Contemporary Topics in Cardio-Obstetrics (Contemporary Cardiology) 3031341023, 9783031341021

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Contemporary Cardiology Series Editor: Peter P. Toth

Garima Sharma Nandita S. Scott Melinda B. Davis Katherine E. Economy   Editors

Contemporary Topics in Cardio-Obstetrics

Contemporary Cardiology Series Editor Peter P. Toth Ciccarone Ctr Prevent. Cardio. Disease Johns Hopkins University Sterling, IL, USA

For more than a decade, cardiologists have relied on the Contemporary Cardiology series to provide them with forefront medical references on all aspects of cardiology. Each title is carefully crafted by world-renown cardiologists who comprehensively cover the most important topics in this rapidly advancing field. With more than 75 titles in print covering everything from diabetes and cardiovascular disease to the management of acute coronary syndromes, the Contemporary Cardiology series has become the leading reference source for the practice of cardiac care.

Garima Sharma  •  Nandita S. Scott Melinda B. Davis  •  Katherine E. Economy Editors

Contemporary Topics in Cardio-Obstetrics

Editors Garima Sharma Division of Cardiology Johns Hopkins Medicine Baltimore, MD, USA Melinda B. Davis Division of Cardiovascular Medicine University of Michigan–Ann Arbor Ann Arbor, MI, USA

Nandita S. Scott Massachusetts General Hospital Harvard Medical School Boston, MA, USA Katherine E. Economy Obstetrics, Gynecology and Reproductive Biology Brigham and Women's Hospital Boston, MA, USA

ISSN 2196-8969     ISSN 2196-8977 (electronic) Contemporary Cardiology ISBN 978-3-031-34102-1    ISBN 978-3-031-34103-8 (eBook) https://doi.org/10.1007/978-3-031-34103-8 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Humana imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

I’m grateful to all my patients and colleagues for the wonderful privilege of working and learning together. My work would be impossible without the loving support from the lights of my life: Ryan, Amelia, Kevin, and Nora. To my parents, Drs. Shobha and Vishwanath Sharma, who instilled in me the curiosity and desire to pursue medicine, the greatest of all professions. To my children—Reyansh and Anika Roy, who remain the great joys and the purpose of my life and who taught the meaning of being a mother. To my loving husband, Toshal Roy, who teaches me every day how to be a better human being. And to all my mentors and sponsors, thank you for believing in me, I cannot pay you back, I can only pay it forward. Garima Sharma MD To my husband, Farouc Jaffer, and my children, James, Benjamin, and Nicholas, for the constant and enduring love and support. To the MFM fellows and all my colleagues in the Department of Ob-Gyn at the Brigham for inspiring me to be better every day. To

the patients who trust me to care for them throughout their high-risk pregnancies. And to my parents, James and Anastasia Economy, who taught me to believe that with love, optimism, and energy anything is possible. To my parents, Drs. Arni and Radhika Sekar who made me believe I could achieve anything, Dr. Donald S. Beanlands who fostered my love for cardiology, and of course the five souls who bring me daily joy: Adam, Aidan, Zack, and our two beautiful goldens, Tuukky and Luna. Nandita S. Scott

Preface

There has a been a global effort to establish reliable and relevant statistics and standards of care in the management of cardiovascular disease in pregnancy. This textbook comes at an important time in the history of maternal cardiovascular care, where maternal mortality in certain parts of the world, including the United States, continues to rise. Several organizations have established the importance of developing guidelines and metrics and the evidence-based care in the management and treatment of cardiovascular disease in pregnancy. The burgeoning field of Cardio-­ Obstetrics combines the principles of multidisciplinary team-based care from Cardiology, MATERNAL FETAL MEDICINE, Anaesthesia, advanced nursing, pharmacology, and social work to enhance the care of birthing individuals. This care has shown to have significant impact in improving the outcomes of mothers, their babies, and society at large. In this book, we outline the contemporary and practical knowledge from emerging data in the field. Each chapter is written by experts in the field that have contributed to improving the knowledge and care of these patients. We cover the topics from prevention, prenatal counselling, obstetrical care, to management of complex cardiovascular conditions antenatally and post-­ partum. We are hopeful that this will fulfil an existing gap in the knowledge. Baltimore, MD, USA Boston, MA, USA  Ann Arbor, MI, USA  Boston, MA, USA 

Garima Sharma Nandita S. Scott Melinda B. Davis Katherine E. Economy

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Acknowledgements

The editors acknowledge the effort of the cardio-obstetrics teams across the world that are working together to reduce the burden of cardiac disease in pregnancy and post-partum. We are deeply indebted to our patients and their families, who have trusted us in their care. We look forward to the new innovations in care in the field of cardio-obstetrics.

