Research Paper

Navya Krishna
Independent Research I
2018-2019
Mortality from cardiovascular events during pregnancy and postpartum

Pregnancy ensures the continuation of mammals on this planet. Though humanity depends

on women having children, pregnancy brings its own life-threatening risks for both the woman

and the fetus. Physicians are becoming aware of the increasing maternal mortality rate in the

United States, especially due to cardiovascular disease. Hence, prompt assessment of concerning

symptoms has become essential in the effort to decrease mortality from cardiovascular disease in

pregnant and postpartum women.

Pregnancy stresses the heart and puts women at risk of cardiovascular disease. There is "a

deterioration in both contractile and relaxation capacity of the myocardium" (Zentner et al., 2009,

pg. 6) in the resting state during pregnancy. This impairment in maternal heart function is mainly

due to the high oxygen and energy demands, and resulting increased cardiac output, of the fetus,

and it may be dangerous for the woman. Not only can cardiovascular disease complicate

pregnancy, but “insufficient maternal cardiovascular adaptation to pregnancy is a contributing

factor to...complications such as pre-eclampsia and intrauterine fetal growth” (Flo et al., 2010, pg.

6). Pregnancy complications within the heart can extend beyond immediate effects to other chronic

life-threatening issues. There are also different ways that pregnancy and cardiovascular disease are

related. Some patients have a pre-existing cardiovascular disease, such as a congenital heart

disease. Cardiologists know to observe these women very closely, especially because pregnancy

is known to exacerbate these diseases and the risk of mortality is more commonly known. Women

with pre-existing heart conditions are more often warned about the cardiovascular risks associated

with their pregnancies, so they can be better prepared. Some

 Krishna 2

women have had heart-related problems with previous pregnancies. These women, along with their

physicians, are also aware of the cardiac risks of subsequent pregnancies, as they know which

symptoms to look out for and they are more aware of how to reduce their risk of mortality. The

group who are most at risk of mortality from cardiovascular disease is women with cardiac events

caused by pregnancy, but with no history of any type of cardiac incident. The risk of mortality

from these cardiovascular diseases is prevalent for all pregnant women, but some of those women

are more at risk than others.

Postpartum, the recovery period after a pregnancy, is a critical time during which these

women have to be monitored regularly by cardiologists for lingering cardiovascular risk. The heart

does not recover immediately from pregnancy, so there is still a chance of cardiovascular events

postpartum. Cardiologists should continue to observe women because a study found that 1/10

women with a congenital heart disease had a late cardiac event after pregnancy, of which

arrhythmias and heart failure are the most common (Balint et al., 2010, pg. 3). The physiological

changes that occur during pregnancy don’t go away immediately after labor. In fact, “stroke

volume, heart rate, and cardiac output increase, whereas peripheral vascular resistance and

hemoglobin decrease. All changes occur slowly...normalizing only weeks after delivery” (Roos-

Hesselink & Stein, 2017, pg. 1). All the cardiovascular problems encountered by women during

pregnancy pose significant risks postpartum. To minimize these risks, “post-partum follow-up

is...important to assess for deterioration following pregnancy and to monitor for peripartum

cardiomyopathy, which can occur late in the post-partum period” (Ashrafi & Curtis, 2017, pg. 12-

13). Knowing to extend observation can help save lives, so physicians should be educated in proper

prenatal care, especially when looking out for cardiovascular diseases.

 Krishna 3

The United States has a problem of rising maternal mortality, particularly from

cardiovascular disease. Other developed countries, however, do not seem to have the same

problem.

Maternal mortality in the United States is increasing, but not in other developed countries.

