Maternal mortality has been in the news over the past few years because it appears its incidence may be rising in the U.S.
While part of the documented rise is artifactual because we are doing a better job of detecting maternal deaths, it is true that many older women with pre-existing health problems are becoming pregnant, and this may place them at higher risk for adverse events. The rates of obesity, hypertension, diabetes, and other serious medical illnesses are increasing in women, and these may cause a pregnancy to be at higher risk of complications, such as preeclampsia, hemorrhage, and thromobotic disease (such as pulmonary embolus, deep venous thrombosis, or stroke). In addition, artificial reproductive technologies allow women to become pregnant at older ages than was previously possible. The CDC has documented that 20 percent of maternal deaths occur in women older than 45 years of age.
Many of these deaths are related to cardiac events, and that may cause women to worry.
This article about a woman pregnant with twins who experienced two heart attacks demonstrates such a case. A “heart attack” is a common expression for cardiac damage usually related to the inability of the heart to obtain adequate blood flow. While heart attacks in older Americans are often due to vessel blockage from atherosclerosis (plaques), in younger women it usually isn’t caused by that. It may be initiated by a spasm in a blood vessel, an arrhythmia that keeps the heart from pumping properly, an obstetric emergency such as massive blood loss that depletes the oxygen carrying capacity of the blood, or sometimes from a pre-existing heart defect, often one that a woman was born with.
The advances in surgical techniques to repair complex congenital heart defects has allowed many affected female infants to grow into adulthood where they may have higher risks if they should become pregnant.
Women do not need to fear pregnancy and childbirth. Awareness is improving about these problems, and doctors have experience in managing each of these emergency situations.
An entire obstetrics subspecialty, maternal-fetal medicine, is devoted to managing high-risk pregnancies so that both a woman and her child can be safely delivered.
If a woman had a congenital defect repaired as a child, she should obtain a preconceptual consultation from a cardiologist to see if the hemodynamic changes that will occur during pregnancy may place her at risk. She should follow the cardiologist’s recommendations throughout the pregnancy.
It is rare that a woman has a heart defect so severe that she should not attempt to become pregnant, but if she does, her physicians will undoubtedly have warned her about this.
If a woman develops a severe condition, such as preeclampsia, during pregnancy that threatens her heart, obstetricians have much experience managing this complication.
If she is being cared for in a community hospital, her OB may arrange transfer to a higher level facility that has more experience and equipment available to care for her and her baby.
Sometimes, the problem arises during delivery, such as an obstetric hemorrhage.
Hospitals have emergency checklists and conduct periodic drills so that they will be able to quickly manage emergencies in order to keep women safe.
By Ingrid Skop, M.D.
