Heart Failure in Pregnancy: A Problem Hiding in Plain Sight.

Introduction

Cardiac diseases are the most common cause of death and complications during pregnancy in the United States and the developed world.1 Pregnancy is associated with a high level of physiological stress and associated altered hemodynamics, which can aggravate underlying cardiac disease or manifest new maladies in those who are otherwise compensated but have suboptimal baseline cardiovascular status. Among the various cardiovascular abnormalities associated with pregnancy is a predisposition to new‐onset or deterioration of preexisting cardiomyopathy. The progression of pregnancy is accompanied by hemodynamic demands on the maternal cardiovascular system that increase the risk for complications in women with limited cardiovascular reserve. In pregnancy, the circulating blood volume markedly increases, leading to an increase in stroke volume and, in turn, cardiac output by 30% to 50%. These physiologic changes are further exaggerated as the pregnancy progresses to the third trimester, in labor, and in delivery and the postpartum period, which are all points of heightened risk for heart failure.

Maternal mortality in the United States is on the rise. In part this is related to a rise in cardiac disease in pregnancy, including an escalation in the incidence of cardiomyopathy by over 18% from 2003 to 2012.2 Correlates of cardiac disease in pregnancy are race, access to care, and a rise in preeclampsia or other hypertensive syndromes of pregnancy by 6‐fold. Furthermore, black women have a higher maternal mortality compared with white women.1 The prevalence of women with cardiac disease delivering babies has increased by 24% and complications in such pregnancies by 18% in the past decade.2 This is attributable to more women with cardiomyopathy and pulmonary hypertension choosing pregnancy.

Heart failure (HF) remains the most common complication among all women with heart disease regardless of the cause (eg, valvular or congenital heart disease, pulmonary hypertension, and cardiomyopathy).3 The prevalence of pregnant women who present with HF has increased from 2001 to 2011, particularly in the postpartum period.4 HF places pregnant women at high risk for preterm labor and delivery, admission to an intensive care unit, respiratory failure, arrhythmias, and maternal death. Babies born to women with HF are at risk for prematurity, fetal death, small‐for‐gestational‐age status, infant respiratory distress syndrome, and fetal and neonatal death.5

Increases in pregnant women with cardiomyopathy and pulmonary hypertension is alarming, since both are considered World Health Organization class III or IV pregnancy risk classification (pregnancy confers a significantly elevated risk of maternal mortality and morbidity or is contraindicated altogether). The largest group of women who present with HF are related to cardiomyopathy, in which the risk of adverse cardiovascular events during pregnancy has been notably high at close to 50%.6

The increasing trend for women with heart disease who become pregnant may be related to lack of prepregnancy risk stratification, lack of knowledge by patients and providers, and poor transitions of care between pediatric and adult medical care. Women may not be properly counseled about pregnancy and contraception. Most women often cannot remember ever receiving counseling regarding pregnancy risks or contraception,7 despite this being a class I recommendation by guidelines. Even with adequate medical care, however, some women opt for pregnancy and motherhood as it remains their right. This underscores the need for better clinician education and systems of care to promote safer outcomes in this high‐risk group of patients whose proportions are increasing.

Maternal death is a devastating event. Few clinical scenarios are as shocking as cardiac disease in pregnancy when complications occur. Among pregnant women with HF, in‐hospital mortality rates are more than 30 times more likely to result in an in‐hospital death than the general population, with over 9% of maternal in‐hospital deaths attributable to HF.4 Future strategies to mitigate risk and complications may include creating a greater awareness of heart disease in women of childbearing age and their impact on pregnancy; individualized preconception counseling, or counseling before pregnancy coordinated between maternal fetal medicine and cardiology; better education of cardiovascular clinicians for issues related to pregnancy, individualized prepregnancy, or pregnancy risk stratification; meticulous pregnancy follow‐up with maternal fetal medicine and cardiology departments; and a multidisciplinary approach to labor and delivery, coordinated between cardiology, maternal fetal medicine, obstetrical anesthesiology, neonatology, and nursing departments at centers experienced in high‐risk deliveries (Figure). These approaches hold promise in changing outcomes for mothers and their babies, as most complications may be preventable. Moreover, increased opportunities for collaboration between cardiologists and obstetrician‐gynecologists during training phases of the physicians’ career are required; however, such training exposure is lacking in most cardiology fellowship programs. Formalizing this requirement is critical to education. Research and collaboration are further opportunities to improve the quality of care in these special populations.

Figure 1

Transitions of care in pregnant women with cardiac disease.

Getting women through pregnancy and delivery is not enough as most cardiovascular mortalities occur within the first month postpartum and are related to undiagnosed cardiomyopathies. Discontinuation in health insurance is high in the postpartum periods, as many women have public insurance for the pregnancy only. Loss of healthcare coverage is a barrier to postpartum follow‐up and treatment. Most practices in the United States offer a single follow‐up visit at ≈6 weeks postdischarge from delivery. These patients require more, not less, close monitoring in the postpartum period. Emphasizing systems‐based approaches with transitions of care teams and close follow‐up soon after delivery should be performed in pregnant patients with heart disease. Index hospital cardiac complications, clinical characteristics, and demographics could easily be screened for, which represent an opportunity for identification of patients who need close tracking in the postpartum period to avoid complications. A multidisciplinary team, inclusive of cardiology, obstetrics/gynecology, and primary care should be closely involved with following patients early in the postpartum period, as most complications occur in 1 to 4 weeks postpartum. Increases in provider flexibility may increase the likelihood that patients will maintain follow‐up and utilize essential postpartum services. We owe this to our mothers, their children, their partners, their parents, and all the other people they touch every day.

Disclosures

Butler has received research support from the National Institutes of Health, Patient‐Centered Outcomes Research Institute, and the European Union and is on the Speakers’ Bureau for Novartis, Janssen, and Novo Nordisk. He serves as a consultant for Abbott, Adrenomed, Amgen, Array, Astra Zeneca, Bayer, BerlinCures, Boehringer Ingelheim, Bristol‐Myers Squibb, Cardiocell, Corvidia, CVRx, G3 Pharmaceutical, Innolife, Janssen, Lantheus, LinaNova, Luitpold, Medscape, Medtronic, Merck, Novartis, NovoNordisk, Relypsa, Roche, Sanofi, StealthPeptide, SC Pharma, V‐Wave Limited, Vifor, and ZS Pharma. The remaining authors have no disclosures to report.