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Management of Cardiovascular Disease in Pregnancy

1 Contact Hour
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Friday, March 21, 2025

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥ 92% of participants will understand evidence-based guidelines for caring for pregnant women with cardiovascular disease.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Identify risk factors for developing cardiovascular disease (CVD).
  2. Summarize cardiac changes in pregnancy.
  3. Outline ways to diagnose CVD in pregnancy.
  4. Compare guidelines for cardiovascular evaluation.
  5. Paraphrase postpartum cardiomyopathy care.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Kelly LaMonica (DNP(c), MSN, RNC-OB, EFM)

Background

Cardiovascular disease (CVD) affects up to 4% of almost four million pregnancies annually in the United States (American College of Obstetricians and Gynecologists [ACOG], 2019). CVD is now the leading cause of maternal morbidity and mortality in the United States. Maternal morbidity and mortality rates have remained stable for women with congenital CVD, whereas rates have increased for women with acquired CVD. The most common types of acquired heart disease during pregnancy and postpartum are heart failure, myocardial infarction, arrhythmia, and aortic dissection. About 25% of deaths due to CVD are considered to be preventable (ACOG, 2019).

Identifying CVD

Most pregnancies occur in young, healthy women. Signs and symptoms of CVD can be similar to those of normal pregnancy, such as shortness of breath, fatigue, limitation of exercise capacity, and swelling (Iftikhar & Biswas, 2022). Other signs and symptoms of CVD include chest pain and syncope.

Pregnant or postpartum women presenting with symptoms should be evaluated by looking at risk factors, vital sign abnormalities, and abnormal physical examination findings. Physical exam findings may include tachycardia, tachypnea, hypotension, cyanosis, rales, jugular vein distension, and peripheral edema (Iftikhar & Biswas, 2022).

These signs should not be ignored. Pregnancy can mask CVD. Evaluating signs and symptoms and obtaining a thorough patient and family history are important. Pregnant or postpartum women with significant risk factors should be counseled about their future risks. Women with known CVD should receive preconception counseling by a perinatologist and cardiologist experienced in high-risk pregnancies. These women must be monitored closely and deliver at a hospital equipped to handle their disease and condition.

Risk Factors

There are four important risk factors linked to CVD in pregnancy. Race and ethnicity are the first factors. Non-Hispanic African American/Black women have a three to four times higher risk of dying from CVD-related pregnancy complications than non-Hispanic White women (ACOG, 2019). Age is the next risk factor. A woman older than 40 years has 30 times the risk of dying from heart disease in pregnancy than a woman younger than 20. The third risk factor is hypertension. Severe and early-onset hypertension during pregnancy also increases a woman’s risk of CVD. The fourth risk factor is pre-pregnancy obesity, which increases the risk of maternal death due to a cardiovascular cause, especially if associated with obstructive sleep apnea (ACOG, 2019).

When discussing race and ethnicity, it is essential to point out that racial disparities exist in maternal health. The differences in outcomes between Black women versus White women are due to various reasons. Black women have higher rates of pre-existing CVD and hypertension. They also have lower rates of adequate prenatal care. Racism, stress, and the environment may affect these outcomes. Low socioeconomic status can prevent adequate nutrition and medical care. Implicit bias by providers and hospitals can have a negative impact. Black women may also receive care from lower-quality healthcare providers. Women who are part of the Medicaid population have also been shown to have a greater incidence of CVD (Marschner et al., 2022). Poverty is also a risk factor for CVD.

Pregnancy

Pregnancy causes hemodynamic changes from the beginning to the postpartum period. Cardiac output during pregnancy can increase by 20 to 50%; this change begins early and continues throughout most of the pregnancy. The heart ventricles adapt to the plasma volume increase during pregnancy. Both the ventricles and atria may enlarge due to the increased volume. There are dramatic changes in cardiac output, heart rate, blood pressure, and plasma volume during labor until after delivery (Friel, 2022).

Heart rate increases by 15 to 30% at the beginning of pregnancy. Systemic vascular resistance decreases by up to 30% in early pregnancy. Blood pressure usually decreases early in pregnancy but may return to normal and can even be elevated by the end of pregnancy (Friel, 2022).

