Maternal Morbidity - Cardiovascular Disease Resources

The gestational period serves as a natural stress test that can be used to predict future cardiovascular health risks of female patients. Recent evidence confirms that mothers with hypertensive pregnancies have higher cardiovascular disease (CVD) risks compared to other women of similar age. In women with preeclampsia, those delivering before 37 weeks of gestation and mothers with recurring preeclampsia in subsequent pregnancies carry the greater risks. These sex-specific risks are of similar magnitude to traditional CVD risk factors, such as smoking and obesity. Unfortunately, none of the commonly used CVD risk stratification models make use of these sex-specific markers, which can powerfully predict future CVD outcomes. Because women have historically posed a greater diagnostic challenge than men in assessing CVD risks, better models for risk stratification in this sex group are needed. A history of hypertension in pregnancy should be included as a variable in cardiovascular risk stratification. In addition, screening women for a history of preeclampsia should become routine practice, with greater emphasis placed on therapies to modify adverse outcomes for these higher-risk women.

Peripartum cardiomyopathy (PPCM) is a relatively rare idiopathic form of heart failure that affects women during the last months of pregnancy or the first months after delivery. The aetiology and pathophysiological mechanisms of this disease are poorly characterised and incompletely understood. Diagnosis remains a challenge, as PPCM symptoms vary and may mimic those commonly experienced by women during pregnancy and postpartum due to normal physiological changes that occur during this period. The clinical course varies between complete recovery to rapid progression to end stage heart failure and even death. Standard heart failure treatment, with adjustments for women who are pregnant or lactating, is the treatment of choice. Disease specific therapeutic strategies, including prolactin blockade, show promise. National and international registries and collaborative research efforts are warranted to characterise this disease better and to develop novel treatments that can improve outcomes.

Objectives: The purpose of this study was to assess whether African-American women are at increased risk of having peripartum cardiomyopathy. Background: Peripartum cardiomyopathy is a heart disease of unknown cause that affects young women, often with devastating consequences. The frequency of peripartum cardiomyopathy varies markedly between African and non-African regions. Methods: A case-control study was performed at a regional center that provides medical care to a racially heterogeneous population. For each case, 3 healthy control patients were randomly selected who delivered babies within the same month. Results: African-American women had a 15.7-fold higher relative risk of peripartum cardiomyopathy than non–African Americans (odds ratio [OR]: 15.7, 95% confidence interval [CI]: 3.5 to 70.6). Other significant univariate risk factors were hypertension (
OR: 10.8, 95%
CI: 2.6 to 44.4), being unmarried (
OR: 4.2, 95%
CI: 1.4 to 12.3), and having had >2 previous pregnancies (
OR: 2.9, 95%
CI: 1.1 to 7.4). African-American ethnicity remained a significant risk factor for peripartum cardiomyopathy when other risk factors were considered in multivariable (
OR: 31.5, 95%
CI: 3.6 to 277.6) and stratified analyses (
OR: 12.9 to 29.1, p <0.001). Although the frequency of peripartum cardiomyopathy (185 of 100,000 deliveries) at this center was higher than in previous U.S. reports, it was comparable to the frequency in countries with more women of African descent (100 to 980 of 100,000). Analysis of other U.S. studies confirmed that the frequency of peripartum cardiomyopathy was significantly higher among African-American women.

Objective: To examine associations of gravidity and parity with all-cause, cardiovascular disease (CVD), and coronary heart disease (CHD) mortality in postmenopausal women. Design: Prospective cohort study. Setting: Rancho Bernardo, a southern California community. Patient(s): One thousand two hundred ninety-four postmenopausal women ages 50–96 who attended a 1984–87 research clinic visit at which reproductive and medical histories were obtained and who were followed through 2007. Intervention(s): None. Main Outcome Measure(s): All-cause, CVD, CHD, and non-CHD CVD mortality, determined by nosologist-coded death certificates. Result(s): Average baseline age was 70.6
9.2. Numbers of pregnancies ranged from 0 to 13 (median ¼ 2); births ranged from 0 to 11 (median ¼ 2). During a median of 19.3 years of follow-up, 707 women (54.6%) died, with 46.5% attributed to CVD, 20.5% to CHD, and 26.0% to non-CHD CVD. Trend analyses showed inverse associations of gravidity with CVD mortality and non-CHD CVD mortality. Women with four or more pregnancies were less likely than nulligravidas to have fatal CVD (hazard ratio [HR] ¼ 0.63, 95% confidence interval [CI] ¼ 0.40–0.99) and non-CHD CVD (HR ¼ 0.48, 95% CI ¼ 0.26–0.91) independent of age, years postmenopause, obesity, and HDL. Associations increased after the first decade of follow-up. Parity and gravidity were not associated with overall or CHD mortality. Conclusion(s): High gravidity was associated with reduced CVD and non-CHD CVD mortality in postmenopausal women. Protective associations could reflect biological mechanisms that occur with repeated pregnancy or greater social support related to family size among multiparous women.

