that is still "catching on" even in other patients with potential heart failure. So the threshold for doing a blood BNP should be very low, meaning that doctors should do it "at the drop of a hat."

James

[SerenaWelsh]

let me lose my composure and just say - WELL POOP.

So basically, it still depends on the doctor recognizing the symptoms of heart failure....

[SusanD]

It depends upon where you live. In Haiti, high-incidence area for PPCM, it is economically sound to do an echo on every term pregnancy or shortly postpartum mother. [See Fett JD, Christie LG, Carraway RD, Sundstrom JB, Ansari AA, Murphy JG. Unrecognized peripartum cardiomyopathy in Haitian women. Int J Gynaecol Obstet 2005;90:161-6.](do an Entrez PubMed search for abstract) There are other African countries where the same is true.

In most places in the USA, Canada and Europe it is deemed too expensive with too few cases to justify doing an echo in that fashion. So far, medical economists, obstetricians, and epidemiologists feel that not even a blood BNP (around $30 per test) in every term pregnancy patient is economically feasible, so far as insurance companies paying.

Persons with higher risk, such as family history of PPCM or familial DCM make it necessary to do screening tests for same during pregnancy. Otherwise, symptoms of heart failure justify doing the tests (echocardiogram, BNP) and having them paid for by insurance companies.

Even so, in the USA doctors who care for pregnant patients should have a very high index of suspicion for heart failure symptoms, and at the very least do the blood BNP---that's a test that is still "catching on" even in other patients with potential heart failure. So the threshold for doing a blood BNP should be very low, meaning that doctors should do it "at the drop of a hat."

James

I agree with this, their should be some sort of treatment algorhythim (sp? I just took a final exam and my brain is fried) for women in pg who present with sob, edema > 5 lbs in two weeks and tachycardia. I envision treatment guidelines similar to those that already exist for CHF, Acute MI and are standard in ER's and in offices across the country.

If the patient is + for those symptoms, the various treatment arrows on the diagram could point towards (or away) from the differential diagnoses of eclampsia , PE and PPCM ==>

SOB, no edema, elevated BP =eclampsia screenings ==> urine protein levels normal => BNP

SOB, tachycardia, no edema, normal BP ==> rule out PE

etc.etc.etc. To me it is such a no brainer, but I am at a different stage in the game of assessment and ordering labs and such AND on the other side of the PPCM diagnoses.

[JAMESFETT]

Serena, I sympathize with your reaction. It's real fecal to have to have things come down to dollars and cents, insurance companies, and too many doctors with low index of suspicion of heart failure in supposedly healthy mothers. I know all of you will insist that your daughters are screened adequately when they become pregnant.

James