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Contents

1

 Trends in Maternal Morbidity and Mortality ��������������������������������������    1 Eunjung Choi, Nandita S. Scott, Katherine E. Economy, Melinda B. Davis, and Garima Sharma

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Health Disparities������������������������������������������������������������������������������������    9 S. Michelle Ogunwole, Naomi Fields, Ceshae C. Harding, and Melody Tran

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 Normal Physiology of Pregnancy and Labor����������������������������������������   25 Maïgane Diop, Katherine Bianco, and Abha Khandelwal

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CVD Risk Factors������������������������������������������������������������������������������������   39 Allison Bigeh, Lauren Hassen, Laxmi Mehta, Elisa Bradley, Matthew Schreier, Mahmoud Abdelwahab, and Lauren Lastinger

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Diabetes and Pregnancy��������������������������������������������������������������������������   57 Natasha P. Malkani, Emily A. Rosenberg, and Sarah C. Lassey

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Breastfeeding��������������������������������������������������������������������������������������������   71 Tooba Z. Anwer and Katherine E. Economy

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Cardiac Anesthesia and Delivery Considerations in Cardiac Patients����������������������������������������������������������������������������������   87 Sarah Rae Easter and Bushra Taha

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The Fourth Trimester: Adverse Pregnancy Outcomes and Long-Term Cardiovascular Risk����������������������������������������������������  113 Lindsay G. Panah, Ki Park, and Michael C. Honigberg

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 Preeclampsia in Pregnancy: Diagnosis, Management, and Future Implications for Maternal Health����������������������������������������������������������  139 Alexandria Williams, Mackenzie Naert, and Saba Berhie

10 Preeclampsia:  Effects on Cardiovascular Outcomes����������������������������  157 Vennela Avula, Aarti Thakkar, and Garima Sharma xi

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11 Maternal Stroke ��������������������������������������������������������������������������������������  197 David Zhao, Karissa Arthur, Iman Moeini-Naghani, and Michelle Johansen 12 Peripartum Cardiomyopathy������������������������������������������������������������������  219 Ashley Hesson and Melinda B. Davis 13 Hypertrophic Cardiomyopathy��������������������������������������������������������������  237 Sara Saberi and Eric Smith 14 Cardio-Obstetric  Considerations in Advanced Heart Failure, Mechanical Circulatory Support, and Heart Transplantation������������  251 Ersilia M. DeFilippis and Michelle M. Kittleson 15 Acute  Coronary Syndrome in Pregnancy����������������������������������������������  267 Daniela Crousillat, Ki Park, and Malissa J. Wood 16 Cardiovascular  Imaging in Pregnancy��������������������������������������������������  281 Henrietta A. Afari, Anna C. O’Kelly, Brian B. Ghoshhajra, and Amy A. Sarma 17 Native  Valvular Heart Disease in Pregnancy����������������������������������������  303 Anna C. O’Kelly, Jennifer Riggs, Colleen Harrington, and Nandita S. Scott 18 Prosthetic Valves��������������������������������������������������������������������������������������  315 Christopher Learn and Emily S. Lau 19 Simple  Congenital Heart Disease in Pregnancy������������������������������������  325 Amrit Misra, Carla P. Rodriguez-Monserrate, and Anne Marie Valente 20 Moderate  and Complex Congenital Heart Disease in Pregnancy ������  341 Valeria E. Duarte, Anna C. O’Kelly, and Doreen DeFaria Yeh 21 Aortopathies and Vascular Complications��������������������������������������������  367 Christina Marie Thaler and Timothy B. Cotts 22 Overview  of Pulmonary Arterial Hypertension in Pregnancy������������  387 Aardra Rajendran, Danish Iltaf Satti, Faith E. Metlock, and Garima Sharma 23 Pregnancy  Management in Patients with Pulmonary Arterial Hypertension��������������������������������������������������������������������������������������������  395 Ting Ting Low and Candice K. Silversides 24 Maternal Shock����������������������������������������������������������������������������������������  407 Arthur Jason Vaught 25 Arrhythmias in Pregnancy����������������������������������������������������������������������  415 Aardra Rajendran, Rachit Vakil, Eunice Yang, and Jonathan Chrispin Index�������������������������������������������������������������������������������������������������������������������� 431

