ACOG Releases comprehensive Guidance on Heart Disease in Pregnancy

American College of Obstetricians and Gynecologists (ACOG) has released comprehensive guidance on pregnancy and heart disease. The Practice Bulletin, Pregnancy and Heart Disease, is the product of a task force convened and led by ACOG President Lisa Hollier, M.D., M.P.H., aimed at addressing cardiac contributors to maternal mortality. The guidance outlines the screening, diagnosis, and management of CVD for women from pre-pregnancy to postpartum. It has appeared in May edition of Obstetrics & Gynecology.

Cardiovascular disease (CVD) is now the leading cause of death in pregnancy and the postpartum period in the United States, It constitutes 26.5% of pregnancy-related deaths, with higher rates of mortality among women of colour and women with lower incomes.

In addition to preexisting cardiac conditions, the Practice Bulletin also addresses acquired heart conditions, which are by far the most common and can develop silently and acutely during or after pregnancy. Currently, peripartum cardiomyopathy, a disease affecting the heart muscle, is the leading cause of maternal deaths, accounting for 23% of deaths in the late postpartum period.

“The rise we’re seeing in maternal deaths is largely due to acquired cardiac disease in pregnancy,” said Hollier. “Most of these deaths are preventable, but we are missing opportunities to identify risk factors prior to pregnancy and there are often delays in recognizing symptoms during pregnancy and postpartum, particularly for black women. The new guidance clearly delineates between common signs and symptoms of normal pregnancy versus those that are abnormal and indicative of underlying cardiovascular disease. As clinicians, we need to be adept at distinguishing between the two if we’re going to improve maternal outcomes.”

Common risk factors for CVD-related mortality include race and ethnicity, age, hypertension during pregnancy, and obesity. However, according to the data, the leading factor is race. Black women’s risk of dying from CVD is 3.4 times higher than that of white women. This disparity is due, in part, to racial bias and overt racism that exists in the provision of health care and in health system processes. The greatest health disparities in the management of CVD for black women usually exist prior to pregnancy when risk factors are not identified.

The new Practice Bulletin contains major ACOG’s recommendation like-

• The four key risk factors linked to cardiovascular disease-related maternal mortality are race/ethnicity, with non-Hispanic black women having a 3.4-fold increased risk for dying from cardiovascular disease-related pregnancy complications; age; hypertension; and obesity.


• All women should be assessed for CVD in the prenatal and postpartum period using the California CVD Tool Kit algorithm. According to what California learned from its experience with their mothers, 88% of women who died would have been identified as high risk requiring further evaluation and referral had this new screening algorithm been used.


• Women with known heart disease should see a cardiologist prior to pregnancy and receive pre-pregnancy counselling.


• Patients determined to have moderate and high-risk CVD should be managed during pregnancy, delivery, and postpartum in a medical centre that is able to provide a higher level of care, including a multidisciplinary Pregnancy Heart Team that includes obstetric providers, maternal-fetal medicine specialists, and cardiologists and anesthesiologists at a minimum. Collaboration between providers, particularly ob-gyns and cardiologists, is key.


• The postpartum period is a time of increased risk for cardiovascular disease-related complications. The elevated risk is both in the immediate period and can extend from six months to a year. A follow-up visit with a primary care clinician or cardiologist should occur within seven to 10 days for all women with hypertensive disorders and seven to 14 days for all women with heart disease or cardiovascular disorders.

“Pregnancy is a natural stress test,” said James Martin, M.D., chair of the Pregnancy and Heart Disease Task Force. “The cardiovascular system must undergo major changes to its structure to sustain tremendous increases in blood volume. That’s why it is critical to identify the risk factors beforehand so that a woman’s care can be properly managed throughout the pregnancy and a detailed delivery plan can be developed through shared decision making between the patient and provider. Moreover, we must think of heart disease as a possibility in every pregnant or postpartum patient we see to detect and treat at-risk mothers.”

“It is crucial for these women to have a longer-term care plan,” said Hollier. “So, we also recommend a comprehensive, cardiovascular postpartum visit at the three-month mark, at which time the clinician and patient can discuss collaborative plans for yearly follow-up and future pregnancy intentions. Our maternity care payment models must provide coverage for these additional visits. Currently, many women are going home and taking excellent care of their babies, but how are we demonstrating that we’re taking care of them? It is our job to make sure our clinical practices, policies, and systems reflect our commitment to the health and well-being of the moms in this country.”