Pregnancy ‘heart disease deaths’ could be avoided     


Dr Ben Janaway  II  DEC 7 2016

Concerns raised as the  ‘Confidential Enquiry into Maternal Death’, suggests that an increase in heart disease related deaths during pregnancy may be due to misdiagnosis.  The research suggested that cardinal symptoms of heart failure, disease or infection were often misattributed to other causes. The report called for a ‘higher index of suspicion’ by doctors of atypical symptoms. Cardiac disease is the highest cause of death in and immediately after pregnancy, accounting for 25%.

‘This report highlighted many instances when pregnant and postpartum women had clear symptoms and signs of cardiac disease, which were not recognised, often because the diagnosis was simply not considered in a young pregnant woman.’ the study concluded.

Maternal heart disease is responsible for approximately 2 deaths per 100000 pregnancies, with up to 83% of these cases either new or undiagnosed. Changes in body physiology, including increased pressure on the heart, means that pregnancy can precipitate heart disease in those with borderline function. Risk factors for maternal heart disease include Hypertrophic cardiomyopathy (a large, weak heart,) gestational diabetes, pre -eclampsia or small babies during previous pregnancies. Those with certain valve disorders are at increased risk.

Despite this knowledge, the report showed that findings such as chest pain, high blood pressure, breathlessness and sustained palpitations were not investigated appropriately. Although some breathlessness on exertion and ankle swelling is common in most pregnancies, these symptoms demonstrate heart disease above and beyond usual pregnancy induced impairment.

"Pregnancy and childbirth can put extra strain on the heart, particularly if you have a pre-existing heart condition, and some of these deaths are likely to have been caused by undiagnosed conditions which can cause fatal heart attacks without warning.’  said Dr. Mike Knapton of the British Heart Foundation.

Heart disease and pregnancy

Pregnancy  induces a number of broad physiological changes on a woman’s body in order to establish an adequate environment for baby. The increased demand for energy generated by the growing baby means a greater blood volume and metabolic rate, which means the heart must beat harder and faster. Increased abdominal pressure, seen more markedly in late pregnancy, increases pressure and blood volume in the heart, increasing its risk of overload and failure.

Significant changes in blood pressure, arterial resistance and heart beat strength and rate can cause abnormal heart growth which can precipitate ‘heart failure’. During birth, these parameters are pushed to an extreme and can tip susceptible hearts (i.e. those with structural abnormalities, or in patients with other risk factors) over the edge. With substantial intra-delivery blood loss this risk increases.

Heart attacks themselves occur when the heart can no longer supply its own muscle with adequate oxygen. This can occur for a number of reasons, but includes the higher risk of clots found in pregnancy, as well as higher risk of poor overall heart function.

Call for action

The report suggests that a greater vigilance should be taken when handling new symptoms presumptive of heart disease in pregnant patients. Although heart disease is usually considered a disease of the obese, male and usually much older, the increased strain placed on the heart by pregnancy can precipitate disease in much younger female patients. Special consideration should be taken in those with high risk factors.

"Doctors should be vigilant and consider heart disease when a pregnant woman is experiencing symptoms such as chest pain. These findings are an urgent reminder that heart disease comes in many forms and can strike almost anyone’ concluded Dr Knapton

With this in mind the report has called for women to themselves monitor for symptoms and raise concerns early. Public education around symptoms may improve outcomes by catching disease earlier.
 
Dr Ben Janaway MBChB  //   @drjanaway

Any opinions above are the author's alone and may not represent those of the NHS or Mind and Medicine. Any comment is based on the best available evidence at the time of writing.  All data is based on externally validated studies unless expressed otherwise. Novel data is representative of sample surveyed. Online recommendation is no substitute for seeing your own doctor and should not be taken as medical advice.
 
Dr Ben Janaway is a medical doctor and Editor for the online healthcare and education  source ‘Mind and Medicine’.  He writes regularly for patient.co.uk and other national news sources. Contact Dr Janaway at www.twitter.com/drjanaway with stories or for discussion

Sources

https://www.npeu.ox.ac.uk/mbrrace-uk

http://www.heraldscotland.com/news/14951258.Doctors_missing_heart_attack_signs_in_pregnant_women__report_warns/http://www.heraldscotland.com/news/14951258.Doctors_missing_heart_attack_signs_in_pregnant_women__report_warns/


http://www.dailymail.co.uk/news/article-4007684/Pregnant-women-dying-doctors-miss-clear-symptoms-heart-disease.html


http://emedicine.medscape.com/article/162004-overview


http://www.uptodate.com/contents/management-of-heart-failure-during-pregnancy


http://www.nhs.uk/news/2008/07July/Pages/Heartattackinpregnancy.aspx