Cardiovascular Disease Leading Cause of Maternal Death

Tara Haelle

May 06, 2019

During pregnancy and the postpartum period, cardiovascular disease is the leading cause of maternal death in the United States, according to the American College of Obstetricians and Gynecologists (ACOG), which released a practice bulletin on pregnancy and heart disease at the ACOG 2019 Annual Meeting in Nashville, Tennessee.

"We must think of heart disease as a possibility in every pregnant or postpartum patient we see to detect and treat at-risk mothers," James Martin, MD, chair of the ACOG pregnancy and heart disease task force, said in a news release.

In the practice bulletin, the task force describes risk factors for cardiovascular-related mortality, the most common cardiovascular conditions in pregnant and postpartum women, and recommendations for the diagnosis and management of these conditions.

Although cardiovascular disease affects only 1% to 4% of pregnant women in the United States, it accounts for 26.5% of peripartum and postpartum maternal deaths. An estimated 4.23 mothers per 100,000 live births die from cardiovascular-related causes, according to the bulletin, and rates are even higher for low-income women and women of color.

"Most of these deaths are preventable, but we are missing opportunities to identify risk factors prior to pregnancy and there are often delays in recognizing symptoms during pregnancy and postpartum, particularly for black women," ACOG Past President Lisa Hollier, MD, explained in the news release.

Many of these deaths result from pre-existing heart conditions, but the majority of them are related to heart disease that develops during pregnancy, she pointed out. For example, peripartum cardiomyopathy is responsible for 23% of late postpartum deaths.

Pregnancy is "a natural stress test," said Martin. "The cardiovascular system must undergo major changes to its structure to sustain tremendous increases in blood volume."

"That's why it is critical to identify the risk factors beforehand, so that a woman's care can be properly managed throughout the pregnancy and a detailed delivery plan can be developed through shared decision-making between the patient and provider," he added.

Black Women Have Triple the Risk

From 2011 to 2013, when 11.0 Hispanic women and 12.7 non-Hispanic white women died per 100,000 live births, 43.5 non-Hispanic black women died per 100,000 live births died. That risk for death for black women — which is 3.4 times higher than it is for white women — is largely due to systemic racism in healthcare systems, the task force reports.

"Physician implicit and explicit bias and overt racism often can result in missed diagnoses or inappropriate treatment," it notes. "Health system barriers to efficient triage based on symptom severity, language barriers, and differences in cultural humility are important factors that must be investigated to understand fully the pervasiveness of disparities that women of color face when encountering the healthcare system."

Risk for gestational diabetes is also higher for black women, as is risk for pre-eclampsia, preterm delivery, and delivery of low-birthweight infants. Past experiences of injustice in the healthcare system might lead women of color to distrust the medical system, the task force suggests, which can exacerbate and contribute to the prevalence of these conditions.

"It is important to improve education for these women and their trusted lay sources of information by emphasizing the value of medical care and the importance of healthy dietary habits and regular exercise," the task force writes.

Other significant risk factors include older age, obesity (particularly if accompanied by obstructive sleep apnea), and hypertension during pregnancy, which occurs in about 10% of pregnancies. "In pregnancies complicated by hypertension, the incidence of myocardial infarction and heart failure is 13-fold and 8-fold higher, respectively, than in healthy pregnancies," the bulletin notes.

A flowchart is provided that can be used to assess cardiovascular disease in pregnant and postpartum women, as is a table that can be used to designate risk classification for women with pre-existing cardiovascular disease.

The bulletin also discusses indicated testing and imaging, their associated interpretation, a list of cardiac medications with information on teratogenicity and other potential interference with pregnancy or lactation, and obstetric medications with possible cardiac influences.

ACOG recommends that women with known cardiovascular disease undergo a cardiologist's evaluation before pregnancy, or as soon as possible after becoming pregnant, to determine the most appropriate facility, physician team, and management, regardless of whether she is symptomatic.

Symptoms such as shortness of breath, chest discomfort, palpitations, arrhythmias, and fluid retention are indications for peripartum cardiomyopathy evaluation, generally with an echocardiogram.

However, regardless of known conditions or symptoms, "all women should be assessed for cardiovascular disease in the antepartum and postpartum periods using the California Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum toolkit algorithm," the task force recommends.

Because of the increased risk for cardiovascular-related complications up to a year after delivery, the practice bulletin recommends that women with hypertensive disorders have a follow-up visit with their primary care provider or cardiologist seven to 10 days after delivery. Those with heart disease or cardiovascular disorders should have a follow-up visit seven to 14 days after delivery. These women should then undergo a comprehensive cardiovascular visit 3 months after delivery to discuss future pregnancy plans and annual follow-ups.

"It is crucial for these women to have a longer-term care plan," said Hollier. "Currently, many women are going home and taking excellent care of their babies, but how are we demonstrating that we're taking care of them? It is our job to make sure our clinical practices, policies, and systems reflect our commitment to the health and well-being of the moms in this country."

The task force received no external funding when developing the practice bulletin. Martin and Hollier have disclosed no relevant financial relationships.

Obstet Gynecol. 2019;133:e320-e356. Abstract

American College of Obstetricians and Gynecologists (ACOG) 2019 Annual Meeting. Presented May 3, 2019.

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