Disclosures: Ramirez reports no relevant financial disclosures.
May 31, 2022
4 min read
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Q&A: Anti-abortion laws and implications for pregnant patients with CVD

Disclosures: Ramirez reports no relevant financial disclosures.
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As the U.S. Supreme Court prepares to issue a decision that could potentially overturn Roe v. Wade, many states are preparing to restrict or eliminate abortion rights for patients, including those with CVD.

“CVD is the leading cause of pregnancy-related mortality in the United States,” Verity N. Ramirez, MD, a cardiology fellow at the University of Connecticut and Hartford Hospital, told Healio. “Cardiologists must own abortion access as a topic that is important to our patients’ cardiovascular and reproductive health.”

Graphical depiction of source quote presented in the article
Ramirez is a cardiology fellow at the University of Connecticut and Hartford Hospital.

As Healio previously reported, CVD and cardiomyopathy are the leading causes of maternal mortality up to 1 year after pregnancy, accounting for one-quarter of maternal deaths in the U.S., according to the Pregnancy Mortality Surveillance System.

Healio spoke with Ramirez about the risks for CVD during pregnancy, the impact of lack of access to abortion care and the importance of preconception planning and counseling. Ramirez, along with Melissa Ferraro-Borgida, MD, of Hartford HealthCare Heart & Vascular Institute, and Sarah Lindsay, MD, of Hartford HealthCare Medical Group, co-wrote a viewpoint article on anti-abortion laws and implications for patients with CVD in pregnancy, published in JAMA Cardiology.

Healio: What led you and your colleagues to write this viewpoint now?

Ramirez: We started working on this article in December 2021, as the arguments for Dobbs v. Jackson Women’s Health Organization were happening. We felt there was an urgency, as there was a case before the Supreme Court that could overturn Roe v. Wade. That sense of urgency prompted us all to consider what might happen to patients with CVD in pregnancy if they lost access to abortion care.

Healio: Can you outline some of the risks for pregnant women with CV conditions?

Ramirez: Pregnant patients with conditions like aortopathies, cardiomyopathies, valvular heart disease and congenital heart disease are at high risk for pregnancy complications. There are many physiological changes that occur during pregnancy that can be poorly tolerated in patients with underlying or undiagnosed CVD. With pregnancy, there is an increase in total blood volume and cardiac output that is poorly tolerated, particularly for patients with HF, stenotic valvular disease and congenital heart conditions. The increase in volume along with increase in heart rate, hormonal changes and triggering of the autonomic system can stress the heart and trigger arrythmias. Even with conditions like aortopathies, pregnancy can weaken the aortic wall, increase aortic diameter and risk for dissection. Additionally, CV decompensation during pregnancy can affects a patient’s functional status, ability to raise children and future CV health.

Healio: What is the shared decision-making process like for patients with CVD who are pregnant?

Ramirez: Cardiologists may engage in shared decision-making on pregnancy termination for patients with CVD when there is high maternal risk or when pregnancy interferes with medical or surgical treatment. There are different risk calculators used in cardio-obstetrics. One commonly used is the modified WHO classification of maternal cardiovascular risk. Using this framework, class III to class IV conditions are defined as those that pose significantly increased risk for maternal mortality or severe morbidity during pregnancy. Class IV conditions, such as pulmonary arterial hypertension of any cause, severe systemic ventricular dysfunction (a left ventricular ejection fraction < 30%), previous peripartum cardiomyopathy or severe symptomatic mitral or aortic stenosis, confer extremely high risk for maternal mortality or severe morbidity. For these women, pregnancy should be discouraged during the preconception period.

We have individualized discussions with patients about their specific conditions and the risk to their CV health, risk to the fetus, what medications they are taking, if their medications could or should be changed, and what risks any medication changes pose to the pregnant patient or the fetus. We discuss the relative safety of undergoing pregnancy termination as an option to the risk posed by pregnancy. For people with a class IV CV condition, discussion regarding pregnancy termination should occur immediately, but many patients discover their pregnancy after 6 weeks. In states with abortion bans after 6 weeks’ gestation, these women are at risk for CV complications.

Healio: As you and your co-authors wrote, over 500 state laws already reduce or restrict access to abortion care across the country. How does this already complicate care for these patients? What might be the impact of no longer having access to abortion care?

Ramirez: There are hundreds of laws restricting abortion access already. They add many non-evidence-based restrictions on abortion providers, clinics and patients.

Abortion bans, such as Mississippi’s 15-week law, do not consider changes in CV symptoms and risk that can occur throughout pregnancy. Even in currently compensated CV conditions, pregnancy can cause decompensation or recurrence in any trimester. In peripartum cardiomyopathy with recovered EF, there is a 20% chance of recurrent HF with subsequent pregnancies. Recurrence can have a more malignant outcome, such as the need for heart transplant or death. For patients with Turner or Marfan syndrome, the aorta can become significantly dilated as pregnancy progresses, putting them at risk for possible dissection or rupture.

In areas of the U.S. with the highest burden of abortion restrictions, data are clear: We see increased maternal mortality. These laws disproportionately affect patients of color, those living in rural areas and patients of lower socioeconomic status, all of whom are more likely to die during pregnancy and experience adverse CV complications yet are less likely to have access to an abortion. Not having any access — removing that right — will worsen what we already see with restrictive abortion laws.

Healio: How should cardiologists who practice in areas where restrictive legislation is being proposed and/or passed counsel patients who have CV conditions?

Ramirez: Particularly in areas where restrictive legislation exists or will further exist, it is important to focus on the preconception period. The contraception discussion must happen earlier, starting with pediatric cardiologists and continuing through the transition into adult care. As cardiologists, we must be discussing effective and safe contraception methods, particularly for the patients we care for with CVD, and encourage our patients to consider these methods.

It is also imperative to improve the transition period from pediatric to adult cardiology care, which occurs during the reproductive years, for adolescents and young adults with congenital heart disease.

Another important aspect of preconception care is better access to primary care. Chronic health conditions are often not well managed during the preconception period. We also must work to address social determinants of health and increase access to comprehensive care for those who need it most. Having all of these risk factors better controlled is so important.

For more information:

Verity N. Ramirez, MD, can be reached at verity.ramirez@hhchealth.org.