Stacy Ann Walker could have died.

During what she thought was going to be a normal exam, Stacy learned that she would need to have a C-section. While recovering in the hospital, she began to have breathing problems and after some testing was told that her heart had been scarred by an earlier bout of rheumatic fever. Shortly after, she also learned that she had heart failure, an enlarged heart, and problems with multiple heart valves.

She was 29.

Stacy’s heart condition had likely worsened due to the strain of pregnancy. In the years following her daughter’s birth, Stacy had to undergo multiple surgeries to repair her mitral and tricuspid valves. Luckily, today, Stacy and her daughter are alive and well.

I had the pleasure of meeting Stacy last year when she spoke at the launch of the new clinical guidance on pregnancy and heart disease that was the centerpiece of my presidency at the American College of Obstetricians and Gynecologists. It aims to address cardiac contributors to maternal mortality and outlines plans for screening, diagnosis, and management of cardiovascular disease (CVD) for women from before pregnancy to postpartum. 

It is stories like Stacy’s that remind me why it is so important for clinicians and women to be educated about the risks of heart disease.

Heart Conditions Behind Pregnancy-related Death

In the United States, CVD and cardiomyopathy are now the leading causes of pregnancy-related death. They constitute 26.5 percent of these deaths, with higher rates of mortality among women of color, like Stacy, and women with lower incomes. 

In addition to preexisting cardiac conditions, the College’s guidance also addresses acquired heart conditions, which are by far the most common presentation and can develop silently and acutely during or after pregnancy. Currently, peripartum cardiomyopathy, a condition affecting the heart muscle, accounts for 23.0 percent of deaths in the late postpartum period.

The rise we’re seeing in maternal deaths is largely due to these acquired cardiac conditions. Most of these deaths are preventable. We are missing opportunities to identify women at risk with screening. And often delays in recognizing symptoms during pregnancy and postpartum, particularly for black women, put lives on the line.

It is critical to be able to differentiate common signs and symptoms of normal pregnancy from those that are abnormal, tell-tale marks of underlying cardiovascular disease. As clinicians, we need to be adept at distinguishing between the two if we’re going to improve maternal outcomes.

Common associated risks for cardiovascular disease-related mortality include age, hypertension during pregnancy, and obesity. In addition, black women’s risk of dying from CVD is three to four times higher than that of white women.  This unacceptable disparity in outcomes results from many factors including racism and bias in access to and delivery of quality health care.  Health disparities are often amplified by missed opportunities to identify cardiovascular disease risk factors before pregnancy and limited access to cardiac-related care protocols during intrapartum and postpartum care.   

Pregnancy Stresses the Heart

Why do we see these problems?  Pregnancy is a natural stress test. A woman’s heart undergoes major functional and structural changes and must work much harder than usual due to increases in blood volume. During every cycle of pregnancy, labor/delivery, and immediately postpartum, a woman’s heart may need to work anywhere from 5 to 80 percent harder, depending on the individual and the circumstances of the pregnancy. That’s why it is critical to identify women at risk beforehand, so that 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.

Successful outcomes depend on timely identification of risk and a team-based approach to care. 

Women with known heart disease should see a cardiologist prior to pregnancy to ensure accurate diagnosis, learn the effects of pregnancy on her heart, and optimize her cardiac condition. Patients determined to have moderate and high-risk cardiovascular disease should be managed during pregnancy, delivery, and postpartum in a medical center that is able to provide a higher level of care, including a multidisciplinary Pregnancy Heart Team that includes obstetric providers, maternal-fetal medicine specialists, and cardiologists and anesthesiologists at a minimum. Collaboration between providers, particularly ob-gyns and cardiologists, is key.

Elevated Postpartum Risk

Many women do not realize that they face increased risk for cardiovascular-related complications during the postpartum period. The risk is elevated not only immediately after birth, but also from six months to a year later.  An early follow-up visit with the primary care clinician or cardiologist should occur within 7 to 14 days for all women with heart disease or cardiovascular disorders.  

To address the longer-term risk, it is recommended that women identified as high-risk have a comprehensive, cardiovascular postpartum visit at the three-month mark, at which time the clinicians and patient can discuss collaborative plans for yearly follow-up and future pregnancy intentions.

Finally, maternity care payment models must cover these additional visits for a more individualized approach to these women. It is our responsibility to make sure our clinical practices, policies, and systems reflect our commitment to the health and well-being of the moms in this country.