CVD in pregnancy can cause complications such as excess weight gain, preeclampsia, preterm birth, intrauterine growth restriction, hemorrhage, placental abruption, gestational diabetes, progressive heart failure, and maternal or fetal death.

Hematologic, coagulation, and metabolic changes during pregnancy also increase the risk of CVD (ACOG, 2019). As normal pregnancy and postpartum symptoms can mimic cardiovascular issues, healthcare providers should investigate further to rule out CVD (ACOG, 2019).

Some guidelines can help to guide providers. The following women should receive routine care (ACOG, 2019):

  • Women with no history of CVD
  • Women with no or mild shortness of breath that does not interfere with activities of daily living
  • Women with chest pain due to reflux that resolves with treatment
  • Women with palpitations that last only a few seconds and are self-limited
  • Dizziness only with dehydration or prolonged standing
  • Mild fatigue
  • Normal vital signs
    • Heart rate (beats per minute) <90
    • Systolic blood pressure (mm Hg) 120-139
    • Respiratory rate (per minute) 12-15
    • Oxygen saturation >97%
  • Physical exam
    • Jugular venous pulse (JVP) - not visible
    • Heart – S3, barely audible soft systolic murmur
    • Lungs – clear
    • Edema – mild

Women with the following symptoms should receive non-emergent evaluation (ACOG, 2019):

  • Women with no history of CVD
  • Women with moderate shortness of breath, new onset asthma, persistent cough, or moderate or severe obstructive sleep apnea
  • Women with atypical chest pain
  • Women with palpitations that are brief and self-limited without syncope or lightheadedness
  • Vasovagal syncope
  • Mild or moderate fatigue
  • Vital signs
    • Heart rate (beats per minute) 90 - 119
    • Systolic blood pressure (mm Hg) 140-159
    • Respiratory rate (per minute) 16-25
    • Oxygen saturation 95 - 97%
  • Physical exam
    • JVP - not visible
    • Heart – S3, systolic murmur
    • Lungs – clear
    • Edema – moderate

Women with the following symptoms should receive prompt cardiovascular evaluation (ACOG, 2019):

  • Women with a history of CVD
  • Women with shortness of breath at rest, paroxysmal nocturnal dyspnea or orthopnea, bilateral chest infiltrates on x-ray, or refractory pneumonia
  • Women with chest pain at rest or with minimal exertion
  • Women with palpitations with near syncope
  • Syncope that is exertional or unprovoked
  • Extreme fatigue
  • Vital signs
    • Heart rate (beats per minute) ≥120
    • Systolic blood pressure (mm Hg) > 160 or symptomatic hypotension
    • Respiratory rate (per minute) ≥25
    • Oxygen saturation <95%
  • Physical exam
    • JVP – visible, > 2cm above the clavicle
    • Heart – loud systolic murmur or S4, diastolic murmur
    • Lungs – wheezing, crackles, effusion
    • Edema – marked

Diagnosing CVD

Women without known CVD who present with signs or symptoms should have a thorough exam and family history. Lab tests should be done for natriuretic peptides, cardiac troponin I, troponin T, and “high-sensitivity” troponin. Lab work should also include a complete blood count (CBC) and comprehensive metabolic panel (CMP) to rule out preeclampsia and inflammatory conditions.

These women should also have an electrocardiogram (EKG) and an echocardiogram. An EKG could reveal cardiovascular problems, especially abnormal heart rhythms. Some common dysrhythmias in pregnancy include premature atrial contractions (PACs), supraventricular tachycardias, and premature ventricular contractions (PVCs). ST-elevations or depressions, T-wave inversion, or formation of Q-waves can indicate ischemic cardiovascular disease (Iftikhar & Biswas, 2022).

An echocardiogram should also be done to evaluate for structural cardiovascular defects (Iftikhar & Biswas, 2022). Abnormal findings include chamber enlargement, physiologic aortic, mitral, or tricuspid regurgitation, and valvular dilatation (Iftikhar & Biswas, 2022). An echocardiogram could diagnose cardiomyopathy.