Chapter 1

Trends in Maternal Morbidity and Mortality Eunjung Choi, Nandita S. Scott, Katherine E. Economy, Melinda B. Davis, and Garima Sharma

Key Points • Cardiovascular disease is the leading cause of increasing maternal mortality in the United States. • Careful consideration of mother’s socioeconomic status, health education, access to care, timely screening, early follow-up and seamless postpartum transition to primary/specialty care for long-term cardiovascular risk management needs to take place in order to address existing disparities in maternal health. • Including more didactics and clinical exposure to Cardio-Obstetrics during general Cardiovascular Disease fellowship training will improve trainees’ skills and E. Choi (*) Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] N. S. Scott Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA e-mail: [email protected] K. E. Economy Division of Maternal Fetal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA e-mail: [email protected] M. B. Davis Division of Cardiology, University of Michigan, Ann Arbor, MI, USA e-mail: [email protected] G. Sharma Inova Heart and Vascular Institute, Inova Fairfax, Virginia, Falls Churh, USA Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 G. Sharma et al. (eds.), Contemporary Topics in Cardio-Obstetrics, Contemporary Cardiology, https://doi.org/10.1007/978-3-031-34103-8_1

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comfort level with managing high-risk pregnant patients in a multidisciplinary team setting.

Maternal Mortality in the United States—Recent Trends The Pregnancy Mortality Surveillance System (PMSS) conducted by Centers for Disease Control and Prevention (CDC) defines a pregnancy-related death as “the death of woman while pregnant or within 1 year of the end of pregnancy from any cause related to or aggravated by pregnancy” [1]. Since the implementation of the PMSS, the number of reported pregnancy-related deaths in the United States has been increasing for the past three decades from 7.2 deaths in 1987 to 17.3 deaths per 100,000 live births in 2018 [1]. More recent data from the National Vital Statistics System showed a steady increase in maternal death with maternal mortality rate of 20.1 in 2019 and 23.8 deaths per 100,000 live births in 2020 using the World Health Organization (WHO) definition of maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes” [2, 3]. According to the PMSS data, the three most common causes of pregnancy-related death are other cardiovascular conditions (16.2%), infection (13.9%) and cardiomyopathy (12.5%) [1]. Other notable causes include thrombotic pulmonary or other embolism (9.4%), cerebrovascular accidents (7%), and hypertensive disorders of pregnancy (HDP) (6.8%) [1]. There are statistically significant associations between higher maternal mortality rates and maternal age of 40 years and older (7.8 times the rate for women who are 25 years and younger) and non-Hispanic Black race (2.9 times the rate for non-Hispanic White women) [3].

Trends in Cardiovascular Disease The United States is the only developed country with increasing maternal mortality in the recent decades and approximately half of pregnancy-related deaths are due to cardiovascular disease such as cardiomyopathy, thrombotic pulmonary or other embolism, cerebrovascular accidents, hypertensive disorders of pregnancy, and other cardiovascular complications [1]. Cardiovascular disease is now the leading cause of pregnancy-related death while obstetric causes of death have decreased over time [4]. A recent study using the National Vital Statistics System showed that the rates of HDP and chronic hypertension increased from 1989 to 2020 with annual increases of 3.6% and 4.1%, respectively, whereas the rate of eclampsia decreased. With advances in treatment of congenital heart disease (CHD), there is an increasing number of women with CHD who are in reproductive age [5]. A recent study

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showed that the prevalence of maternal CHD during delivery hospitalizations rose from 4.2 to 10.9 per 10,000 deliveries from 2000 to 2018 [6].

