Preventing Deaths from Cardiovascular Complications During and After Pregnancy

Interview conducted by Laura DeStefano 

The United States has one of the highest maternal mortality rates among developed nations, and a large portion of those deaths arise from cardiovascular complications. A new report from the National Academies reveals some surprising facts: more than half of maternal deaths occur in the year after the birth, and more than three-quarters of pregnancy-related cardiovascular deaths are potentially preventable. 

We spoke with Michelle Debbink, MD, PhD, an NAM fellow and maternal-fetal medicine specialist based in Utah who contributed to the report. Debbink explains the physiology behind pregnancy-related cardiovascular strain, what pregnancy complications can reveal about a person’s long-term health, and how gaps in the US health care system contribute to preventable maternal deaths. 

This interview has been edited for length and clarity.

Why does pregnancy cause cardiovascular strain?  

A lot of people don’t realize that the cardiovascular impacts of pregnancy can start very early in the first trimester. Your blood volume continues to increase up until weeks 32-34 of pregnancy, which means your heart is working harder to move more blood around your body, and to get enough blood flow to the uterus. Because of the extra volume and extra work, there can be a stretch or strain on the heart. There can be arrhythmias where the heart is not beating at a normal rate or rhythm, or there can be damage to the cardiac muscle.  

One of the other changes that happens in pregnancy is your peripheral blood pressure (the pressure in your arms and legs) is supposed to drop substantially. So, even though the heart is working harder, it’s easier work. The pipes are more open. But if you have high blood pressure or a vascular problem that means your body can’t respond to those pregnancy signals as well, and your peripheral blood pressure stays high, you’ve got a heart that is working harder against pipes that are less open.

Preeclampsia is one of the major cardiovascular complications in pregnancy. Can you explain what that is?  

Preeclampsia is a disease that’s caused by the placenta. It is unique to pregnancy. We don’t understand exactly how it develops, but hormones released by the placenta play a role in making your blood pressure go up, and that creates downstream consequences for other organs, including the kidneys, liver, and lungs. It also causes something called capillary leak, which means the tiniest blood vessels where the arteries and veins connect start to leak plasma and proteins. When that happens, the surrounding organs can get “waterlogged,” if you will. An example of this is pulmonary edema, which means “water on the lungs.” There can also be consequences for the brain with preeclampsia, including seizures and stroke. But the most common neurologic symptom people report is an unrelenting severe headache, sometimes with vision changes. 

Does the health of the male partner play a role? Can I blame my husband because I got preeclampsia? 

While the male partner’s health may not directly play a role, there are some interesting data around the male partner’s contribution to pregnancy, placental function, and adverse pregnancy outcomes. For example, if someone has had several pregnancies with one partner, and then they have a pregnancy with a new partner, their risk for preeclampsia changes and can look more like the risk profile for a first pregnancy.  

We do see some placental function as being primarily driven by the male contribution to the pregnancy. But the relationship between male health and cardiovascular problems in pregnancy is not really well understood. It’s certainly worth investigating. 

What are other possible cardiovascular complications in pregnancy? 

Preeclampsia exists on a spectrum that also includes gestational hypertension, HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets), and eclampsia (which is when preeclampsia has progressed to causing seizures). In addition, changes in pregnancy can induce heart failure, most often as a result of peripartum cardiomyopathy, which is heart failure that starts abruptly during pregnancy (often near the end) or soon after delivery. You can have a stroke, either from preeclampsia or from blood clots in your legs or lungs. Patients can also experience dissections – tears in their arteries – especially in the setting of high blood pressure. 

Can these complications be prevented?  

Many of them can be, through close attention to symptoms, especially blood pressure. The challenge is that many of the symptoms of heart failure, for instance, can overlap really closely with the symptoms of pregnancy – shortness of breath, trouble sleeping, swelling in your feet. So, providers need to have a high index of suspicion to make sure that the symptoms someone’s reporting are not blown off but really interrogated to make sure they aren’t cardiac related. 

Why do so many deaths occur in the postpartum period? It seems counterintuitive because the additional strain on the body is gone. 

Deaths in the postpartum period are less related to physiology, or ongoing changes in how the body works due to pregnancy, and more related to problems with care coordination or loss of care due to lack of coverage, unreliable transportation, or other factors. People with risk factors for cardiovascular problems, or who have pregnancy-related conditions that increase their risk for cardiovascular problems, often have access to stabilizing care around the time of pregnancy and delivery. However, after pregnancy, they can lose coverage, which interrupts continuity of care. 

Pregnancy and delivery create a big strain on the body, and patients need eyes on them a little bit more during that first year postpartum, especially if they have developed a hypertensive disorder of pregnancy (the spectrum of diseases related to preeclampsia) or have underlying risk factors for cardiovascular disease (such as diabetes or chronic hypertension).  

We as obstetric clinicians need to do a much better job with warm handoffs between patients with risk factors for cardiovascular disease and primary care providers or other clinicians who can take care of them throughout that first year postpartum. When patients don’t have follow-up and their blood pressure remains high or not treated, or they have an underlying risk factor for heart failure or stroke that goes untreated, that’s when we can see deaths in the postpartum period. 

Are there implications for health more than 1 year postpartum?  

There are some really good emerging data that indicate that for folks who have preeclampsia, lifelong risk is elevated for heart attack, stroke, and other cardiovascular issues. While the way we assess and study risk for pregnancy-related death ends around 1one year postpartum , the risk for lifelong cardiovascular disease does not. 

