You may have heard about the distressing rise in maternal mortality in the U.S., which disproportionately affects Black women.
In a study of 11 high-income countries, the U.S. had the highest rate of maternal mortality.
“Pregnancy-related deaths are defined as the death of a woman while pregnant or within 1 year of the end of pregnancy from any cause related to or aggravated by the pregnancy,” Shanna Cox, associate director for science at the Centers for Disease Control and Prevention’s Division of Reproductive Health, told HuffPost.
CDC analysis of pregnancy-related deaths between 2017-2019 found that the top cause of those deaths was mental health conditions, including suicides and drug overdoses.
These accounted for 23% of pregnancy-related deaths. Cardiac and coronary conditions accounted for 13%, and cardiomyopathy (heart failure) for 9%, meaning that, when combined, these heart-related issues were the second most common cause of pregnancy-related death.
“The leading underlying causes of pregnancy-related death vary by race and ethnicity,” explained Cox. “Cardiac and coronary conditions were the leading underlying cause of pregnancy-related deaths among non-Hispanic Black people.” For non-Hispanic white people, the leading cause was mental health conditions.
In the general non-pregnant female population, heart disease is the number one killer of women overall, causing more deaths in women than all cancers combined. Many people associate heart disease with old age, not pregnancy, but heart health and pregnancy health are connected.
There are heart health risks unique to pregnancy and the postpartum period. Certain problems during pregnancy put women at greater risk for heart disease later in life, so it’s important to understand your medical history. Luckily, many of these conditions can be treated or managed. Since early diagnosis helps, awareness is key.
Heart health during pregnancy
Pregnancy is a normal condition, not a disease, but it’s a real workout for your heart.
Dr Johanna Quist-Nelson is the director of the women’s heart health clinic at the University of North Carolina School of Medicine. During pregnancy, she explained, the heart is essentially working overtime: “The number of beats per minute increase, the volume of blood that it has to pump through the body increases.” This explains why it’s not uncommon for pregnant people to experience occasional heart palpitations.
Dr Paula Miller, a cardiologist and director of the women’s heart program at the University of North Carolina, told HuffPost that by the end of pregnancy, your heart is “processing two times as much volume as it would if you’re not pregnant.”
“A lot of women in pregnancy [have] palpitations, that resolves with delivery and that doesn’t go on to indicate any kind of issue down the road. That’s just a function of that bigger blood volume that you have,” she said.
Stress on the heart peaks at two points, explained Quist-Nelson: “The particular stresses are during the delivery timeframe and in the postpartum timeframe where the amount of water and blood into your body is changing so, so drastically.”
If a patient has a preexisting heart condition, they will be carefully monitored by their health care team while pregnant. It’s also possible to have an undiagnosed heart condition that becomes symptomatic during pregnancy while the heart is working harder than usual.
Postpartum cardiomyopathy
Postpartum (or peripartum) cardiomyopathy is a heart condition unique to the time surrounding delivery and is responsible for 9% of pregnancy-related deaths.
In the final month of pregnancy through the first five months following delivery, a small number of people experience heart failure. This affects 1,000-1,300 people per year in the U.S., although other countries have higher rates for reasons that aren’t fully understood.
Quist-Nelson said that the outcomes for these patients break fairly evenly into three categories. “A third of the patients will not have any improvement and will just get worse. A third will stay with the changes in the heart but will not get worse and a third of those patients will have improvement back to baseline heart activity.”
Gestational hypertension and preeclampsia
While postpartum cardiomyopathy is relatively rare, there are more common conditions of pregnancy related to heart health that all pregnant people get screened for.
“Everyone gets a blood pressure and heart rate [check] at every prenatal visit and throughout labor and postpartum timeframe,” said Quist-Nelson.
Blood pressure generally drops during the first part of pregnancy, followed by what Quist-Nelson describes as “a gentle rise during the third trimester.”
Gestational hypertension is when you have high blood pressure, defined as a top number over 140 or a bottom number over 90, that develops after 20 weeks of pregnancy. (High blood pressure prior to 20 weeks is considered chronic hypertension, or not pregnancy-related.)