Maternal Mortality Related to COVID-19 Since the WHO declared the Coronavirus Disease 2019 (COVID-19), a global pandemic in March 2020, many countries, their healthcare systems, and individuals including those who are pregnant have been profoundly impacted by the disease. Studies have found that pregnant individuals with COVID-19 are at increased risk of intensive care unit admission, mechanical ventilation, and death compared with both pregnant individuals without the infection and non-pregnant individuals with the infection [7–9]. Various cardiovascular complications in pregnancy-associated COVID-19 have also been described [10]. A meta-analysis of international data on the effects of the pandemic on maternal, fetal, and neonatal outcomes (31 studies included for analysis) has found that there was a significant increases in stillbirth (pooled OR 1.28 [95% CI 1.07–1.54]), maternal death (OR 1.37 [95% CI 1.22–1.53]), and maternal stress as measured by mean Edinburgh Postnatal Depression Scale scores (pooled mean difference 0.42 [95% CI 0.02–0.81]) during versus before the pandemic [11]. In a retrospective study of a large cohort involving more than 1.6 million pregnant patients across 463 hospital in the United States, COVID-19 pandemic was associated with increases in maternal mortality rate (5.17 per 100,000 pregnant patients during the pre-pandemic period and 8.69 per 100,000 during pandemic) and pregnancy complications such as HDP and hemorrhage [12]. Clearly, the COVID-19 pandemic has negatively impacted maternal and fetal health, the effects of which are exacerbated in resource-limited communities [11].

Racial and Ethnic Disparities Gaping disparities in maternal mortality exist in the United States between ethnic minority women and non-Hispanic White women. In 2020, maternal mortality rates for non-Hispanic Black women were 2.9  times the rate for non-Hispanic White women [3]. There were statistically significant increases in maternal mortality rates for non-Hispanic Black women and Hispanic women from 2019 to 2020, whereas the mortality rate for non-Hispanic White women remained relatively stable [3]. Unfortunately, increased maternal mortality in Black women is still present after adjusting for education and socioeconomic status [13]. Racial and ethnic disparities are also evident in rates of severe maternal morbidity. Non-Hispanic Black women are more likely to have preterm labor, premature rupture of membranes, preeclampsia, other HDP, infection, placenta previa, and placental abruption compared to non-­ Hispanic White women [14–16]. Similarly, Hispanic and Asian/Pacific Islander women have an increased risk of gestational diabetes mellitus, placenta previa, and

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postpartum hemorrhage compared to non-Hispanic White women [14, 15, 17, 18]. Additionally, non-Hispanic Black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women have been found to have higher rates of severe morbidity measured with and without blood transfusion relative to non-Hispanic White women [19]. Many risk factors that contribute to severe maternal morbidity including hypertension and gestational diabetes are preventable and treatable when detected early. There is an urgent need to understand how maternal race/ethnicity affects mortality, morbidity, and pregnancy outcomes. To eliminate racial disparities in maternal health, careful consideration of mother’s socioeconomic status, health education, access to care, timely screening, early follow-up, and seamless postpartum transition to primary/specialty care for long-term cardiovascular risk management needs to take place.

Trends in Adverse Pregnancy Outcomes Pregnancy leads to many physiological and metabolic changes in the mother to support fetal growth and development. However, the physiological stress on the cardiovascular system during pregnancy and labor may unmask underlying cardiovascular conditions and reveal adverse pregnancy outcomes (APOs). An adverse pregnancy outcome is one of maternal or fetal complications, including HDP, gestational diabetes, fetal growth restriction, small-for-gestational-age (SGA) infants, placental abruption, and preterm delivery. These complications have been associated with future cardiovascular disease development such as atherosclerotic coronary artery disease, heart failure, and stroke [20–22]. Similar to the trends in maternal mortality, there has been a significant increase in APOs in the United States, now affecting approximately 10–20% of all pregnancies [22]. Rates of HDP have increased dramatically and affected 912 per 10,000 delivery hospitalizations in 2014 [23]. Similar increases have been reported in the rates of preterm birth and SGA infants [23, 24]. The rise in APOs is largely due to the increased prevalence of obesity, advanced age, and chronic medical conditions such as hypertension and diabetes mellitus in pregnant individuals. The rise in the rates of APOs, cardiovascular disease, and maternal mortality over time are closely interconnected. Addressing maternal health is a public health emergency and should involve interventions that involve increasing awareness/education, improving access to care, providing social support, and creating multidisciplinary team approaches to medical care.