A chest x-ray or computerized tomography (CT) scan may be done if a woman has shortness of breath or chest pain to rule out a pulmonary embolism. A Holter monitor may be used for prolonged cardiac monitoring in women with palpitations, lightheadedness, and syncope during pregnancy (ACOG, 2019). An exercise stress test may be performed before pregnancy or at submaximal exercise testing levels if already pregnant (ACOG, 2019).

Care of the Pregnant Woman with Known CVD

Advances in medicine have led women with congenital heart disease to live longer and reach childbearing age. There are many specific recommendations based on the type of CVD a woman has. Women with CVD must have a primary doctor and a cardiovascular specialist. Ideally, these women should have preconception counseling to learn the risks associated with pregnancy and develop a care plan for pregnancy and delivery. Some medications should be avoided during pregnancy. These include warfarin, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), aldosterone antagonists, thiazide diuretics, and certain antiarrhythmics (e.g., amiodarone). The World Health Organization (WHO) categorizes patients into four pregnancy risk classes (I-IV), depending on their specific condition (Friel, 2022).

Women with category I CVD have no increased risk of maternal mortality or morbidity. These are women with (Friel, 2022; Suwanrath et al., 2018):

  • Uncomplicated or mild:
    1. Patient ductus arteriosus
    2. Pulmonic stenosis
    3. Mitral valve prolapse
  • Repaired atrial septal defect
  • Repaired ventricular septal defect
  • Repaired anomalous pulmonary venous drainage
  • Repaired patent ductus arteriosus
  • Atrial ectopic beats
  • Ventricular ectopic beats

Women with category II CVD have a mild risk of maternal mortality and a moderate risk of morbidity. These are women with (Friel, 2022; Suwanrath et al., 2018):

  • Unrepaired atrial septal defect
  • Unrepaired ventricular defect
  • Repaired tetralogy of Fallot
  • Mild left ventricle compromise
  • Repaired coarctation of the aorta
  • Hypertrophic obstructive cardiomyopathy
  • Marfan syndrome without aortic dilation
  • Bicuspid aortic valve with aorta < 45 mm

Women with category III CVD have a substantially elevated risk of maternal mortality and a severely elevated risk of morbidity. These women need to be closely monitored by a cardiologist throughout pregnancy and after pregnancy. These are women with (Friel, 2022; Suwanrath et al., 2018):

  • Mechanical valve
  • Fontan circulation
  • Unrepaired cyanotic heart defects
  • Systemic right ventricle
  • Marfan syndrome with aorta dilated to 40-45 mm
  • Bicuspid aortic valve with aorta dilated to 45-50 mm

Category IV patients may have an extremely high risk for maternal mortality or severe morbidity, so pregnancy is not advised. Termination is recommended for these women; close monitoring is necessary if the woman chooses to continue the pregnancy. These are women with (Friel, 2022; Suwanrath et al., 2018):

  • Pulmonary arterial hypertension (any class)
  • Severe left ventricular compromise (ejection fraction < 30%)
  • Prior postpartum cardiomyopathy
  • Severe mitral stenosis
  • Severe aortic stenosis
  • Marfan syndrome with aortic dilatation > 45 mm
  • Bicuspid aortic valve disease with aortic dilatation > 50 mm

These women may require activity restriction or bed rest after 20 weeks of gestation.

Women with category I and II CVDs can deliver at their local hospital with cardiovascular consultation. Maternal-fetal medicine should be available for women with category II CVD. Women with categories III and IV should deliver at a hospital with appropriate care, where cardiovascular team members can participate in caring for these women. Women with category IV CVD may require care from the obstetrician, maternal-fetal medicine provider, interventional cardiologist, cardiovascular surgeon, and mental health specialists.

Women should have baseline labs and cardiovascular tests during the first trimester. Medications should be altered as needed. A coordinated labor, delivery, and postpartum care plan should be developed by the end of the second trimester and reviewed with a multidisciplinary team, including labor and delivery staff and the anesthesiology department. In the third trimester, normal pregnancy symptoms may worsen and require close monitoring.

