Saving the Heart and Lives of Mothers: Management of Cardiovascular Disease Risk in Pregnancy and Beyond

In 2018, there were 17.4 maternal deaths per 100,000 live births or approximately 700 deaths that occurred during pregnancy, at birth, or within 42 day of birth in the United States.1 Women of childbearing ages are often thought of as being low-risk for cardiovascular disease (CVD). Unfortunately, CVD remains a leading cause of maternal morbidity and mortality,2 and maternal mortality rates are actually increasing in the United States – a trend that should worry us all. The demographics of women during pregnancy have changed over the past few decades, with more pregnancies occurring in older women and among women who have CVD risk factors such as obesity, diabetes, and hypertension. Furthermore, the stress of pregnancy can exacerbate pre-existing cardiovascular conditions, unmask unknown cardiovascular problems, or herald future CVD risk. Black women in particular are at greatest risk for life-threatening cardiovascular complications associated with pregnancy such as stroke and heart failure, compared to other race/ethnic groups.3

These dismal maternal statistics highlight an urgency for increased knowledge competency for all clinicians caring for women patients with CVD or at heightened CVD risk during pregnancy and emphasizes the critical role for highly-trained multi-disciplinary specialists in the emerging field of Cardio-Obstetrics.4 In efforts to save the lives and hearts of these mothers, close collaboration is needed from the Obstetrician, the Maternal Fetal Medicine (MFM) specialist, the Cardiologist, and the Primary Care clinician, as well as other disciplines such as Genetics, Pharmacy, and Anesthesia, who together make up the “Pregnancy Heart Team”.

The identification of women who have high-risk features for a maternal pregnancy complication is paramount. Delivery of pre-conception counseling and early involvement of a specialized Cardio-Obstetrics team during pregnancy for these women can help mitigate some of these increased maternal risks. The American Heart Association (AHA) and the American College of Obstetrics and Gynecology (ACOG) previously collaborated to release an advisory statement of principles for CVD prevention in women throughout their lifespan.5 Complimenting that, in this latest comprehensive and wonderful overview put forth by the AHA, Mehta et al provide guidance on the identification and management of women at higher risk for a cardiovascular complication during pregnancy and recommendations for how best to optimize the antenatal, birth, and post-partum care for these women.

Notably, women who have severe obstruction of their left sided heart valves (mitral stenosis and/or aortic stenosis), severe LV dysfunction (EF <30%), pulmonary arterial hypertension, significant aortic dilation [in Marfans (>45 mm) or bicuspid aortic valve disease (>50 mm)], or severe aortic coarctation should be counseled to avoid pregnancy (World Health Organization (WHO) IV; pregnancy contraindications). Among women with cardiovascular conditions in the WHO III category, pregnancy may not be contraindicated but these women still have high risk of maternal complications. Unfortunately, many high-risk women present to medical attention late while already in midst of their pregnancies, and this not-uncommon situation requires collaborative engagement of specialized obstetric, cardiac, and MFM teams to work together to determining best path forward for the health of the mother and the fetus.

This newly released AHA statement provides guidance on the management of CVD in pregnancy for women with valvular heart disease, congenital heart disease, ischemic heart disease, dilated cardiomyopathies, arrhythmias, venous thromboembolic and cerebrovascular diseases. With its figures and tables, this document serves as a handy reference resource on how to treat hypertensive and lipid disorders during pregnancy, and use anti-thrombotic therapies when indicated, including strategies for anticoagulation for women with mechanical valves during pregnancy. The timing and mode of delivery is also reviewed, with the spontaneous labor and vaginal birth recommended for most women with heart disease in pregnancy, with C-section generally being reserved for obstetric (rather than cardiac) indications. After delivery, contraception and future pregnancy planning should be discussed. Women with increased risk for early cardiovascular complications need very close monitoring and attention in the post-partum period.

In addition to women who have immediate short-term risks during pregnancy and in the post-partum period, there are also many women who are at risk for developing later CVD from pregnancy related complications such as pre-eclampsia, gestational hypertension, gestational diabetes, and pre-term birth.6 These adverse pregnancy outcomes are considered “risk-enhancing” factors that increase a women’s risk of future CVD even decades after her complicated pregnancy,7 but unfortunately these women are often lost to follow up after delivery and unaware of their elevated future risks. These women at increased risk for later CVD need implementation of preventive strategies including intensified lifestyle and control of CVD risk factors. The hand-off from the obstetric team to the primary care team is critically important for their long-term follow-up.

Although learning about the impact of pregnancy on risk of CVD and heart failure is part of standard cardiology fellowship training curriculum, there often are still large gaps in competency and knowledge acquisition in this area, and many cardiologists often have some discomfort with management of these women given limited exposure. While this AHA document serves as a useful reference for any clinician caring for these women during the pre-pregnancy, pregnancy and post-partum time points, there is also increased need to train future cardiologists who have specialized expertise in this area through a designated Cardio-Obstetrics fellowship training program track and establishment of core clinical workforce competencies.

For everyone, knowledge of management of CVD in pregnancy is important and this AHA document provides a useful framework for cardiologists and other clinicians to improve clinical practice for management of these vulnerable women patients. Together, in partnership with multi-disciplinary teams, we can improve the care of women with CVD, or at risk of CVD, during their child-bearing years to keep them healthy for decades to come.