Importance of Cardio-Obstetrics Training Cardio-obstetrics is an emerging subspecialty in cardiology that focuses on management of individuals with or at high risk for cardiovascular disease who are pregnant or considering pregnancy [25]. With increasing numbers of pregnant people

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with complex congenital heart disease, acquired cardiovascular conditions and APOs, general adult cardiologists need to be familiar with normal physiology of pregnancy, existing disparities, modifiable cardiometabolic risk factors, management of hypertension during pregnancy, interpretation of biomarkers, and echocardiographic changes during pregnancy [26]. Similar to other multidisciplinary teams within cardiology, cardio-obstetrics teams require a group of dedicated individuals with effective communication across various disciplines (Maternal Fetal Medicine, Obstetrics-Gynecology, Anesthesiology, Cardiology, Adult Congenital Heart Disease, Social Work, Nursing, and Pharmacy) [26]. Currently, large knowledge gaps exist among cardiovascular clinicians [27]. While most cardiovascular disease fellowships do not provide formal training in cardio-obstetrics, adding exposure and didactics about cardio-obstetrics would improve trainees’ skill and comfort with managing this high-risk patient population.

I mplications of the Overturning of Roe v. Wade on Maternal Mortality The US Supreme Court’s decision to overturn Roe v. Wade in June 2022 will impact the lives of many women, especially those with existing cardiovascular conditions and high risk for the development of APOs. For those with pre-existing high-risk cardiac conditions, the physiologic stress of pregnancy can be a threat to their health and well-being. The Supreme Court’s ruling unfortunately creates a barrier to providing appropriate care to pregnant women with high-risk cardiovascular disease, with greater impact on those individuals without resources to seek care in an abortion protected state. This decision is expected to have greater impact on racial/ethnic minority groups that suffer from higher rates of cardiovascular disease and APOs). Abortion restriction will undoubtedly further marginalize this high-risk group during pregnancy. With limited access to abortion care in many states, there needs to be heightened awareness of overall cardiovascular health in reproductive age women. The risks of pregnancy should be considered at each patient encounter. Risk stratification tools such as CARPREG II, ZAHARA, and modified WHO classification should be utilized routinely during preconception counseling to provide sufficient information about future risk related to pregnancy. These issues are now in the lane of all cardiologists, not just those with cardio-obstetrics expertise. For those with high-risk cardiovascular conditions, individualized counseling for risk assessment/ management, contraception, family planning, and pregnancy termination should take place by a multidisciplinary team including Primary Care, Obstetrics, Maternal Fetal Medicine, and Cardiology specialists.

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References 1. CDC. Pregnancy mortality surveillance system. Centers for Disease and Prevention; 2022. 2. Organization WH. International health regulations. World Health Organization; 2005. p. 2008. 3. Hoyert LD. Maternal mortality rates in the United States, 2020. NCHS Health E-Stats; 2022. 4. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related mortality in the United States, 2011-2013. Obstet Gynecol. 2017;130:366–73. 5. Marelli AJ, Ionescu-Ittu R, Mackie AS, Guo L, Dendukuri N, Kaouache M. Lifetime prevalence of congenital heart disease in the general population from 2000 to 2010. Circulation. 2014;130:749–56. 6. Linder AH, Wen T, Guglielminotti JR, et al. Delivery outcomes associated with maternal congenital heart disease, 2000–2018. J Matern Fetal Neonatal Med. 2022;35:1–10. 7. Zambrano LD, Ellington S, Strid P, et al. Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status— United States, January 22-October 3, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1641–7. 8. Jering KS, Claggett BL, Cunningham JW, et al. Clinical characteristics and outcomes of hospitalized women giving birth with and without COVID-19. JAMA Intern Med. 2021;181:714–7. 9. Allotey J, Stallings E, Bonet M, et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ. 2020;370:m3320. 10. Briller JE, Aggarwal NR, Davis MB, et  al. Cardiovascular complications of pregnancy-­ associated COVID-19 infections. JACC Adv. 2022;1:100057. 11. Chmielewska B, Barratt I, Townsend R, et al. Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis. Lancet Glob Health. 2021;9:e759–72. 12. Molina RL, Tsai TC, Dai D, et al. Comparison of pregnancy and birth outcomes before vs during the COVID-19 pandemic. JAMA Netw Open. 2022;5:e2226531. 13. Petersen EE, Davis NL, Goodman D, et  al. Racial/ethnic disparities in pregnancy-related deaths—United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2019;68:762–5. 14. Shen JJ, Tymkow C, MacMullen N. Disparities in maternal outcomes among four ethnic populations. Ethn Dis. 2005;15:492–7. 15. Cabacungan ET, Ngui EM, McGinley EL. Racial/ethnic disparities in maternal morbidities: a statewide study of labor and delivery hospitalizations in Wisconsin. Matern Child Health J. 2012;16:1455–67. 16. Tanaka M, Jaamaa G, Kaiser M, et  al. Racial disparity in hypertensive disorders of pregnancy in New York state: a 10-year longitudinal population-based study. Am J Public Health. 2007;97:163–70. 17. Bardenheier BH, Elixhauser A, Imperatore G, et al. Variation in prevalence of gestational diabetes mellitus among hospital discharges for obstetric delivery across 23 states in the United States. Diabetes Care. 2013;36:1209–14. 18. Bryant AS, Worjoloh A, Caughey AB, Washington AE. Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. Am J Obstet Gynecol. 2010;202:335–43. 19. Creanga AA, Bateman BT, Kuklina EV, Callaghan WM.  Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008–2010. Am J Obstet Gynecol. 2014;210(435):e1–8. 20. Hauspurg A, Ying W, Hubel CA, Michos ED, Ouyang P. Adverse pregnancy outcomes and future maternal cardiovascular disease. Clin Cardiol. 2018;41:239–46. 21. Parikh NI, Gonzalez JM, Anderson CA, et al. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women: a scientific statement from the American Heart Association. Circulation. 2021;143:e902–16.

