CVD, Often Undiagnosed, Key Cause of Pregnancy-Related Deaths

Shelley Wood

November 17, 2013

DALLAS, TX — Women of childbearing age are typically young and healthy, which makes it all the more surprising that heart disease may be the leading cause of death in women who die during pregnancy.

And yet, an investigation into cause of death among 732 women in California who died during pregnancy (or within the first year after giving birth) over a three-year-period found that 209 were pregnancy-related, and of those, more than one-quarter were cardiovascular deaths—as least some of which could have been prevented.

That's important, Dr Afshan B Hameed (University of California, Irvine) said here at the American Heart Association 2013 Scientific Sessions , because pregnancy-related deaths in California have actually been on the rise in recent years, tripling in number between 1996 and 2006, although that death rate has improved slightly in subsequent years.

"Heart disease shouldn't be the leading cause of pregnancy-related deaths, but it is," Hameed commented.

While Hameed and colleagues have been looking only into deaths in Californian mothers, they believe their numbers likely mirror those of the US as a whole.

Indeed, a study conducted in the UK last year came to similar conclusions.

CVD Undiagnosed in Most Women

Dr Afshan Hameed

More than two-thirds of the cardiovascular-disease deaths among the women who died in the years studied was due to an underlying cardiomyopathy that in many cases was not diagnosed prior to the patient's death. Indeed, for the 52 deaths, only 6% had been diagnosed prior to the pregnancy. Another 16% were diagnosed during pregnancy or childbirth, but a full 37% were not diagnosed until after the women had given birth. The remaining 41% "were not, unfortunately, diagnosed until the autopsy was performed."

Predictors of CVD death among pregnant women included African American race, obesity, and substance abuse during pregnancy. Women who died of cardiovascular disease also tended to be younger, with more hypertension or preeclampsia. Similar predictors were seen for cardiomyopathy-related deaths, Hameed noted.

Overall, said Hameed, "almost 30% of all CVD pregnancy-related deaths were determined to be potentially preventable," something that should serve as a wake-up call for physicians.

"The bottom line is, if we know the diagnosis preconception . . . they can be followed very closely, and their outcomes are way better than someone who does not get diagnosed until after a problem has occurred."

Complicating diagnosis is the fact that many of the symptoms of an underlying cardiomyopathy or other form of cardiovascular disease are similar to common complaints of pregnant women: shortness of breath, fatigue, altered mental status manifesting as anxiety, tachycardia, and blood-pressure changes.

The key, said Hameed, is to be able to differentiate between mild shortness of breath and tiredness vs symptoms that actually limit "the usual activities of life."

Some of the women who subsequently died in this study had actually presented to the emergency room two, three, even four times and were sent home with a diagnosis of a respiratory infection, only to return a week later complaining of the same symptoms and sent home again.

"The message is . . . if there is any doubt, further workup is indicated," Hameed said. For every mortality picked up in this study, she added, there are a multitude—over 50 to 100 times more women who are not dying but who may have undiagnosed cardiovascular disease.

Hameed had no conflicts of interest.

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