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Health Professionals

Why It’s Urgent to Act to Against Cardiovascular Disease, Leading Cause of Maternal Death

The accumulated total of maternal deaths caused by a cardiovascular disease, including venous thromboembolism, stroke and gestational hypertension, made it by far the leading cause of maternal death in France between 2013 and 2015.

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It is estimated that 150,000 women of childbearing age in France have a cardiovascular disease. If these patients don’t receive appropriate care during pregnancy, the risk of complications for their children is 15 times higher and their risk of death is 100 times higher.

Pregnancy is a true physiological stress test for the cardiovascular system. The heart and arteries work hard during pregnancy and after delivery. The body has an unexpected capacity for physiological adaptation that allows the placenta to develop properly. This new vascular organ will enable the fetus to grow after it’s conceived. Pregnancy is also like an endurance marathon that lasts for several months. Early in pregnancy, the size of the heart cavities increases, vessels dilate, and the heart rate and cardiac output increase to meet the increasing demands of the new placenta/fetal unit. Delivery also requires the heart to work much harder due to the contractions and expulsion, the pain, the bleeding and the anesthesia. At the same time, the body’s coagulation systems are activated to avoid postpartum hemorrhage. The increase in cardiac workload and blood volume may then destabilize or even reveal a cardiac or arterial disease, most often during the third trimester, when the heart’s workload becomes the highest. In addition, in 10 to 15% of cases, the placenta, a new vascular organ that provides nourishment, may not develop correctly leading to placental ischemia starting at the end of the second trimester with sometimes fatal complications for the fetus (growth restriction, prematurity, fetal death) and the mother.

As more women have babies later in life, the risk of placental ischemia is increasing. Women are also exposed at younger ages to a range of environmental risk factors with insidious effects over the years, including tobacco use, stress, sedentary lifestyle, unbalanced diet, excess weight, obesity, diabetes, high cholesterol and high blood pressure. These make placentation more difficult, highlighting the importance of more systematic screening at this key stage in a woman’s life. For those with a known cardiovascular disease, pregnancy increases the risk of developing a progressive complication. The frequency and severity depend on the type of disease. Several scores allow medical staff to evaluate the risk of serious cardiovascular complications to which these women will be exposed during a possible pregnancy.

This sixth trial in France highlights three warnings we need to act on:
- First warning: cardiovascular disease has become the leading cause of maternal mortality. This is a major shift in risk factor epidemiology.
- Second warning: 66% percent of maternal deaths due to cardiovascular causes are preventable. This is a disturbing warning because it calls our current practices into question. This shocking result highlights the enormous room for improvement in our healthcare system, which must move faster towards preventive maternal medicine.
- Third warning: women in high-risk situations who are psychologically and financially vulnerable and for whom pregnancy is not their most pressing concern experience a loss of chance. These women have left a care pathway for various social reasons like unemployment, domestic violence, social isolation, single parenthood, immigration, etc. They are more exposed to cardiovascular risk factors such as obesity, sedentary lifestyle, high blood pressure and tobacco use. Nearly 30% of preventable maternal deaths happen to women in high-risk situations. Explanatory causes include refusal of care, lack of adherence and more frequent comorbidities like obesity. We cannot remain inactive when facing these facts. We must act to reverse this trend, save the lives of these young, vulnerable women and give them the support they need for a successful pregnancy.

We created Women’s Cardiovascular Healthcare Foundation (Agir pour le Cœur des Femmes) to take concrete action with all of these women focused on three As:
Alert – Anticipate – Act.

We must advocate together for development of effective preventive medicine, especially during pregnancy, by working on these three As:
- Alert women who have cardiovascular risk factors or heart disease that they need to prepare for pregnancy, to change certain teratogenic medications, and to reevaluate their cardiovascular situation in consultation with their primary doctor, cardiologist and obstetrician before getting pregnant. It’s essential to inform health professionals, as well as all women, about cardiovascular warning signs during pregnancy and postpartum before it’s too late.
- Anticipate through preconception and postpartum consultations such as those recommended by the French Society of Hypertension (www.sfhta.eu). Preventive maternal medicine must encourage women to talk to their primary doctor or gynecologist about their desire to have a baby and encourage health professionals to question their young patients of childbearing age. For a woman with cardiovascular risk factors, the cardiologist will decide the check-ups to be completed before conception. Depending on the level of cardiovascular risk, the case will be discussed with the cardio-obstetrical team using the WHO classification to give a green light or red light to pregnancy. Women with a cardiovascular disease must carefully plan for pregnancy in close consultation with a multidisciplinary team for optimal safety to avoid a fatal event at all costs. After delivery, the cardiovascular situation will be reevaluated, the treatment adapted and the gynecardiological monitoring outlined.
- Act by monitoring these at-risk women all throughout their pregnancy at an obstetrical and cardiovascular center of expertise that provides sustained prenatal care. Regular pregnancy check-ups will be set up through a dedicated coordinated pathway that brings together all health professionals and patients to avoid the unacceptable death of a young woman. We must act beyond pregnancy, as well, through long-term cardiovascular and gynecardiology care to avoid later events through preventive, offensive and positive medicine. We must reverse this dramatic epidemiology: in France, 200 women per day die from a cardiovascular disease, including young mothers whose deaths could have been prevented in many cases.

Together, we can change the medical system to focus more on prevention with careful observation for women during pregnancy. This study shakes us up, challenges us and causes us to question what we do as medical professionals since our vocation is to care for people and save lives. It highlights the urgency of developing multidisciplinary care pathways that are more focused on preventive medicine with local medical-social activities in neighborhoods that have been neglected.

View the full report in French at this link
http://www.epopé-inserm.fr/grandes-enquetes/enquete-nationale-confidentielle-sur-les-morts-maternelles

 

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