Some treatments may be required during pregnancy. Patients with cardiomyopathy may experience atrial fibrillation during pregnancy. Medications to control a safe heart rate in pregnancy may include beta-blockers, calcium channel blockers, or digoxin. Anticoagulation may also be required. Pregnant women may be given standard or low-molecular-weight heparin. The timing and dosage of these medications may be altered at the time of delivery. The American Heart Association (AHA) guidelines do not recommend endocarditis prophylaxis because the rate of bacteremia is low (Friel, 2022). Loop diuretics can be used to treat pulmonary edema. It is important to treat hypertension during pregnancy. Severely high blood pressure (> 160/110 mm Hg) persisting for 15 minutes requires prompt treatment (within 60 minutes).

The AHA recommends delivery methods for patients with specific cardiovascular conditions such as arrhythmias, mechanical heart valves, heart failure, pulmonary arterial hypertension, aortic stenosis, and left ventricular outflow tract obstruction. Women with stable CVD can usually try to have a vaginal delivery at 39 weeks of gestation, with cesarean delivery performed as needed for obstetric complications. Some patients with high-risk cardiovascular conditions may not tolerate the fluctuations in cardiac output or Valsalva efforts that occur during vaginal delivery. Regional anesthesia during labor may provide sufficient pain relief for many patients to render a vaginal delivery feasible. Some of these women may require operative vaginal assistance during the 2nd stage of labor, and some women will need a cesarean section (ACOG, 2019). Women with aortic stenosis should have it repaired before pregnancy. These patients should not receive epidural or spinal anesthesia if the repair has not occurred. Women with arrhythmias may require cardiac monitoring during labor, so ensuring that the labor and delivery unit can accommodate this is essential. It is also important to have a plan to manage anticoagulation medications. The most important part of caring for a woman with CVD is to have a plan for these women when they come to the hospital to deliver. The anesthesiologists should know their history and have a plan of action. Most of these women will benefit from an epidural, whether in labor or having a cesarean section.

If cardiac arrest occurs, although rare, resuscitation is similar to a non-pregnant person. However, early intubation is recommended due to increased oxygen needs, and the woman’s uterus should be displaced. Prompt delivery is also recommended (ACOG, 2019).

Postpartum Care

The postpartum period has the highest risk of CVD-related maternal morbidity and mortality. Postpartum cardiomyopathy is the leading cause of late postpartum death and occurs in about 1 in 2289 live births (Friel, 2022). Congenital heart defects generally cause fewer complications. Regurgitant lesions have better outcomes than stenotic lesions. Mortality is rare in patients with congenital heart disease, but these patients have a risk of pulmonary edema and cardiac events, such as non-sustained tachyarrhythmia.

Women with known CVD are at high risk for immediate postpartum complications (within seven days of delivery). Women require frequent monitoring of the signs and symptoms of CVD, including the development of shortness of breath or cough, using pulse oximetry, lung assessments, and monitoring intake and output. These women should follow up with their cardiologists (Friel, 2022).

Providers need to be aware of the signs and symptoms of CVD and when to consult a cardiologist. Nurses must be aware of changes in the patient’s status and report the changes to the provider. Women with cardiovascular complications require an interdisciplinary team to provide quality care with good outcomes.

Postpartum Cardiomyopathy

Postpartum cardiomyopathy is a rare, life-threatening cardiac condition with no known cause that can occur in previously healthy women during the peripartum period and up to 5 months postpartum. The heart chambers enlarge, and the muscles weaken. Risk factors include obesity, high parity, twin pregnancy, use of tocolytic therapy, personal history of cardiovascular disorders, smoking, alcoholism, advanced maternal age, preeclampsia, cocaine use, poverty, and African American descent. The incidence and prevalence vary greatly by region (Mubarik et al., 2022). Cardiomyopathy is the highest in women 40 to 52 years old.

Reasons for cardiomyopathy may include the following (Mubarik et al., 2022):

  • Viral myocarditis during the peripartum period
  • Inability to clear cardiac antigen autoantibodies due to reduced humoral immunity
  • Inadequate response to hemodynamic stress of pregnancy
  • Aggressive cardiac cell apoptosis
  • Inflammation due to cytokines
  • Selenium deficiency due to malnutrition
  • Familial predisposition due to genetics
  • Increased prolactin effect on the heart
  • Estrogen and progesterone effect
  • Myocardial stunning due to adrenergic surge
  • Myocardial ischemia

Symptoms include fatigue, palpitations, nocturia, shortness of breath with activity and lying flat, swelling of the ankles, swollen neck veins, and low blood pressure. Physical examination findings may include tachycardia, elevated JVP, bilateral pulmonary crackles, third heart sound (S3), and a displaced apical pulse (Mubarik et al., 2022). The diagnosis is made when heart failure has an ejection fraction of less than 45% and no known cause.

