Sarah Goldstein, MD, assistant professor of medicine (cardiovascular medicine), serves as the medical director for Cardiovascular Medicine of the Cardiovascular Disease and Pregnancy Program in partnership with the medical directors for Maternal-Fetal Medicine, Annalies Denoble, MD, MSC, assistant professor of medicine (obstetrics, gynecology, and reproductive services) and Katherine Campbell, MD, MPH, assistant professor of medicine (obstetrics, gynecology, and reproductive services).
In the following Q&A, Goldstein shares five things everyone should know about pregnancy and its impact on heart health.
1. Heart disease is the number one cause of maternal mortality in the United States – and it’s rising.
Heart disease is responsible for more than a quarter of all pregnancy-related deaths and is the number one cause of maternal mortality in the U.S. There are two primary reasons for this, Goldstein says.
First, patients are getting pregnant later in life when they’ve had more time to acquire heart disease or risk factors for heart disease. Second, cardiologists do a great job of caring for kids with congenital heart disease. This means that patients with congenital heart disease live into adulthood and are healthy enough to consider becoming pregnant.
“The changes that the cardiovascular system must undergo to sustain a healthy pregnancy can be considered a 9-month stress test for the heart. Patients with cardiovascular disease may not be able to tolerate this, thus putting them at risk for complications related to their heart during or after pregnancy,” she said.
2. Most people with heart disease can carry a pregnancy safely if they receive appropriate care and monitoring during pregnancy and delivery.
The good news is that many adverse outcomes are preventable if patients receive the right care.
“Doctors can tell most people with heart disease that it is okay to get pregnant. Most patients can typically have a safe and successful pregnancy. All patients who are considering pregnancy, however, should understand potential risks related to their cardiovascular disease,” said Goldstein. “Before, during, and after pregnancy, patients with heart disease should receive close care from a specialist who can assess their risk and monitor their heart health closely.”
3. For people with heart conditions, pregnancy should be carefully planned.
Goldstein stresses that although typically safe for people with heart conditions, pregnancy should be very carefully planned.
“It is important to perform comprehensive risk assessment, get up-to-date imaging and diagnostic studies, and make sure our patients are on pregnancy-safe medications before they conceive,” Goldstein said. “We want pregnancy to be planned so we can make sure it is going to be safe for our patients and their baby.”
That’s why it’s especially important for people with heart disease who are of childbearing age to use a reliable form of contraception.
“The best form of contraception may be different for each individual patient,” she said. “There are lifestyle considerations, but also cardiac disease-specific considerations.” For example, systemic estrogen is one of the most prescribed oral birth control medications, but it is unsafe for many patients with heart disease.
Goldstein says that all patients with heart disease – or even risk factors for heart disease – should have a formal consultation to determine which form of contraception will be best for them.
4. Some conditions that emerge during pregnancy, like preeclampsia, are associated with an increased risk of future cardiovascular disease.
Adverse outcomes that emerge during pregnancy can be a helpful window into a patient’s overall cardiovascular health.
“It can be scary and disruptive for patients to experience preeclampsia around the time of their delivery,” said Goldstein. “They’re adjusting to life with a new baby and yet likely have concerns about why this happened to them and what it means for their overall health.”
For patients who experience preeclampsia, it can be helpful to see a specialist to determine if they have other risk factors for heart disease.
"When we screen patients who have had preeclampsia with no other identified risk factors for heart disease, we often see that their cholesterol or lipoprotein(a) is elevated, or they have pre-diabetes,” said Goldstein. “If they did not have this experience during pregnancy, they may not have received cardiovascular risk factor screening at this early stage of their life.”
5. Most people with heart disease can safely lactate or breastfeed if they want to.
Most patients with heart disease should be able to breastfeed if they want to.
But there are challenges. Patients with heart disease may need consultations to determine if their cardiac medications are safe for their baby during lactation. Other medications may negatively affect breast milk supply, leading to problems right from the start. Patients with heart disease often have more complicated deliveries or need procedures or surgeries after delivery that can make breastfeeding more logistically difficult.
The new Cardiovascular Disease and Pregnancy Program includes a lactation clinic focused specifically on providing this counseling to patients with heart disease.
“Lactation and breastfeeding are associated with lower rates of acquired heart disease and cardiovascular comorbidities later in life,” said Goldstein. “Any measure we can take to improve cardiovascular health in our patients is important. Our goal is to help our patients have a safe and healthy pregnancy and to set them up for better long-term cardiovascular health.”
The Department of Internal Medicine at Yale School of Medicine is among the nation's premier departments, bringing together an elite cadre of clinicians, investigators, educators, and staff in one of the world's top medical schools. To learn more, visit Internal Medicine.