ACOG Releases Comprehensive Guidance on How to Treat the Leading Cause of U.S. Maternal Deaths: Heart Disease in Pregnancy

May 3, 2019

Washington, D.C. – Today, the American College of Obstetricians and Gynecologists (ACOG) released comprehensive guidance on pregnancy and heart disease. In the United States, cardiovascular disease (CVD) is now the leading cause of death in pregnancy and the postpartum period. It constitutes 26.5% of pregnancy-related deaths, with higher rates of mortality among women of color and women with lower incomes. 

The Practice Bulletin, Pregnancy and Heart Disease, is the product of a task force convened and led by ACOG President Lisa Hollier, M.D., M.P.H., aimed at addressing cardiac contributors to maternal mortality. The guidance outlines screening, diagnosis, and management of CVD for women from prepregnancy to postpartum. 

In addition to preexisting cardiac conditions, the Practice Bulletin also addresses acquired heart conditions, which are by far the most common and can develop silently and acutely during or after pregnancy. Currently, peripartum cardiomyopathy, a disease affecting the heart muscle, is the leading cause of maternal deaths, accounting for 23% of deaths in the late postpartum period.

“The rise we’re seeing in maternal deaths is largely due to acquired cardiac disease in pregnancy,” said Hollier. “Most of these deaths are preventable, but we are missing opportunities to identify risk factors prior to pregnancy and there are often delays in recognizing symptoms during pregnancy and postpartum, particularly for black women. The new guidance clearly delineates between common signs and symptoms of normal pregnancy versus those that are abnormal and indicative 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 risk factors for CVD-related mortality include race and ethnicity, age, hypertension during pregnancy, and obesity. However, according to the data, the leading factor is race. Black women’s risk of dying from CVD is 3.4 times higher than that of white women. This disparity is due, in part, to racial bias and overt racism that exists in the provision of health care and in health system processes. The greatest health disparities in the management of CVD for black women usually exist prior to pregnancy when risk factors are not identified. 

Included in the new Practice Bulletin is ACOG’s recommendation that all women be assessed for CVD in the prenatal and postpartum period using the California CVD Tool Kit algorithm. According to what California learned from its experience with their mothers, 88% of women who died would have been identified as high risk requiring further evaluation and referral had this new screening algorithm been used.

“Pregnancy is a natural stress test,” said James Martin, M.D., chair of the Pregnancy and Heart Disease Task Force. “The cardiovascular system must undergo major changes to its structure to sustain tremendous increases in blood volume. That’s why it is critical to identify the risk factors beforehand, so that a woman’s 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. Moreover, we must think of heart disease as a possibility in every pregnant or postpartum patient we see to detect and treat at-risk mothers.” 

Women with known heart disease should see a cardiologist prior to pregnancy and receive pre-pregnancy counseling. Patients determined to have moderate and high-risk CVD 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.

The Practice Bulletin states that the postpartum period is a time of increased risk for cardiovascular disease related complications. The elevated risk is both in the immediate period and can extends from six months to a year. A follow-up visit with a primary care clinician or cardiologist should occur within seven to 10 days for all women with hypertensive disorders and seven to 14 days for all women with heart disease or cardiovascular disorders.  

“It is crucial for these women to have a longer-term care plan,” said Hollier. “So, we also recommend a comprehensive, cardiovascular postpartum visit at the three-month mark, at which time the clinician and patient can discuss collaborative plans for yearly follow-up and future pregnancy intentions. Our maternity care payment models must provide coverage for these additional visits. Currently, many women are going home and taking excellent care of their babies, but how are we demonstrating that we’re taking care of them? It is our job to make sure our clinical practices, policies, and systems reflect our commitment to the health and well-being of the moms in this country.”

Practice Bulletin 212, Pregnancy and Heart Disease, is published in the May edition of Obstetrics & Gynecology.

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Other recommendations issued in the May edition of Obstetrics & Gynecology

Committee Opinion 778, Newborn Screening and the Role of the Obstetrician–Gynecologist

Newborn screening is the largest genetic screening program in the United States, with approximately 4 million infants screened annually. Newborn screening is a mandatory state-based public health program that provides all newborns in the United States with testing and necessary follow-up health care for a variety of medical conditions. The goal of this public health program is to decrease morbidity and mortality by screening for disorders in which early intervention will improve neonatal and long-term health outcomes. The program’s functions include the initial screening of all newborns, identifying screen-positive newborns, diagnosing conditions, communicating with families, ensuring that affected children are referred to treatment centers, following up with long-term outcomes, and educating physicians and the public according to individual state or jurisdictional guidelines. All states and the District of Columbia have newborn screening programs with varying screening panels, policies, statutes, and regulations. Most programs have adopted the guidelines suggested by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children. Obstetrician–gynecologists and other obstetric care providers should make resources about newborn screening available to patients during pregnancy. Providing newborn screening information during prenatal care visits can be accomplished in several ways and should be adapted to individual practice style. Integrating education about newborn screening into prenatal care allows parents to be prepared for having their child undergo screening as well as for receiving newborn screening test results. This document includes updated information on the Recommended Uniform Screening Panel (RUSP) and recommendations for incorporating newborn screening into obstetric practice.

Practice Bulletin 211, Critical Care in Pregnancy
Critical care in pregnancy relies predominantly on recommendations from nonpregnant adult critical care with only limited research available for obstetric critical care specifically. The purpose of this document is to review available evidence, propose strategies for obstetric-related critical care, and highlight the need for additional research. Much of the review will, of necessity, focus on general principles of critical care, extrapolating when possible to critical care in pregnancy and the puerperium. This Practice Bulletin is updated to include information about unique issues to pregnancy when conditions such as sepsis or acute respiratory distress syndrome (ARDS) are encountered and the obstetrician’s role in the management of the critically ill pregnant woman, which is dependent upon the care setting and the intensive care unit (ICU) model used. The role of the tele-intensive care unit in the care of critically ill pregnant women also is explored.

The American College of Obstetricians and Gynecologists (ACOG) is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. www.acog.org