Treatment of postpartum cardiomyopathy keeps extra fluid from collecting in the lungs and helps the heart recover as fully as possible. Treatment is based on symptoms. Beta-1-selective blockers and ACE inhibitors are the most commonly used drugs and have been shown to lower mortality. An ACE inhibitor is contraindicated in pregnant patients. Diuretics are used to ease symptoms related to heart failure. Heart failure medications, such as sacubitril/valsartan, have been shown to improve heart failure symptoms in pregnancy-related cardiomyopathies. Some women require hospitalization, possibly in the intensive care unit, depending on the severity of the illness. About 50% of women can recover and have normal heart function once on medications, about 25% of women have long-term heart failure, and others die from it (Mubarik et al., 2022).

Case Study

A 42-year-old obese African American patient with a body mass index (BMI) of 42 had an uncomplicated vaginal delivery ten days ago. She presents to the emergency room with fatigue and persistent cough complaints since delivery. Her blood pressure is 110/80 mmHg. Her heart rate is 110 bpm, respiratory rate of 28/minute, and temperature is 98.6°F. Chest X-ray reveals bilateral infiltrates. Her oxygen saturation is 94% on room air. The patient is diagnosed with a respiratory infection, and her fatigue is thought to be due to a lack of sleep. She is prescribed an antibiotic and sent home. One week later, she presented again in the emergency room with the same symptoms. Her blood pressure is 106/76 mmHg. Her heart rate is 122 bpm, respiratory rate of 28/minute, and temperature is 98.8ºF. Her pulse oximetry is 93% on room air. Her antibiotics are switched at this time, she is given an inhaler, and she is diagnosed with new-onset asthma, as evidenced by physical examination findings. Two days later, the patient experienced cardiac arrest at home. Resuscitation attempts are unsuccessful. Autopsy findings were indicative of cardiomyopathy.

What should the emergency room care providers have done differently during the first visit?

Her complaints were vague and similar to any woman with a new baby and a cold. Obstetricians and providers must know the cardiovascular risks for pregnant or postpartum women. The patient was African American, older than 40, and obese, all factors that increase a woman’s risk of cardiovascular events. She should have had an EKG and echocardiogram to rule out cardiovascular issues.

Conclusion

Heart disease is a serious medical condition that can have severe consequences for pregnant women. These women need specialized, coordinated care. Multidisciplinary team members need to prepare for the delivery and care in the postpartum period. The obstetrician and nurses must coordinate care with cardiology and intensivists. The patient may need monitoring in the intensive care unit. It is important to note that women can alter some of their lifestyle habits to decrease their risk of complications, but many cases cannot be prevented. It is important that these women seek appropriate care and that all providers know the signs and symptoms of CVD.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

  • American College of Obstetricians and Gynecologists (ACOG). (2019). ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease. Obstetrics and gynecology, 133(5), e320–e356. Visit Source.
  • Friel, L. A. (2022). Heart disorders in pregnancy - gynecology and Obstetrics. MSD Manual Professional Edition. Visit Source.
  • Iftikhar, S.F., & Biswas, M. (2022). Cardiac Disease In Pregnancy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Visit Source.
  • Marschner, S., von Huben, A., Zaman, S., Reynolds, H. R., Lee, V., Choudhary, P., Mehta, L. S., & Chow, C. K. (2022). Pregnancy-related cardiovascular conditions and outcomes in a United States medicaid population. Heart, 108(19), 1524–1529. Visit Source.
  • Mubarik, A., Chippa, V., & Iqbal, A.M. (2022). Postpartum Cardiomyopathy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Visit Source.
  • Suwanrath, C., Thongphanang, P., Pinjaroen, S., & Suwanugsorn, S. (2018). Validation of modified World Health Organization classification for pregnant women with heart disease in a tertiary care center in southern Thailand. International journal of women's health, 10, 47–53. Visit Source.