Data on maternal mortality is collected by individual states, so most national statistics are based

on analysis of state statistics. Researchers often run into problems with state data because data

collection methods vary among states and it is hard to tell the accuracy of the record keeping in

some states. However, some people have been able find national trends, all of which show an

increase in U.S. maternal mortality. In fact, researchers conducted a study using the data of 48

states and Washington D.C. which showed an “increase in the estimated maternal mortality rate

from 18.8 in 2000 to 23.8 in 2014 – a 26.6% increase” (MacDorman et al., 2016, pg. 7). Trends in

maternal mortality data, adjusted for varying data collection methods, show that the rate of

maternal mortality in the United States has risen recently, making it a problem seriously worth

addressing. Unless serious action is taken to reduce the rate of maternal mortality, it will continue

rise into the future. There needs to be a concentrated effort to identify specific solutions to this

problem because any rate of maternal mortality is too high, particularly a rising rate of maternal

mortality. In comparison to many other countries, the United States maternal mortality rate is

especially high. Not only does the U.S. have a rate of maternal mortality that is high enough that

it must be addressed, but other developed countries have figured out how to maintain a relatively

low rate of maternal mortality. Studies show that “between 1990 and 2013, the maternal mortality

ratio for the USA more than doubled from an estimated 12 to 28 maternal deaths per 100, 000

births and the country has now a higher ratio

 Krishna 4

than those reported for most high-income countries” (Agrawal, 2015, pg. 1). Since people in the

United States have a similar quality of life to people in other developed countries, the main cause

of this problem is not necessarily an issue like poor sanitation or disease. Not only does the United

States have a maternal mortality rate that is higher than other high-income countries, but “the

global maternal mortality ratio decreased from 385 deaths per 100 000 livebirths (80% UI 359–

427) in 1990, to 216 (207–249) in 2015, corresponding to a 43.9% (34.0–48.7) decline and an

annual continuous rate of reduction of 2·3% (1.7–2.7...)” (Alknema et al., 2015, pg. 6). Because

the rate of maternal mortality is decreasing in the rest of the world overall, this issue is not a global

problem. A recent upward trend in maternal mortality in the United States and a global downward

trend indicate that this issue has a solution. By examining international healthcare, a solution to

the increasing maternal mortality in the United States may be found. Some experts claim that the

United States maternal mortality is unique compared to the other developed countries particularly

because of its health care system. A cardiologist with experience in addressing maternal mortality

says that many women die in the United States from pregnancy-related complications because they

did not have thorough and regular access to prenatal care until very late in their pregnancy. (E.

Foster, personal communication, December 12, 2018). If more women in the U.S. have better

access to improved health care, like women in other developed countries with universal health

care, then those women significantly reduce their risk of mortality from complications associated

with pregnancy.

Cardiovascular disease is a major cause of maternal mortality. Because of the

cardiovascular risk that pregnancy poses to women, mortality from cardiovascular disease is a

problem that must be addressed. Research reveals that “in developed Western countries, heart
 Krishna 5

disease in pregnancy (HDP)...is the most frequent cause of maternal death” (Alatawi, 2016, pg. 2).

The United States is one such developed Western country where cardiovascular disease is a major

cause of maternal death. This may occur because the causes of maternal mortality in less developed

countries have been eliminated in more developed countries, but if cardiovascular disease is still a

problem, then addressing it is key to decreasing overall maternal mortality. Heart disease is hard

to diagnose during pregnancy because many symptoms of heart failure are also normal pregnancy

symptoms, so it is sometimes hard to tell which applies. Not only is cardiovascular disease a

current issue, it will be an even bigger problem in the future if no one takes action to mitigate it.

Studies show that “during 2006–2010, the contribution of traditional causes of pregnancy-related

deaths (hemorrhage, hypertensive disorders of pregnancy, embolism) continued to decline,

whereas that of cardiovascular conditions, including cardiomyopathy, increased to 26.4% of

pregnancy-related deaths” (Creanga et al., 2015, pg. 7). Surface-level problems that contribute to

maternal mortality are being confronted and consequently subdued, but underlying conditions such

as cardiovascular disease still linger and are actually increasing in prevalence. Cardiovascular

diseases are, in fact, a cause of some of the more traditional causes of pregnancy-related death

such as pre-eclampsia and hypertension. If those disease are treated, then other pregnancy-related

conditions linked to cardiovascular disease may be controlled. Cardiovascular diseases, both

caused by pregnancy and independent of pregnancy, must be prevented or diagnosed early and

treated if the U.S. has any hope of reducing maternal mortality.

