Viewing Pregnancy as a Cardiovascular Stress Test: New Information

Pregnancy and the first year postpartum are important times to monitor for life-long cardiovascular risk. Christina Ackerman-Banks, MD, maternal-fetal medicine specialist with Texas Children’s Hospital, sees pregnancy as a unique time to evaluate a woman’s heart health and make adjustments that could benefit her for the rest of her life.  

“I feel really strongly that we have a unique opportunity as providers who see patients during pregnancy to not only improve their health and that of their baby during pregnancy but also long term. It’s an important time when patients are open to education, awareness about their risks and definitely they’re more open to intervention,” said Dr. Ackerman-Banks. 

Empowering women to improve their health during pregnancy 

Physiologic changes during pregnancy, such as increased blood volume and increased heart rate, can act as a cardiac stress test and give obstetricians insight into a patient’s heart health, and determine when cardiovascular interventions are appropriate during pregnancy. Recent recommendations from the American College of Obstetrics and Gynecology (ACOG) have shown that during pregnancy, blood pressure should be monitored closely and kept below 140/90, tighter control than previous guidelines.  

In addition to these important considerations, some pregnancy complications are important indicators of heart health after pregnancy.  

“We know that people with gestational diabetes have an increased risk for type 2 diabetes. It is the same for placental syndromes: not just preeclampsia but also preterm birth, fetal growth restriction, placental abruption and most recently, prenatal depression. We have not yet determined the mechanism for how those things are directly related to someone’s cardiovascular health, but we do know that they are an early sign of long-term cardiovascular disease risk,” said Dr. Ackerman-Banks. 

Accessing long-term care to assess long-term risks 

The signs of long-term cardiovascular disease that may appear in pregnancy allow for early interventions and monitoring. Many women who do not otherwise have insurance can find coverage for prenatal visits, but this often ends 42 days postpartum.  

“Cardiac disease, outside of pregnancy, is the leading cause of death among women, accounting for 1 in 5 deaths. To optimize long-term health for women, I think that we need to allow patients better access beyond 42 days postpartum,” said Dr. Ackerman-Banks. 

ACOG recommends that any woman who experienced preeclampsia, gestational diabetes or preterm birth have a cardiovascular screening exam that includes evaluations of blood pressure, weight, diabetes risk, smoking status and lipid levels at 1 year postpartum. Many of the women referred for these follow-up visits are young enough that lifestyle changes can eliminate their hypertension or type 2 diabetes risk, which will impact the risks during a subsequent pregnancy and for their lifelong health.  

“There is a lot of literature coming out now looking at the incidence of de novo chronic hypertension within a year postpartum for someone who did not have a pregnancy complication, and it’s actually quite high. There have been studies showing it to be between 20 and 30%,” said Dr. Ackerman-Banks.  

These studies suggest that all postpartum women will benefit from routine blood pressure checks following pregnancy so that hypertension can be treated early on.  

The role of the cardiologist 

Cardiologists can also use an obstetric history to gauge a woman’s risk for future cardiovascular disease. Detailed questions about a woman's reproductive history, including number of pregnancies, preterm deliveries, pregnancy complications and history of depression can signal how aggressively to monitor or treat a person’s heart health.  

“A lot of providers who are not OB/GYNs are cautious to ask about a person’s reproductive history, but I think that is the first step,” said Dr. Ackerman-Banks. 

Cardiology patients who are pregnant or plan to become pregnant can receive the same treatment for cardiac conditions as anyone else. While there were once concerns that tight blood pressure control could lead to fetal growth restriction, recent evidence has shown that keeping maternal blood pressure below 140/90 is safe for the fetus.  

Having a close relationship with obstetricians can help a cardiologist, or any other provider, align their care with the needs of pregnancy.  

Refer a patient to Texas Children’s Maternal-Fetal Medicine through their online portal, or by calling 832-826-4636.