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Cardiovascular disease is a leading cause of death for women before, during and after pregnancy. But current clinical preventive services miss many opportunities to identify and manage risk for these women, particularly after pregnancy, say the authors of a new consensus study report from the National Academies of Sciences, Engineering and Medicine, including Kathryn Lindley, MD, director of the Vanderbilt Health Women’s Heart Center.
To help reduce deaths and cardiovascular complications among mothers, the report calls for stronger clinical preventive services, better follow-up after delivery, and improved care coordination across the course of reproductive life. The study was funded by the Health Resources and Services Administration (HRSA), an agency of the Department of Health and Human Services, which issues clinical guidelines for preventive care.
More than 75% of pregnancy-related cardiovascular deaths are preventable, the report states. But despite data showing 57% of deaths occur between seven days and one year after pregnancy, preventive care related to cardiovascular risk is more often offered during the prenatal and immediate postpartum periods, with less attention on counseling prior to pregnancy, postpartum follow-up, care transitions and longer-term cardiovascular risk.
“Cardiovascular disease is a leading contributor to pregnancy-related deaths, and most of these are preventable,” said Lindley, associate professor of Medicine and Obstetrics and Gynecology. “Pregnancy isn’t an isolated event. It’s a part of a continuum of lifelong cardiovascular health and a window into the future, recognizing that these adverse events like high blood pressure that happen in pregnancy really do have long-term implications for a woman’s heart health. Both our society and clinicians really need to take this opportunity to apply preventive services to not only improve short-term outcomes, but long-term outcomes.”
The authors reviewed nine clinical preventive services for maternal cardiovascular health and found sufficient evidence to call for updated clinical guidelines in two areas — better management of chronic hypertension and stronger postpartum blood pressure monitoring.
Treating chronic hypertension, for example, is clearly associated with better maternal and fetal outcomes without increased risk, said Lindley, who holds the Samuel S. Riven, MD, Directorship in Cardiology. The authors found substantial evidence that this approach reduces severe-range hypertension, preeclampsia, medically indicated preterm birth and related adverse outcomes.
Secondly, stronger postpartum blood pressure monitoring for women with chronic high blood pressure or other hypertensive disorders of pregnancy is found to increase adherence and reduce adverse outcomes in women, Lindley said. Evidence shows that programs such as a combination of remote, self-measured blood pressure monitoring and more structured telehealth, home or clinic visits are effective.
The report notes the two recommendations are not inclusive of all preventive services necessary, just the ones with enough evidence to issue immediate recommendations. The other areas require further study, the authors wrote.
Lindley said she and other authors were asked to examine what clinical preventive services are needed to better address cardiovascular disease risk and related risk factors among women of reproductive age, during pregnancy and postpartum; to consider issues related to timing and populations at risk; to assess how HRSA programs could help address barriers to access and use; and to identify research priorities where evidence remains limited. More broadly, the report looks at gaps in prevention and care before, during and after pregnancy and the challenge of improving continuity across these periods.
Lindley said HRSA will now review the report’s recommendations to consider implementing changes in preventive care services for women with cardiovascular disorders.
“The majority of maternal deaths and adverse outcomes occur postpartum, but really our system is built around pregnancy, not the postpartum period,” Lindley said. “While we have very clear systems and protocols in place for pregnancy care, that starts to fall apart after delivery. And that’s where we really need to think about broader programming to ensure that we don’t have those care gaps, that care is better coordinated, and that we have better protocols for ensuring that every patient receives the same quality of care.”
