Better CV management could improve pregnancy-related mortality
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CVD is the leading cause of maternal deaths in the U.S., contributing to a more than twofold increase in pregnancy-related mortality from 1987 to 2015, and better CV management in pregnant women is needed, according to a presenter.
Additionally, Black women experienced a more than threefold greater risk for pregnancy-related mortality compared with white or non-Hispanic women, Renee P. Bullock-Palmer, MD, FACC, FAHA, FASNC, FASE, FSCCT, director of the Women’s Heart Center at the Deborah Heart and Lung Center in Browns Mills, New Jersey, said during a presentation at the American Society for Preventive Cardiology Congress on CVD Prevention.
Bullock-Palmer also detailed some of the most prevalent CVDs afflicting pregnant women and discussed methods for management of each.
“Unfortunately, despite advances in health care in the United States, mortality and morbidity remains significantly higher in the U.S. relative to other developing countries,” Bullock-Palmer said. “Unfortunately, the mortality rate continues to steadily increase and has been increasing over the last 20 years.”
Hypertension management
“Hypertensive disease in pregnancy occurs on average in over 900 individuals per 10,000 delivery hospitalizations and is quite common as a cardiovascular risk factor in pregnancy in this country,” Bullock-Palmer said during the presentation. “Hypertensive disorders of pregnancy are classified in four main categories with preeclampsia and eclampsia having the greatest cardiovascular mortality and morbidity, and this is defined as hypertension above 140/90 [mm Hg] after 20 weeks of gestation and associated with significant proteinuria or other end-organ dysfunction.”
According to the presentation, hypertensive disorders of pregnancy are classified as preeclampsia-eclampsia, gestational hypertension, chronic hypertension and chronic hypertension with superimposed preeclampsia. Women with preeclampsia are at an approximately 71% elevated risk for CVD mortality.
Bullock-Palmer said a multidisciplinary approach to management of hypertensive disorders of pregnancy that includes lifestyle and behavioral modifications may be the most beneficial, and several studies have suggested that exercise during pregnancy my confer improved vascular function.
Among women with high-risk conditions, such as preterm birth at less than 34 weeks and diabetes, low-dose aspirin treatment could be considered and initiated at the end of the first trimester, she said.
Ischemic heart disease management
Ischemic heart disease, although rare, is three to four times more prevalent among pregnant women than nonpregnant women of childbearing age, occurring in 2.8 to 8.1 per 100,000 deliveries, according to the presentation.
“Ischemic heart disease can be due to atherosclerosis, which accounts for less than 50% of these cases, but may sometimes be secondary to coronary artery dissection or myocardial ischemia with nonobstructed coronaries,” Bullock-Palmer said in her presentation.
Among pregnant women with atherosclerotic plaque rupture or coronary thrombosis, PCI with stent implantation should be performed and low-dose aspirin should be initiated after the procedure, she said.
According to the presentation, clopidogrel may be considered for use for the shortest possible durations, but other antiplatelet medications should be avoided.
Management of peripartum cardiomyopathy
Peripartum cardiomyopathy, defined as new-onset cardiomyopathy with left ventricular ejection fraction of less than 45% with no reversible cause toward the end of pregnancy or postpartum, is a significant risk factor for pregnancy-related mortality.
According to the presentation, probable risk factors for peripartum cardiomyopathy include twin pregnancy, high parity, high gravidity, extremes of reproductive age and prolonged tocolysis, but preeclampsia, genetics and obesity may be among other factors involved.
“Treatment is dependent on the stability of the mother,” Bullock-Palmer said during the presentation. “If the patient is stable and their blood pressure is not significantly elevated and they’re not having any significant symptoms, you can actually manage these patients, without medications with very strong sodium fluid restriction and encouraging a mild to moderate degree of exercise.
“If these patients’ blood pressure needs to be controlled or they are symptomatic, then hydralazine, nitrates, beta-blockers and or diuretics may be used,” Bullock-Palmer said in her presentation. “For patients who are unstable, advanced therapies such as inotropic support or vasopressor support may have to be considered. There are times that you may have to determine if urgent delivery of the fetus should be considered to allow these patients to enter the postpartum period where we can then start more appropriate heart failure medications.”
Arrhythmia management
According to the presentation, Black and/or older women experience the greatest risk for arrhythmia hospitalizations during pregnancy.
“Generally speaking, atrial and ventricular ectopy and sinus tachycardia are self-limited and benign and usually do not require pharmacologic treatment. However, complex arrhythmias such as an [atrioventricular nodal reentrant tachycardia], [atrioventricular reentry tachycardia] or atrial flutter sometimes have to be treated with medications, primarily beta-blockers, sometimes more advanced therapies,” Bullock-Palmer said during the presentation. “If beta-blockers are not helping, catheter ablation may have to be considered. For long-term management for patients with ventricular tachycardia, first line is again a beta-blocker, and a second line would be an ICD in cases where the beta-blocker is not helping.”
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Bullock-Palmer RP. Adverse Pregnancy Outcomes and Cardiovascular Risk. Presented at: American Society for Preventive Cardiology Congress on CVD Prevention; July 25-26, 2020 (virtual meeting).
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