Management of Cardiovascular Disease in Pregnancy

Cardiovascular disease affects 1–4% of almost 4 million pregnancies in the United States each year.¹ Cardiovascular disease 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 cardiovascular disease, whereas the rates for women with acquired cardiovascular disease have increased. The most common types of acquired heart disease during pregnancy and the postpartum periods are heart failure, myocardial infarction, arrhythmia, or aortic dissection.² About 25% of deaths due to cardiovascular disease are preventable.

Most pregnancies occur in young, healthy women and signs and symptoms of cardiac disease can be similar to those of normal pregnancy such as shortness of breath, fatigue, limitation of exercise capacity and swelling.³ Pregnant or postpartum women presenting with symptoms should be evaluated by looking at risk factors, vital sign abnormalities and abnormal physical examination findings.³ These signs should not be ignored. Pregnant or postpartum women with significant risk factors should be counseled about their future risks. Women with known cardiovascular disease should receive preconception counseling by a perinatologist and cardiologist experienced in high-risk pregnancies. These women will need to be monitored closely and should deliver at a hospital that is equipped to handle their disease.

There are four important risk factors linked to cardiovascular disease in pregnancy. Race and ethnicity are the first factors. Non-Hispanic black women have a 3 to 4 times higher risk of dying from cardiovascular disease-related pregnancy complications compared with non-Hispanic white women.⁴ Age is the next 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. Severe and early-onset hypertension during pregnancy also increases a woman’s risk of cardiovascular disease. The fourth risk is pre-pregnancy obesity, which increases maternal death risk due to a cardiac cause, especially if associated with obstructive sleep apnea.¹

When discussing race and ethnicity, it is essential to point out that racial disparities exist in maternal health. There are many reasons that can contribute to differences in outcomes of black women versus white women. Black women have higher rates of pre-existing cardiovascular disease and hypertension. They also have lower rates of adequate prenatal care. Racism, stress, and the environment all may have a role in these outcomes. Low socioeconomic status can prevent adequate nutrition and medical care. Implicit bias by providers and hospitals can have a negative impact on the care of a black woman. Black women may also receive care from lower-quality health care providers.

Pregnancy causes hemodynamic changes from the beginning of pregnancy through the postpartum period. Cardiac output is increased throughout pregnancy. The heart ventricles adapt to the plasma volume increase during pregnancy. During labor until after delivery, there are dramatic changes in cardiac output, heart rate, blood pressure, and plasma volume. Hematologic, coagulation, and metabolic changes during pregnancy also increase the risk of cardiovascular disease.1 Normal pregnancy and postpartum symptoms can mimic cardiac issues and healthcare providers should be aware of them (Table 1).¹

Table 1:ACOG Practice Bulletin No. 212. Obstetrics & Gynecology. 2019;133(5). doi:10.1097/aog.0000000000003243.

Women without known cardiovascular disease who present with signs or symptoms should have a thorough exam and family history done. Lab tests should be done for natriuretic peptides, cardiac troponin I, troponin T, and “high-sensitivity” troponin. These women should also have an electrocardiogram (EKG) and an echocardiogram. A chest x-ray or CT scan may be done if a woman has shortness of breath or chest pain. A Holter monitor for prolonged cardiac monitoring is useful for women with palpitations, lightheadedness, and syncope during pregnancy.¹

Advances in medicine have led to women with congenital heart disease to live longer and reach childbearing age. There are many specific recommendations based on the type of cardiac disease that a woman has. It is important that women with cardiac disease have a primary doctor and a cardiac specialist. Ideally, these women should have preconception counseling to learn the risks associated with pregnancy and develop a plan of care for pregnancy and delivery. The World Health Organization (WHO) categorizes patients into 4 pregnancy risk classes (I-IV), depending on their specific condition. Category I has no increased risk of maternal mortality and a slight increase in maternal morbidity. Category II and III may have small increases in maternal mortality or moderate increases in morbidity. Category IV patients may have an extremely high risk for maternal mortality or severe morbidity so much that pregnancy is not advised.