We need to do a better job of teaching our clinicians that these kinds of health problems in pregnancy are important throughout someone’s life and make sure they’re getting screenings on time, or sometimes earlier or more frequently than a person who has not had these pregnancy related disorders. Screenings can reduce risk for poor cardiovascular outcomes. 

What advice do you have for people concerned about their cardiovascular risk? 

It depends on where you are in your reproductive life. If you’ve never had a pregnancy, it can be hard to predict whether you’ll have a complication. For people who start pregnancy with risk factors, like type 2 diabetes or high blood pressure, I recommend chatting with a high-risk obstetrician to discuss how to mitigate your risks. Just at baseline, the best way to mitigate your risks is to have good control over your existing health conditions. The better controlled they are, the safer a pregnancy will be. If you have a family history of heart disease, early cardiac deaths, or other cardiovascular problems, it’s important that your obstetric clinicians know about that as well. 

If you’re pregnant already and concerned that you may be experiencing cardiovascular issues, you can advocate for yourself or ask someone to advocate for you. Say to your doctor, “I just want to be sure we’re not missing something going on with my heart or blood pressure. Can we talk this through in a little more detail?”  

If you’re postpartum and contemplating another pregnancy, check in with your regular physician or obstetrician to make sure your body is recovering well from pregnancy. Make sure your future providers are aware of your history when you begin your next pregnancy, especially if you experienced complications like preeclampsia or gestational diabetes. 

If you’re postpartum with cardiovascular risk factors and not planning another pregnancy, keep a really close eye on any cardiac-related symptoms and monitor your blood pressure throughout your life. That doesn’t necessarily mean checking twice a day, but checking it once a month or twice a quarter might help you to identify a potential problem earlier because high blood pressure can be a silent problem until it is very high. You can even just stop at Walgreen’s and put your arm in the automated blood pressure cuff. To the extent that you are able, maintain good contact with a primary care clinician to ensure you have the needed screenings, and always have a low threshold for checking with your doctor if something feels off with your health.  

What does good preventive care look like? What is the state of things now, and where do we want to be? 

The state we’re in now is generally one of highly fragmented care. Many people pregnant for the first time are young adults who haven’t visited a doctor since they last saw their pediatrician. Ensuring that people have access to care throughout their life course can help uncover risk factors like high blood pressure or type 2 diabetes that can be managed prior to pregnancy. 

Fragmentation after pregnancy is also really problematic. A lot of clinicians don’t receive training or education about how pregnancy-related conditions can increase risk for non-pregnancy-related conditions. For example, gestational diabetes is a risk factor for type 2 diabetes. About half of people with gestational diabetes will end up with type 2 diabetes within 10 years. We need to do a better job communicating about this within the health care community.  

Other contributors to fragmentation are the lack of access to health care or health insurance that many people have, and when information doesn’t carry over when people move between health systems or providers.  We end up with a “Swiss cheese” approach to post-pregnancy care.  

In an ideal world, everyone would have access to preventive care follow-ups after each pregnancy for at least 12 months postpartum, but ideally throughout their reproductive life and beyond. All of their clinicians would know what their risk factors are and how those contribute to lifelong health. Comorbidities like diabetes or high blood pressure would be optimized going into any future pregnancy, and access to the needed tools, medications, support, and care coordination to make that happen would be universally available. Care coordination across systems and across geography would be a lot tighter, so that patients don’t have to repeat their histories all the time. Some of these diagnoses are really nuanced and asking patients to hold all of that can be really challenging when they are also living their lives, taking care of families, jobs, school, and all of the other things we take care of in our lives. 

How can we get closer to the ideal state of preventive care? 

We need to increase education for clinicians and make system changes that allow them to spend as much time as they need with someone who has risk factors going into pregnancy or cardiovascular morbidity (illnesses) in pregnancy. In particular, the National Academies report recommends a focus on increasing capacity within federally qualified health centers to allow for continuity of care. An obvious piece of this puzzle is to increase access to healthcare and decrease barriers to how people use health care, follow up with their providers, and receive treatment for risk factors.  

Obstetrician-gynecologists and maternal fetal medicine doctors need to take responsibility and accountability for handoffs in the postpartum period to ensure that high-risk patients get seen by cardiologists or internal medicine specialists as needed. We could also do a better job of utilizing telehealth to reach people in rural areas or even people in urban areas who may be working multiple jobs,lack reliable transportation, or don’t have childcare support. Systems– level changes are needed to improve our ability to help provide the depth and continuity of care that would create an ideal preventive care landscape to reduce pregnancy-related cardiac deaths. 

Nearly every state in the country has passed 12-month postpartum Medicaid coverage – an increase from 60 days. Could this help to address some of the fragmentation? 

Absolutely. I had a patient with type 1 diabetes who ended up in the ICU in the first trimester of her pregnancy due to very low blood sugars. Unfortunately, she experienced a pregnancy loss, but because Medicaid coverage was extended for 12 months from the end of her pregnancy, she was able to see an endocrinologist and start getting care for her diabetes, which will improve her health going into her next pregnancy as well as her lifelong health. We have anecdotal evidence and also emerging demographic and epidemiologic evidence that postpartum Medicaid expansions are helpful.

Can the United States learn from other countries that are outperforming us in terms of maternal health outcomes? 

Well, comparative research on this issue is actually kind of challenging because other high-income countries have completely different health systems. The vast majority have universal, or nearly universal, health care access. On a foundational level, that’s such a different playing field that porting over another country’s programs wouldn’t necessarily achieve the same outcomes. That said, we desperately need coordinated research efforts to better understand the most effective models for interventions and implementation in the United States.

Download and read the full report.

Laura DeStefano is the Director of Strategic Communications & Engagement at the National Academy of Medicine and a science communicator.