Hypertension may turn into preeclampsia, which is characterised by high blood pressure and signs of damage to other organs, such as the presence of protein in your urine.
Preeclampsia can be life-threatening, so your doctor will monitor your condition carefully. People with preeclampsia may need to deliver their babies early in order to protect their health.
“Many people associate heart disease with old age, not pregnancy, but heart health and pregnancy health are connected.”
Some pregnant people are at a higher risk of developing preeclampsia. These risk factors include preexisting (chronic) hypertension, kidney disease, diabetes and obesity.
Pregnant people who are over 40 and people pregnant with more than one baby (twins/triplets) are also at higher risk.
African-Americans are at higher risk than other racial groups. However, Quist-Nelson noted that these differences “are markers of the racism that exists within our society”.
“There’s no genetic difference between groups that make that make one population at increased risk of heart disease,” she said.
The connection between health during pregnancy and long-term heart health
People who have pregnancy-related hypertension, preeclampsia or deliver pre-term (before 37 weeks) are at a higher risk for heart disease later on in life.
“If you have preeclampsia during pregnancy or you have blood pressure issues during pregnancy, you are at risk for cardiovascular disease down the road,” said Miller. The severity of your symptoms during pregnancy correlates with your future risk, with gestational hypertension increasing your risk less than preeclampsia.
“The severity of preeclampsia, or how bad their preeclampsia is, also correlates with the severity of the future disease,” explained Quist-Nelson.
Scientists do not yet know whether preeclampsia causes changes that put people at greater risk for heart disease, or whether the underlying differences that caused the preeclampsia can also lead to heart disease, but it is important to know your health history so that you can be properly monitored.
Likewise, the correlation between preterm delivery and heart disease isn’t fully understood.
We know that people who develop gestational diabetes are at an increased risk of developing Type 2 diabetes after pregnancy, and diabetes is a major risk factor for heart disease.
Quist-Nelson notes that there are some cardiovascular and other health conditions that make pregnancy unsafe. In these cases and others, the availability of family planning services has a direct impact on maternal health.
“A state with healthy family planning options and the ability for patients to make choices regarding their pregnancy is going to be directly related to our maternal mortality rates,” said Quist-Nelson.
Warning signs
Frustratingly, “there’s so much overlap between what it feels like to be pregnant and what it feels like to have heart disease,” said Quist-Nelson.
For example, many pregnant people experience shortness of breath. However, if you are having trouble breathing while you are at rest, or you need to prop yourself up with pillows at night in order to be able to breathe, you should contact your health care provider.
Heart-related conditions are a leading cause of pregnancy-related death, but there are other serious conditions that require medical attention. Symptoms in pregnancy and after delivery that you shouldn’t ignore include:
- persistent or worsening headache
- dizziness or fainting
- changes in vision
- fever of 100.4 or higher
- extreme swelling of hands or face
- thoughts of harming yourself or your baby
- chest pain or rapid heartbeat
- trouble breathing
- severe nausea/vomiting
- severe belly pain
- baby’s movements slow or stop
- unexpected vaginal bleeding, leaking or discharge
- severe redness, swelling or pain in your leg or arm
- overwhelming tiredness
- high blood pressure, if you are monitoring yourself at home
Because it can be hard to determine when signs like headache, swelling or tiredness are signs of a problem and when they are simply symptoms of pregnancy, it’s important to let your health care provider know whenever you have a concern.
Preventive measures
While heart-related conditions cannot always be prevented, there are things that you can do to reduce your risk. Top among these is exercise.
While in the past, many people thought that pregnant women should take a break from sports or other activities while pregnant, we now know that exercise during all phases of life has a preventive impact on heart health.
“The studies suggest five days a week, 30 minutes at a time,” said Quist-Nelson. “There’s no magic type of exercise that is better, and so I always talk to [my patients] about what are they motivated to do.”
Knowing your health history, getting regular care both during and after pregnancy and staying aware of your symptoms can help your health care team treat and manage conditions like high blood pressure before they develop into something more serious.