CVD in pregnancy the leading cause of death among US mothers

Heart disease is now the leading cause of maternal deaths in the U.S., the American College of Obstetricians and Gynecologists (ACOG) reported in early May, prompting the organization to publish a comprehensive guide on pregnancy and CVD.

In a statement, ACOG President Lisa Hollier, MD, MPH, said the new practice bulletin addresses not only pre-existing cardiac conditions, but also disease that’s acquired during pregnancy. CVD as a whole comprises 26.5% of pregnancy-related deaths each year; 23% of deaths can be attributed to peripartum cardiomyopathy, which typically develops postpartum.

“The rise we’re seeing in maternal deaths is largely due to acquired cardiac disease in pregnancy,” Hollier said. “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.

“The new guidance clearly delineates between common signs and symptoms of normal pregnancy versus those that are abnormal and indicative of underlying cardiovascular disease. As clinicians, we need to be adept at distinguishing between the two if we’re going to improve maternal outcomes.”

Conventional risk factors for CVD mortality include race, ethnicity, age, preeclampsia and obesity, Hollier said, but the leading factor is race, with black women’s risk of dying from CVD coming in 3.4 times higher than white women’s. The disparity is the result of deep-rooted discrimination within the U.S. healthcare system, and the greatest gaps in care for black women usually exist before they’re pregnant, when physicians fail to adequately address their risk factors for heart disease.

The practice bulletin recommends all women be screened for CVD in the prenatal and postpartum periods using the California CVD Tool Kit algorithm. Testing in the state found that 88% of moms who ultimately died in the peripartum period would have been flagged as high-risk using the algorithm.

ACOG also encourages women with known heart disease to see a cardiologist prior to becoming pregnant and receive pre-pregnancy counseling. Those patients should also be taken care of by a multidisciplinary heart team at a high-level center during pregnancy, delivery and postpartum to minimize their risk of cardiac complications.

Hollier said that since the postpartum period is a time of increased CVD risk—a time that can stretch from six months to a year—women with CV conditions should stay on top of their checkups. Women with hypertensive disorders, for example, should see a primary care physician or cardiologist within seven to 10 days of delivery, while those with more general CVD should get to the doctor within two weeks. The ACOG’s new guidance also recommends a comprehensive cardiovascular postpartum visit at the three-month mark and other follow-up exams, which Hollier said insurance companies need to start accommodating.

“It is crucial for these women to have a longer-term care plan,” she said. “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 wellbeing of the moms in this country.”