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22. Lane-Cordova AD, Khan SS, Grobman WA, Greenland P, Shah SJ. Long-term cardiovascular risks associated with adverse pregnancy outcomes: JACC review topic of the week. J Am Coll Cardiol. 2019;73:2106–16. 23. CDC.  Data on selected pregnancy complications in the United States. Atlanta, GA: Reproductive Health; 2017. 24. Martin JA, Hamilton BE, Osterman MJ, Driscoll AK, Drake P. Births: final data for 2016. 2018. 25. Minhas AS, Goldstein SA, Vaught AJ, et al. Instituting a curriculum for cardio-obstetrics subspecialty fellowship training. Methodist Debakey Cardiovasc J. 2022;18:14–23. 26. Davis MB, Walsh MN. Cardio-Obstetrics. Circ Cardiovasc Qual Outcomes. 2019;12:e005417. 27. Bello NA, Agrawal A, Davis MB, et  al. Need for better and broader training in cardio-­ obstetrics: a National Survey of cardiologists, cardiovascular team members, and cardiology fellows in training. J Am Heart Assoc. 2022;11:e024229.

Chapter 2

Health Disparities S. Michelle Ogunwole, Naomi Fields, Ceshae C. Harding, and Melody Tran

Key Points • Cardiovascular disease (CVD) is the leading cause of maternal morbidity and mortality in the United States and disproportionately impacts those from socially marginalized populations, including those who are racially and/or ethnically minoritized, individuals with low socioeconomic status, or those with a disability. • Over the past decade, there has been a steady decline in preconception cardiovascular health. Disparities in CVD risk factors (e.g., hypertension, diabetes, obesity, inadequate physical activity, and smoking) persist across age, racial, ethnic, socioeconomic, geographic, disability, and insurance subgroups, with Black, Hispanic, American Indian/Alaska Native women, those living in rural or Southern regions, on Medicaid or with low socioeconomic status being more likely to experience CVD risk factors. • During pregnancy, Black women have higher odds of experiencing CVD-related mortality and morbidity, regardless of socioeconomic status. Those with a disability are also more likely to experience a cardiovascular event during labor and delivery. • Complications in pregnancy (e.g., hypertensive disorders of pregnancy, gestational diabetes, and preterm birth) are associated with the development of long-­

S. M. Ogunwole (*) · M. Tran Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] N. Fields Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA C. C. Harding Department of Medicine, Duke University Medical Center, Durham, NC, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 G. Sharma et al. (eds.), Contemporary Topics in Cardio-Obstetrics, Contemporary Cardiology, https://doi.org/10.1007/978-3-031-34103-8_2

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term CVD and are more likely to occur in women who are from racial and ethnic minority populations or those with a disability. • Research shows that maternal health disparities occur as a result of structural racism and its influence on the neighborhood environment, as well as interpersonal racism and its effect on perinatal care.

