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13th April 2023
Dr Hannah Douglas is a consultant cardiologist specialising in adult congenital heart disease at Guy’s & St Thomas’ NHS Foundation Trust. She is also the lead cardiologist for heart disease in pregnancy, works on the pulmonary hypertension team and runs a private practice at London Bridge Hospital HCA Healthcare.
Dr Douglas tells Hospital Healthcare Europe why heart disease in pregnancy is on the rise, the impact this has on services and what needs to be done to manage it.
17 years. I graduated in 2006 and obtained my primary medical degree from Queen’s University Belfast. Most of my medical training was at the Royal Victoria Hospital in the city. I then went to work at St Thomas’ Hospital in London as a subspecialty fellow in congenital heart disease. My additional skills include transthoracic and transoesophageal echocardiography, which help clarify complex diagnoses and support procedures such as cardiac surgery and catheter lab interventions.
During my placements as a junior doctor, I was torn between both cardiology and obstetrics and gynaecology. I had some really challenging experiences with difficult high-risk patients during both rotations, but I enjoyed the nature of the work and the patient cohorts. I’ll never forget the pregnant lady who suffered a cardiac arrest due to an undiagnosed, underlying heart condition. It was a completely formative experience in my training as a junior doctor and, without a doubt, influenced my career choices. I realised that I could marry the two specialties by training towards congenital heart disease, which has always been the traditional pathway to access obstetric cardiology or heart disease in pregnancy care.
Heart disease is the leading cause of maternal death in the UK. There remains a healthcare gender gap between men and women, which becomes extremely visible in cardiovascular disease within female-centred fields such as antenatal and obstetric care. I see a significant proportion of the population with undiagnosed conditions, such as cardiomyopathies or heart muscle disorders, which may be asymptomatic but then destabilise due to the added cardiac demands of pregnancy.
The number of women who are of advanced maternal age coming through antenatal care is rising, which means we see an increase in the risk of complications such as high blood pressure, pre-eclampsia and cardiac events during pregnancy.
Acquired heart disease – which traditionally affected older people – also seems to be increasingly present in younger and younger members of the population due to social, demographic and lifestyle issues that increase cardiovascular disease risk factors.
Preventative medicine is not necessarily considered top of the priority list, so there are issues with resources, and there are huge healthcare cost implications, too. We can see multidisciplinary teams of up to 25 to 30 healthcare professionals managing a single woman with a high-risk cardiovascular condition so that we can deliver her and her baby safely in the correct environment.
Busy! Guy’s and St Thomas’ is a tertiary centre university teaching hospital in central London. I’m part of a large cardiovascular department comprising cardiologists and cardiac surgeons. We are a Level 1 adult congenital heart disease cardiac surgical centre and have a pregnancy heart team.
Across my week I am involved in acute inpatient cardiology work, outpatient clinics which comprise general cardiology, adult congenital heart disease and antenatal cardiology, theatre and catheterisation lab support, and frequent strategy, policies, planning and education meetings.
Within the fields of adult congenital heart disease and heart disease in pregnancy, I am what is described as an imaging cardiologist. I perform ultrasound-based imaging diagnostic tests to guide decision-making, monitor longer-term consequences of previous cardiac surgery, look at disease progression and support procedural interventions, such as keyhole type or trans-catheter procedures in the cath lab, but also in open heart surgery. Here, I help to evaluate before and after an operation as to what needs to be done and the repair work that has been done, working closely with my colleague cardiac surgeons.
At my practice in London Bridge Hospital, I look after patients with a range of general cardiac conditions, but I also see patients for pre-pregnancy risk assessment and counselling in women of childbearing age who may require optimisation of cardiovascular health before embarking on pregnancy.
Within the field of adult congenital heart disease, some of the most innovative procedures performed are trans-catheter redirection of complex holes in the heart. This gives our patients additional options other than open-heart bypass surgery.
My main research areas are related to cardiomyopathy in pregnancy and placental dysfunction, focusing on long-term cardiovascular outcomes in women with cardiovascular disease. I was part of a team that jointly published a paper on the prevalence of pre‐eclampsia and adverse pregnancy outcomes in women with pre‐existing cardiomyopathy.
It was a large, multi‐centre retrospective cohort study that found a modest increase in pre-term pre-eclampsia and a significant increase in foetal growth restriction (FGR) with pre-existing cardiac dysfunction. It found that the mechanism underpinning the relationship between cardiac dysfunction and FGR merited further research but could be influenced by concomitant beta blocker use.
Another paper I’m working on, which hasn’t been published yet, is the new British Society of Echocardiography Guidelines for the Pregnant Patient, which will be adopted as UK guidance for cardiac ultrasound scanning pregnant women with heart conditions.
Yes, we have constant fellowship posts across a range of sub-specialties within cardiology to include adult congenital heart disease.
Most of our fellows come from other parts of Europe and Asia where we build links with large international institutions to develop our own skills. We also provide additional experience to doctors towards the end of their training who require extra expertise or are planning to develop services similar to ours in other places.
There is an active research department within cardiology, and, in addition to this, we are at the forefront leading in complex surgical and trans-catheter interventions on patients of all ages and all types of congenital and acquired heart disease backgrounds.
Patient volume will continue to challenge us. We are growing in all areas of cardiology and specifically within the heart disease in pregnancy service. The number of patients we see face to face in the clinic and look after for antenatal surveillance is expanding all the time.
We also have a hub-and-spoke type sector-wide system whereby we reach out to train and support our colleagues in peripheral hospitals so that care can be delivered to women of perceived lower risk closer to home.
Challenges will continue within education and training, which needs to be constant and run rotationally, as well as staff turnover. We must educate medics, nursing staff, physiologists, midwives, interventionalists and anaesthetists – the list is endless. They need to be empowered to challenge their own learning and to recognise subtle or early risk factor signs. These might have important implications in minimising risks for women with a heart condition or who may develop a heart condition during pregnancy.
It is the responsibility of anyone who looks after women of childbearing age from menarche to menopause to address risk factors, contraception and family planning.
We also sometimes struggle to engage patients with this process – optimising women’s health before pregnancy is our long-term goal. Patients are getting older and sicker.
In pregnancy, we see increased advanced maternal age all the time. This is a complex caseload of patients, which will only continue to increase, and, therefore, the risks will increase with the patients.
It is, however, our privilege to provide such a service, and we never back down from a challenge!
Explore the latest advances in clinical care, delivered by renowned experts from recognised Centres of Excellence, at the HHE Clinical Excellence in Cardiovascular Care event on 10 May 2023. Find out more and register for free here.