Maternal mortality is a problem in the United States, a problem that must be addressed. A

major contributor to this problem is cardiovascular disease during pregnancy and postpartum, and

eliminating, or working to eliminate, this factor can decrease overall mortality.

 Krishna 6

Improving the quality of healthcare for pregnant and postpartum women is an effective

way to reduce maternal mortality in the United States. Based on previous efforts to decrease the

rate of maternal mortality, there is a solution that has been proven to be successful.

Better education of physicians in the diagnosis and care of cardiovascular disease during

pregnancy and postpartum must be enacted to solve this problem. Cardiovascular disease during

pregnancy can have dire implications, but catching it early is the best way to prevent pregnancy-

related death. Experts agree that “prompt assessment of the maternal-fetal unit and initiation of

appropriate management are essential for the survival of both patients...Specialty services must be

consulted early in the process. With a basic knowledge of the changes that occur in pregnancy,

appropriate treatments can be instituted, and two lives may be saved.” (Campbell & Sanson, 2007,

pg. 1) Improving prenatal care for more women is the key to saving their lives, as well as the lives

of their fetuses. A movement to change the administration of health care can go a long way to

ensuring the survival of more women. One reason that cardiovascular disease is a leading cause of

death both during pregnancy and postpartum is that some women don’t receive the appropriate

health care. In some cases, “maternal cardiac disease has the potential to remain undiagnosed

during pregnancy, but presentation often occurs after 20 weeks gestation and frequently at the time

of delivery or immediately post-partum. This is most likely to happen in women who have avoided,

or not presented for, antenatal care” (Burt & Durbridge, 2009, pg. 1). It is important for women

with cardiac diseases to be observed regularly so that the appropriate treatments can be

administered and so that a cardiologist can be consulted before the cardiovascular complications

cause lasting damage. Catching a heart condition before it happens so that it can be prevented is

the best way to save the life of the woman, therefore reducing
 Krishna 7

overall maternal mortality, particularly from cardiovascular disease.

People have made efforts in the past, and efforts are continuing to be made, to reduce

maternal mortality in the United States. The solution of improving prenatal care in order to

decrease the prevalence of cardiovascular disease in pregnant and postpartum women is feasible

because it has been done successfully before. One example is when “California...made concerted

efforts to reduce maternal mortality, including initiating a statewide pregnancy-associated

mortality review in 2006, and contracting with the California Maternal Quality Care Collaborative

to investigate primary causes of maternal death...and implemented quality improvement initiatives

throughout the state. These efforts appear to have helped reduce maternal mortality in California”

(MacDorman et al., 2016, pg. 7) This proposed solution can be effective, and this effort is proof.

The aim of the solution implemented in California was to educate physicians in the difference

between pregnancy and cardiovascular disease symptoms and more efficient procedures so women

can be evaluated before they have a cardiovascular event (Hameed et al., 2017, pg. 1) When this

solution was implemented in California, it decreased California maternal mortality, so this solution

could work in other states as well. Not only are the actions taken in California proof that this

solution is realistic, but they show that this problem is worth addressing, as it has been addressed

in the not too distant past. Recently, there has also been a national effort to reduce maternal

mortality. The federal government has vowed “to support States in their work to save and sustain

the health of mothers during pregnancy, childbirth, and in the postpartum period, to eliminate

disparities in maternal health outcomes for pregnancy-related and pregnancy-associated deaths,

[and] to identify solutions to improve health care quality and health outcomes for mothers, and for

other purposes” (H.R.1318 - Preventing

 Krishna 8

Maternal Deaths Act of 2018). If any state, or even just a group of people, wanted to tackle this

issue, they would likely have the support of the national government. This not only ensures that

the measures taken will be permitted by the government and thus likely to last for a prolonged

amount of time, but that a small effort would have the potential to spread to other parts of the

country as well. Because of its success in the past, this type of solution to decreasing maternal

mortality in the U.S. is the best solution.

The best solution to the rising maternal mortality in the U.S. is better education of

physicians and subsequent improved prenatal care. This has worked in the past, so it will very

likely work if tried in another state.