Gender differences in cardiovascular disease (CVD) occurrence and prevention have been studied extensively during the past two decades.1 It is now widely recognized that women are not diagnosed as effectively or treated as aggressively as men and that with acute coronary syndrome, their symptoms may be very different from those of men.1 Although the major CVD risk factors are generally the same among men and women,2 some studies have suggested a more substantial role for diabetes and hypertension as risk factors in women compared to men.3–5 Moreover, during the last decade, it has become increasingly apparent that four common pregnancy complications, gestational diabetes, hypertensive disorders during pregnancy, low birth weight delivery, and preterm delivery, are significant CVD risk factors.6 In this issue of the Journal of Women’s Health, Making Use of a Natural Stress Test: Pregnancy and Cardiovascular Risk, by Bilhartz et al.,7 advances the idea that the history of a hypertensive disorders in pregnancy should be incorporated into models of CVD risk assessment. The authors review the substantial evidence that women with hypertensive disorders in pregnancy have a risk of developing CVD in later life that is 2–8-fold higher than that of unaffected controls. The review of the literature suggests that this risk varies by the type, time of onset, severity, and frequency of the hypertensive disorders, with women with early onset preeclampsia, severe preeclampsia, preeclampsia with preterm delivery, or recurrent preeclampsia carrying the most elevated risk. The strength of the evidence suggesting the association of hypertensive disorders in pregnancy and CVD is undeniable. The major challenge ahead for clinicians, researchers, and public health professionals, however, is to understand the basis for this association and how it should be incorporated into guidelines and preventive interventions aimed at patients with a history of hypertension in pregnancy.

Objectives To describe changes in characteristics of delivery and postpartum hospitalisations with chronic heart disease from 1995 to 2006. Design Cross-sectional study. Setting USA, nationwide hospital discharge data. Population A total of 47 882 817 delivery hospitalisations and 660 038 postpartum hospitalisations. Methods Adjusted odds ratios describing the associations between chronic maternal heart disease and severe obstetric complications were obtained from multivariable logistic models. The contribution of chronic heart disease to severe morbidity was estimated using adjusted population-attributable fractions. Main outcome measures Prevalence and trends in chronic heart disease, rate and risk of severe obstetric complications. Results In 2004–2006, about 1.4% of delivery hospitalisations were complicated with chronic heart disease. No substantial changes in the overall prevalence of chronic heart disease among hospitalisations for delivery were observed from 1995–1997 to 2004–2006. Even so, a linear increase was found for specific congenital heart disease, cardiac dysrhythmias, and cardiomyopathy and congestive heart failure (P < 0.01). During this same period the rate of postpartum hospitalisations with chronic heart disease tripled (P < 0.01). Severe complications during hospitalisations for delivery among women with chronic heart disease were more common in 2004–2006 than in 1995– 1997. In 2004–2006, 64.5% of the cases of acute myocardial infarction, 57.5% of the instances of cardiac arrest/ventricular fibrillation, 27.8% of in-hospital mortality and 26.0% of the cases of adult respiratory distress syndrome were associated with hospitalisations with chronic heart disease. Conclusions In the USA chronic heart disease among women hospitalised during pregnancy may have increased in severity from 1995 to 2006. Keywords Epidemiology, heart diseases, pregnancy.

OBJECTIVES: To estimate the rate of pregnancy hospitalizations for women with two groups of myocardial disorders, cardiomyopathy and other myocardial disorders, and report the rate of severe obstetric complications among these hospitalizations in delivery and postpartum periods. METHODS: We performed a cross-sectional study using 14,323,731 hospitalizations for pregnancy identified from the 2004–2006 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. We reported rates of pregnancy hospitalizations with cardiomyopathy and other myocardial disorders per 1,000 deliveries and rates of severe complications per 1,000 hospitalizations during delivery and postpartum periods by myocardial disease status. We compared these rates by using
2 tests with adjustment of P values for multiple comparisons using the Bonferroni method. RESULTS: Among all pregnancy hospitalizations, the overall prevalence of hospitalizations with myocardial disorders was 1.33 per 1,000 deliveries. The rate of pregnancy hospitalizations with cardiomyopathy was 0.46 per 1,000 deliveries (0.18 for apparent peripartum cardiomyopathy and 0.28 for other cardiomyopathies). The rate of pregnancy hospitalizations with other myocardial disorders was 0.87 per 1,000 deliveries. Myocardial disorders were rare during delivery hospitalizations (0.01%) but not uncommon among postpartum hospitalizations (4.2%). Among hospitalizations with myocardial disorders, the rate of severe complications ranged from 13.2 for acute myocardial infarction to 128.6 for adult respiratory distress syndrome and from 10.7 for pulmonary edema to 193.0 for fluid and electrolyte disorders per 1,000 delivery and postpartum hospitalizations, respectively. Among hospitalizations without myocardial disorders, the rate of severe complications ranged from 0.07 to 1.9 and from 0.4 to 65.5 for cardiac arrest and for fluid and electrolyte disorders per 1,000 hospitalizations, in delivery and postpartum periods, respectively. CONCLUSION: Although only a minority of hospitalizations for cardiomyopathy are consistent with peripartum cardiomyopathy, cardiomyopathy and other myocardial disorders are important contributors to severe obstetric complications. (Obstet Gynecol 2010;115:93–100) LEVEL OF EVIDENCE: III