Heart disease – why is maternal mortality increasing?

Abstract

Please cite this paper as: Gelson E, Gatzoulis M, Steer P, Johnson M. Heart disease -why is maternal mortality increasing ? BJOG 2009;116:609-611. The most recent triennial confidential enquiry confirmed that heart disease is the most common cause of maternal death in the UK. The maternal mortality rate associated with heart disease is 2.27 per 100,000 maternities double that reported in 1990. 1 The incidence of heart disease during pregnancy in the UK has remained constant at 0.9% over several decades. 2 However, the severity of heart disease and the risk it poses during pregnancy appear to be increasing in a wide range of healthcare settings. This commentary examines why mortality rates have risen and makes recommendations as to how this trend can be reversed.Ischaemic heart disease is now the most common cause of cardiac death in the pregnant population in the developed world. This is likely due to increased maternal age; smoking; the adoption of a sedentary lifestyle and poor diet leading to greater rates of obesity, diabetes and hypertension. 3-6 Acute myocardial infarction accounts for the majority of deaths and is most commonly due to coronary atherosclerosis, but coronary artery dissection and consequent occlusion are also relatively frequent. There is a high incidence of recognised risk factors for atherosclerosis in pregnant women suffering an acute myocardial infarction during pregnancy and the postpartum period, which should be targeted both for intervention and for identification. 6 Hyperlipidaemia, hypertension and diabetes should be optimally controlled preconception and smoking cessation and weight loss strongly encouraged. Women with multiple risk factors should be identified, alerting obstetricians to the possibility of ischaemic heart disease and lowering thresholds for the investigation of symptoms. When myocardial infarction is suspected or diagnosed, cardiac catheterisation with acute phase intervention (thrombolysis and/or coronary angioplasty) should not be withheld; these procedures are relatively safe in the pregnancy, 7 although larger studies are required to determine their specific risk to benefit ratios. Following the acute phase, secondary prevention (such as optimal blood pressure control, aspirin and statins [see below]) should be instituted. Many cardiac medications can be used without undue risk in pregnancy, for example beta blockers, digoxin, aspirin, diuretics and hydralazine. ACE inhibitors are known to have teratogenic effects in the first trimester and should therefore best be avoided during early pregnancy. 8 Exposure in the second and third trimesters can lead to marked fetal hypotension and decreased fetal renal blood flow. Where ACE inhibitors must be continued, the lowest possible dose should be used and amniotic fluid levels and fetal growth should be monitored carefully. Statins have been identified as potential teratogens on the basis of theoretical considerations. However, epidemiological data suggest this to be unfounded. Given the scarcity of available data,...

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