It’s not uncommon for women to give birth later in life these days. Women are giving birth in their 50’s and even 60’s. Complications are aplenty, however, in these older gravidas—in large part because the older we get, the harder it becomes for our arteries, blood vessels, and heart to respond to the demands of pregnancy.

Heart disease—a broad term that includes a variety of heart and blood vessel conditions like heart attack, stroke, or high blood pressure—is the leading cause of death in women over age 25 in the U.S. And while the death rate from cardiovascular disease has decreased among men, it continues to increase in women.

Cardiovascular disease and hypertensive disorders in pregnancy take on new—and sometimes frightening—meaning for older women in pregnancy and during birth. And maternal heart disease is a key threat to safe motherhood and women’s long-term cardiovascular health.

Pregnancy puts the heart under pressure

As The American College of Obstetricians and Gynecologists (ACOG) highlighted in a May Practice Bulletin, cardiovascular disease is now the leading cause of death in pregnant women and women in the postpartum period. Cardiovascular disease affects approximately 1-4% of the nearly 4 million pregnancies in the U.S. each year. Critically, there are racial and socioeconomic disparities in cardiovascular outcomes with higher rates of morbidity and mortality among nonwhite and lower-income women.

Pregnancy, itself, is a cardiovascular “stress test”—something I experienced when I was pregnant with my twins at 39. I had premature arterial contractions and had to wear a holter monitor for 24 hours: my heart was saying, “Jane…. Jane…. I’m struggling to keep up with all this extra blood volume, twins, and advanced maternal age!.”

In pregnancy, a woman’s blood volume increases (massively) by 50% to support the pregnancy, meaning more volume and more work for the heart. By the end of pregnancy, 20% of a woman’s cardiac output goes to the uterus—that’s a whole lotta blood, folks!

“Pregnancy, itself, is a cardiovascular ‘stress test’—something I experienced when I was pregnant with my twins at 39.”

Clinical learnings & considerations

There are some helpful learnings we can gather from a study led by the California Maternal Quality Care Collaborative, which found that of the approximately 2.7 million women in California who gave birth between 2002 and 2006, 864 died while pregnant or within one year of pregnancy. Of those who died, 25% were due to cardiovascular disease (comparatively, 18% died from preeclampsia and 10% from postpartum hemorrhage).

It’s important to break down heart disease diagnoses by stages of pregnancy. In this study:

  • 3% of the women had a known history of cardiovascular disease when they entered prenatal care;
  • 8% were diagnosed during pregnancy;
  • 40% were diagnosed during labor or birth; and
  • Nearly 50% were diagnosed in the postpartum period, the majority of which were in the first 42 days after having given birth.

In order to learn from and prevent these outcomes in the future, it’s also helpful to understand patient risk factors and underlying medical conditions. In this research, risk factors included:

  • Underlying medical conditions (64%), such as hypertension
  • Delay in seeking care (31%)
  • Obesity (28%)
  • Presumed or potential lack of awareness regarding the significance of their condition (22%)
  • Substance abuse (19%)
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How access to specialists can help improve outcomes

This study points to how important it is for women to have access to comprehensive cardiovascular screenings in preconception, prenatal, and postpartum care. When a woman is identified with maternal heart disease, it’s essential she sees specialists like a Maternal Fetal Medicine (MFM) physician and a Cardiologist (heart doctor) to help direct her care. She will need to deliver at a tertiary care center that has all of the services and staff that she and the fetus/infant may need. After pregnancy, she will need to follow up with a Cardiologist and/or her OB-GYN or PCP (primary care physician) for long-term cardiovascular care.

At Maven, thanks to our Care Advocates and our virtual network of physicians and specialists, we are uniquely positioned to help improve maternal cardiovascular health outcomes. During pregnancy, we regularly assess risk factors and ask about symptoms women may be experiencing, and can immediately refer them to a specialist on Maven or an in-person physician for evaluation.

In addition, our high-touch care in the postpartum period (aka, the fourth trimester) means that we are in conversation early and often with women as they are transitioning from labor to postpartum—a time when women are often focusing all their efforts on the newborn baby and ignoring symptoms in themselves like shortness of breath or palpitations.

Always listen to your heart

As you bundle up this Fall, remember to ask about your loved ones’ heart health. Ask your friends who are pregnant whether they’ve talked to their doctors about cardiovascular risks and screenings.

Eat well, exercise everyday if you can, and practice some self-love for your own beautiful, bleeding, hard-working heart. You only have one!

Dr. Jane van Dis is Maven’s Medical Director, a board-certified OB-GYN, and a frequent writer and speaker about gender equity in medicine. Follow her @JanevanDis.

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