Background

The number of pregnant persons affected by cardiovascular disease (CVD) is rising and has necessitated the development of multidisciplinary, specialized teams in a field called cardio-obstetrics. Achieving optimal maternal and fetal outcomes for patients with CVD relies on the expertise of these teams, a constant assessment of treatment risks versus benefits, and sometimes termination of pregnancy as a life-saving measure for the pregnant patient. With the recent Supreme Court decision in Dobbs v. Jackson Women’s Health Organization to overturn Roe v. Wade and the right to abortion it established under the U.S. Constitution, states now have the authority to ban or otherwise restrict access to abortion. Pregnant patients with CVD and cardio-obstetrics clinicians face several challenges that threaten patient care, community health, and practice advancement.

Effect on Maternal Mortality and Morbidity

Currently, CVD including hypertensive diseases affect greater than 10% of all pregnancies in the U.S. and account for the greatest proportion, 26.5-35.5%, of maternal deaths during pregnancy.^1,2 Several pregnancy risk scoring systems have been developed to identify patients with CVD at highest or “prohibitive” risk for pregnancy, including those with severe left ventricular dysfunction, severe left-sided obstructive lesions, severe aortic dilation, and pulmonary arterial hypertension^3-5. In these patients, maternal mortality can exceed 50% and termination of pregnancy is recommended as the only reliable and effective life-saving treatment. Risk of maternal mortality from abortion, in contrast, remains low at 0.4 per 100,000 legal abortions and even lower when the procedure is performed by a trained, licensed clinician in a medically supervised setting. Even outside of prohibitive risk groups, pregnancy carries a risk of potential morbidity and mortality for patients with CVD, and certain peripartum CVD-events such as cardiac arrest, arrhythmias, acute myocardial infarction, and aneurysm/ dissection have increased 100-175% in the past few decades despite advances in cardio-obstetrics care. For patients who have CVD that manifests or worsen as pregnancy progresses, access to legal, safe abortion care represents an essential option when other management strategies fail to protect maternal health.

Deepening Disparities in Care

Adverse pregnancy outcomes (APOs) disproportionally affect persons of color, with rates of maternal mortality from CVD up to threefold higher in Black and American Indian and Alaska Native persons as compared to that in White persons.⁶ In addition, APO rates are elevated in rural areas of America, where there are also higher rates of poverty, reduced access to routine medical and obstetrical care.⁷ With laws restricting or eliminating abortion access in 20+ states after the overturning of Roe v. Wade, a large population of at-risk pregnant patients, including children and teenagers, will likely not have the means to travel and pay for abortion care and as a result will also come under significant economic strain with the cost of forced pregnancy, birth, and childcare. In certain states, doctors risk losing their licenses if they continue to offer abortion care, thus further reducing the already limited availability of medical professionals who are trained to offer safe procedures. These and other consequences of Dobbs v. Jackson Women’s Health Organization place cardio-obstetrics patients at risk for not only significant CVD-related morbidity and mortality, but also for significant socioeconomic marginalization further compounding existing health disparities. Guiding Principles and Member Care for providers can help serve as resource for cardiovascular professionals who provide care to women of childbearing age.

Lifelong Implications For Maternal Cardiovascular Health

Individuals who experience APOs are also at heightened risk for the development of chronic illnesses including hypertension, diabetes, heart failure, and ischemic heart disease, all of which reduce both life expectancy and quality.⁸ Reflectively, healthcare expenditure on CVD in women is estimated to top $1.1 trillion by the year 2035 with a concurrent loss of at least $6.6 billion in productivity by women who have had to leave the work force due to CVD-related APO. Incalculable are the costs of psychological harm to patients who are denied the right to bodily autonomy, even at the risk of their own safety and wellbeing.

Conclusion

Access to safe abortion care remains a critical aspect of healthcare, a view shared by several healthcare organizations including The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and World Health Organization. It is furthermore a tenet of cardio-obstetrics practice which requires our urgent advocacy to continue providing the best possible care for pregnant persons with CVD.

References:

1. Ramlakhan KP, Johnson MR, Roos-Hesselink JW. Pregnancy and cardiovascular disease. Nat Rev Cardiol. 2020 Nov;17(11):718-731.
2. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-Related Mortality in the United States, 2011-2013. Obstet Gynecol. 2017 Aug;130(2):366-373.
3. Drenthen W, Boersma E, Balci A et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J. 2010 Sep; 31 (17): 2124-32
4. Silversides CK, Grewal J, Mason J et al. Pregnancy Outcomes in Women with Heart Disease: The CARPREG II study. J Am Coll Cardiol. 2018 May 29; 71 (21): 2419-2430
5. Regitz-Zagrosek V , Roos-Hesselink JW , Bauersachs J , et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018;39:3165–241
6. Gad MM, Elgendy IY, Mahmoud AN, et al. Disparities in Cardiovascular Disease Outcomes Among Pregnant and Post-Partum Women. J Am Heart Assoc. 2021 Jan 5;10(1):e017832.
7. Harrington RA, Califf RM, Balamurugan A, et al. Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association. Circulation. 2020 Mar 10;141(10):e615-e644.
8. Parikh NI, Gonzalez JM, Anderson CAM et al. Adverse Pregnancy Outcomes and Cardiovascular Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association. Circulation. 2021, 143 (18): e902-e916

This article was written by Amanda Cai, MD, FACC, an ACHD FIT at University of Washington and Tripti Gupta, MD, an FIT at Ochsner Medical Center.

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