During the first trimester, the woman should have baseline labs and cardiac tests. Medications should be altered as needed. A coordinated plan for labor, delivery, and postpartum care should be developed by the end of the second trimester and reviewed with a multidisciplinary team, including labor and delivery staff and anesthesia, in the event of a spontaneous or indicated preterm delivery. In the third trimester, normal symptoms of pregnancy may worsen but require close monitoring.⁵

The American Heart Association (AHA) makes recommendations for specific cardiac conditions such as arrhythmia, mechanical heart valves, heart failure, pulmonary arterial hypertension, aortic stenosis, and left ventricular outflow tract obstruction. Women with stable cardiac disease can usually try to have a vaginal delivery at 39 weeks of gestation, with cesarean delivery done as needed for obstetric complications. Some patients with high-risk cardiac conditions may not be able to tolerate the fluctuations in cardiac output or Valsalva efforts that occur during vaginal delivery. For many of these patients, regional anesthesia during labor may provide sufficient pain relief 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 to have a cesarean section.¹ Women with arrhythmias may require cardiac monitoring during labor so it is essential to make sure that the labor and delivery unit can accommodate this. It is also important to have a plan to manage anticoagulation medications. The most important part of caring for a woman with cardiac disease is to have a plan for these women when they come to the hospital to deliver. The anesthesiologists should know about this woman and have a plan ready. Most of these women will benefit from an epidural, whether in labor or cesarean section). The high-risk women should deliver at a tertiary care center that accommodates their needs.

In the event that cardiac arrest occurs, although rare, resuscitation is similar to a non-pregnant person, except that early intubation is recommended due to increased oxygen needs and the woman’s uterus should be displaced. Prompt delivery is also recommended.¹

The postpartum period is the highest risk of cardiovascular disease-related maternal morbidity and mortality. Peripartum cardiomyopathy is the leading cause of late postpartum death. Women with known cardiac disease are at high risk for immediate postpartum complications (within 7 days of delivery). Women require frequent monitoring of the signs and symptoms of cardiovascular disease, 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.

Heart disease is a serious medical condition that can have severe consequences for the pregnant woman. These women need specialized, coordinated care. Multidisciplinary members of a team need to prepare for this delivery. Women can alter some of their lifestyle habits to decrease their risk of complications. It is important that these women seek appropriate care and that all providers know the signs and symptoms of cardiovascular disease.

A 42-year-old obese (Body Mass Index 42) African American G1P1 had an uncomplicated vaginal delivery 10 days ago. She presents to the ED with complaints of fatigue and persistent cough since delivery. Her blood pressure is 110/80 mm Hg, heart rate 110 bpm, respiratory rate of 28/minute, and temperature 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 the lack of sleep. She is prescribed an antibiotic and sent home. One week later, she presents again in the ED with the same symptoms. 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 experiences cardiac arrest at home. Resuscitation attempts are unsuccessful. Autopsy findings were indicative of cardiomyopathy.

What should the ED have done differently during the first visit?

Her complaints were vague and similar to that of any woman with a new baby and a cold. It is important that not only obstetricians but all providers know the cardiovascular risks for pregnant or postpartum women. This woman was black, older than 40, and obese, all factors that increase a woman’s risk. She should have had an EKG and echocardiogram to rule out cardiac issues.

1. ACOG Practice Bulletin No. 212. Obstetrics & Gynecology. 2019;133(5). doi:10.1097/aog.0000000000003243. Visit Source.
2. Fett JD. Peripartum cardiomyopathy: challenges in diagnosis and management [published erratum appears in Expert Rev Cardiovasc Ther 2016;14:1205]. Expert Rev Cardiovasc Ther 2016;14:1035–41.
3. Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum. Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum | California Maternal Quality Care Collaborative. Accessed December 17, 2019. Visit Source.
4. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011-2013. Obstet Gynecol 2017;130:366–73.
5. Gambino B. AHA: Pregnancy Management With Congenital Heart Disease. The Cardiology Advisor.