Cardiovascular adverse events in pregnancy: A global perspective

Abstract

Pregnant women with heart disease are vulnerable to many adverse cardiovascular events (AE). AEs during and after pregnancy continue to be important causes of maternal mortality and morbidity worldwide, with huge variations in burden in different countries and regions. These AEs are classified as having direct or indirect causes, depending on whether they are directly caused by pregnancy or due to some pre-existing disease and/or non-obstetric cause, respectively. The risks continue throughout pregnancy and even after childbirth. Apart from immediate complications during pregnancy, there is increasing evidence of a significant link between several events and the risk of cardiovascular disease (CVD) later in life. A significant number of pregnancy-related deaths caused by cardiovascular disease are preventable. This prevention can be realized through increasing awareness of cardiovascular AE in pregnancy, coupled with the application of strategies for prevention and treatment. Knowledge of the risks associated with CVD and pregnancy is of extreme importance in that regard. We discuss the global distribution of cardiovascular maternal mortality, adverse events during and after pregnancy, their predictors and risk stratification. In addition, we enumerate possible solutions, particularly the role of cardio-obstetric clinics.

Figure 1.. Maternal mortality ratio (MMR; number of deaths per 100,000 livebirths) for countries and territories, GBD 2015.

Figure 2.. Causes of maternal deaths globally, 1990–2017.^,

(A) maternal hypertensive disorders: High blood pressure during pregnancy in women who did not already have hypertension, or preeclampsia in women with preexisting hypertension. (B) Indirect maternal deaths: Deaths due to preexisting conditions made worse by physiologic effects of pregnancy. (C) Late maternal deaths: Deaths due to any cause that occurs six weeks to 12 months after pregnancy. (D) Other maternal disorders: All other direct maternal disorders, including anemia in pregnancy, gestational diabetes and embolism.

Figure 3.. MMR per country across 1990, 2005 and 2017.^,

Figure 4.. Onset of hypertensive disorders at different stages of pregnancy and postpartum (PP) among women without chronic hypertension (adapted from Ramlakhan et al).^,

Figure 5.. Timing of heart failure in women with structural heart disease at different stages of pregnancy and postpartum (PP) (adapted from Ramlakhan et al).^,

Figure 6.. Diagnostic pathway in patients with suspected peripartum cardiomyopathy (PPCM).

BNP, B-type natriuretic peptide; ECG, electrocardiogram; HF, heart failure; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro-B-type natriuretic peptide; RV, right ventricular.

Figure 7.. Time course of left ventricular function (adapted from.)

(A) Changes in left ventricular ejection fraction (LVEF) from baseline (BL) to 5-year follow-up. Remarkably, LVEF further improves even after 1 year. (B) Proportion of patients with full cardiac recovery constantly increases. At 5-year follow-up, 72% had recovered completely and 23% partially. No recovery was observed in 5%. Death occurs up to 5 years.

Figure 8.. Modified WHO classification of maternal cardiovascular risk: application.

Figure 9.. Risk of cardiac event during pregnancy per mWHO class based on CARPREG II and ROPAC data.

12,13,93 adapted from.

Figure 10.. Cardio-obstetrics team in the management of women before pregnancy, during pregnancy, and postpartum (GUCH: grown-up congenital heart disease) Adapted from.