The education of physicians and prompt assessment of cardiovascular disease in pregnant

women is the best way to reduce maternal mortality. This is especially a problem in the United

States, where maternal mortality is increasing. Action must be taken to alleviate this alarming issue

because lives are at stake.

 Research Paper
Navya Krishna
Independent Research I
2018-2019
Works Cited
Agrawal, P. (2015). Maternal mortality and morbidity in the United States of America. Bull
World Health Organ, 135. https://doi.org/10.2471/BLT.14.148627
Alatawi, F. O. (2016). Heart disease during pregnancy in the KSA: A suggested plan. Journal of
Taibah University Medical Sciences, 11(5), 405-412.
https://doi.org/10.1016/j.jtumed.2016.06.004
Alkema, L., Chou, D., Hogan, D., Zhang, S., Moller, A.-B., Gemmill, A., . . . Say, L. (2016).
Global, regional, and national levels and trends in maternal mortality between 1990 and
2015, with scenario-based projections to 2030: A systematic analysis by the UN Maternal
Mortality Estimation Inter-Agency Group. The Lancet, 387(10017), 462-474.
https://doi.org/10.1016/S0140-6736(15)00838-7
Ashrafi, R., & Curtis, S. L. (2017). Heart disease and pregnancy. Cardiol Ther, 157-173.
https://doi.org/10.1007/s40119-017-0096-4
Balint, O. H., Siu, S. C., Mason, J., Grewal, J., Wald, R., Oechslin, E. N., . . . Silversides, C. K.
(2010). Cardiac outcomes after pregnancy in women with congenital heart disease. Heart,
96(20), 1656-1661. https://doi.org/10.1136/hrt.2010.202838
Burt, C. C., & Durbridge, J. (2009). Management of cardiac disease in pregnancy. Continuing
Education in Anesthesia, Critical Care & Pain, 9(2), 44-47.
https://doi.org/10.1093/bjaceaccp/mkp005v
Campbell, T. A., & Sanson, T. G. (2009). Cardiac arrest and pregnancy. Journal of Emergencies,
Trauma, and Shock, 2(1). https://doi.org/10.4103/0974-2700.43586
Creanga, A. A., Berg, C. J., Syverson, C., Seed, K., Bruce, F. C., & Callaghan, W. M. (2015).
Pregnancy-related mortality in the United States, 2006–2010. Obstetrics & Gynecology,
125(1), 5-12. https://doi.org/10.1097/AOG.0000000000000564
Flo, K., Wilsgaard, T., Vårtun, Å., & Acharya, G. (2010). A longitudinal study of the
relationship between maternal cardiac output measured by impedance cardiography and
uterine artery blood flow in the second half of pregnancy. BJOG an International Journal
of Obstetrics and Gynaecology, 117(7), 837-844. https://doi.org/10.1111/j.1471-
0528.2010.02548.x
Hameed, A., Foster, E., Main, E., Khandelwal, A., & Lawton, E. (2017). Cardiovascular disease
assessment in pregnant and postpartum women. Cardiovascular Disease Pregnancy and
Postpartum Toolkit, 7-12.
H.R.1318 - Preventing Maternal Deaths Act of 2018. (2018, December 21). Retrieved January
14, 2019, from congress.gov website:https://www.congress.gov/bill/115th-
congress/house-bill/1318/text
MacDorman, M. F., Declercq, E., Cabral, H., & Morton, C. (2016). Is the United States maternal
mortality rate increasing? Disentangling trends from measurement issues. Obstet
Gynecol, 128(3), 447-455. https://doi.org/10.1097/AOG.0000000000001556
Roos-Hesselink, J. W., & Stein, J. I. (2017). Pregnancy and cardiac disease. Rev Esp Cardiol,
70(2), 78-80. https://doi.org/10.1016/j.rec.2016.08.002
Zentner, D., du Plessis, M., Brennecke, S., Wong, J., Grigg, L., & Harrap, S. B. (2009).
Deterioration in cardiac systolic and diastolic function late in normal human pregnancy.
Clinical Science, 116(7), 599-606. https://doi.org/10.1042/CS20080142