Maternal Health Disparities and Cardiovascular Disease In the United States, Black and Indigenous women are three to four times more likely to die as a complication of pregnancy than their White counterparts and face similar disparities related to maternal morbidity [1–5]. Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality, disproportionally impacting women from racial and ethnic minority populations. Cardiometabolic complications during pregnancy (e.g., hypertensive disorders of pregnancy) increase the risk of future CVD and maternal morbidity and mortality in subsequent pregnancies. These cardiometabolic complications also disproportionately impact racial and ethnic minority populations. Other social risk factors including low socioeconomic status, geographic location, and disability status similarly contribute to disparities in preconception cardiovascular risk factors, cardiometabolic complications during pregnancy, and related CVD sequelae [1, 6–8]. Clinical attention to these disparities throughout the reproductive continuum is needed. Cardio-Obstetrics, which focuses on the intersection of CVD and pregnancy health from preconception through postpartum, has emerged in response to rising rates of CVD-related maternal morbidity and mortality [9, 10]. In order to improve CVD-related maternal health equity, it is necessary to evaluate these disparities through a cardio-obstetric lens that considers social and structural determinants of health. In this chapter, we present data related to disparities in preconception CVD risk factors (Sect. 2.2), CVD in pregnancy (Sect. 2.3), and cardiometabolic complications during pregnancy that increase the risk of future CVD (Sect. 2.4). We also consider causes of these disparities (Sect. 2.5).

Disparities in Preconception CVD Risk Factors Preconception cardiovascular health in the United States has steadily declined over the past decade, with persistent disparities in CVD risk factors (e.g., hypertension, diabetes, overweight/obesity, inadequate physical activity, and smoking) across age, racial, ethnic, socioeconomic, geographic, disability, and insurance subgroups [11].

2  Health Disparities

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Hypertension Based on the Centers for Disease Control and Prevention Natality Database (N = 47,949,381), the rate of preconception hypertension nearly doubled between 2007 and 2018 from 10.9 to 20.5 per 1000 live births [12]. Non-Hispanic Black women have the highest prevalence of preconception hypertension compared with non-Hispanic White or Hispanic women [12, 13]. The 2018 prevalence of chronic hypertension in non-Hispanic Black women was over twice that of non-Hispanic White and Hispanic women, respectively (4.0% non-Hispanic Black; 1.9% White; 1.4% Hispanic. N = 43,890,101) [14]. Additional geographic and age disparities exist: Women in rural areas had a 20% higher rate of preconception hypertension than women in urban areas [12]. Also, women aged 35–44  years have over three times the preconception-hypertension prevalence of those aged 18–24 (5.0% [95% CI: 4.5–5.4] vs. 17.0% [95% CI: 16.4–17.6]) [12, 13].

Diabetes Rates of preconception diabetes (i.e., preexisting diabetes) increased from 0.65% deliveries in 2000 to 0.9% by 2016 [15, 16]. One study of 19 states found that in 2010, the age-standardized prevalence of preconception diabetes was highest among non-Hispanic Black women (1.27 per 100 births), followed by Hispanic (0.94 per 100 births), Asian (0.73 per 100 births), and non-Hispanic White women (0.72 per 100 births) [15]. Another national study found that among women with a live birth (2012–2016), the highest crude prevalence of preexisting diabetes was among American Indian/Alaska Native (AIAN) women (2.1%) and Native Hawaiian/ Pacific Islander (NHPI) women (1.8%), followed by non-Hispanic Black (1.2%), Hispanic (1%), Asian (0.9%), and non-Hispanic White women (0.7%) [16]. Geographically, women in the Southern states have the highest rates of preconception diabetes (1.08 per 100 births) though some of the largest relative increases occur in the West [15]. Rates of preconception diabetes also increase consistently with age, [15, 16] yet remain lowest among those with a college degree versus those with less than high-­ school education (0.6% vs. 1.1%, p  90a – Above criteria twice at least 4 h apart

b

a

SBP: systolic blood pressure; DBP: diastolic blood pressure Chronic hypertension with severe features: BP requiring multiple IV antihypertensives c Delivery timing: before 34 weeks if unable to safely manage the pregnancy expectantly (Table 9.2) d Serum labs: liver function tests >2x upper limit of normal, creatinine >1.1 or doubling of serum creatinine, platelets