Substantial Post-Roe Risks for Patients with Cardiovascular Disease
When the United States (US) Supreme Court overturned the Roe v Wade decision in June 2022, proponents of reproductive choice warned of the wide range of adverse consequences that may result from the decision to end federal protection of abortion access. In addition to the anticipated impact of abortion restrictions on the general population, many medical experts and patient advocacy groups have emphasized the potential dire effects of such restrictions on certain patient populations including those with chronic diseases and disabilities.1,2
Certain cardiovascular diseases (CVDs), for example, are associated with increased risk for morbidity and mortality in pregnancy.3 Recent findings from the US Centers for Disease Control and Prevention show that cardiac conditions represent the leading cause of maternal mortality, accounting for more than one-third of pregnancy-related deaths.4 Thus, it is important that individuals with these conditions retain the option to terminate a pregnancy if it poses risks to the patient.
“Patients with heart disease, including congenital heart disease (CHD), often face increased risks to their health during pregnancy,” said Joseph M Truglio, MD, MPH, assistant professor of medicine, pediatrics, and medical education at the Icahn School of Medicine at Mount Sinai in New York City. “For some, a pregnancy may be life-threatening, while others may be at high risk for complex fetal heart conditions.”
Ali N. Zaidi, MD, associate professor of medicine and pediatrics and director of the Adult Congenital Heart Disease Center at Mount Sinai, noted that an estimated 1% of all live newborns have CHD, and more than 90% of these individuals now reach adulthood.5 “This leads to a considerable number of women of childbearing age who have CHD, including those with moderate and severely complex CHD.” An earlier population-based study based in Quebec, Canada, found that the prevalence of severe CHD among adults increased between 1985 and 2000, with a predominance of such cases observed among women.6
“As physicians, our primary job remains to the welfare and safety of all our patients, including women with CHD who are already at high risk of adverse maternal outcomes during pregnancy,” Dr Zaidi said. The overturning of Roe v Wade “makes it much harder to safeguard a pregnant woman’s health, especially those with complex CHD.”
The Supreme Court’s ruling “represents a catastrophic barrier to evidence-based care for patients with CHD and other cardiovascular diseases – particularly those from marginalized groups and racialized communities, who already experience marked maternal-fetal health inequities,” Dr Truglio stated. He emphasized that clinicians must continue to heed their ethical obligations to patients and advises that clinicians stay abreast of abortion laws in each state as well as resources for locating abortion providers. He points to resources such as the Abortion Finder and the Planned Parenthood abortion access tool.
For additional discussion regarding the implications of increasing abortion restrictions on these patient groups, we interviewed Monica V. Dragoman, MD, MPH, assistant professor and system director of the complex family planning division in the Raquel and Jaime Gilinski Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai; and Linda Cassar, DNP, RNC-OB, CNE, clinical associate professor and program director of the Accelerated BSN program at the George Washington University School of Nursing in Washington, DC.
Regarding the recent Supreme Court decision to overturn Roe v Wade, what are the potential effects of lack of abortion access on patients with CHD and other cardiovascular diseases?
Dr Dragoman: The prevalence of cardiac disease is on the rise among reproductive-age women.7 Increasing rates of acquired disease can be linked to increasing rates of obesity, diabetes, and increasing maternal age, while increasing rates of maternal CHD can be attributed to advancements in treatment – allowing women to live longer and start families.
All women face challenges avoiding unintended pregnancy and planning their families if and when they choose. The stakes can certainly be higher for women living with CVD, especially for those in whom pregnancy can present potentially life-threatening health risks. Restricting access to abortion, an essential health care intervention, is bad for all women’s health. Restricting access to abortion in the context of caring for a person with CVD amplifies impacts in the general population; it exacerbates jeopardy to their life and health, the life and health of their pregnancy, as well as their current or potential future families.
Cassar: Physiologic changes during pregnancy cause significant stress on the heart. Blood volume will increase by approximately 1,500 mL by the end of pregnancy, heart rate will increase by 25%, and cardiac output increases by 30 to 50%, peaking at about 25 weeks of gestation.8 Women without cardiac disease, and even some with lower risk cardiac diseases, can compensate for these changes and have relatively healthy pregnancies with positive outcomes.
For those with certain congenital cardiac complications or those with severely limiting acquired cardiac conditions, pregnancy should be avoided, as the risk of maternal morbidity and mortality can be significant. The World Health Organization (WHO) has classified cardiac disorders into 4 risk classifications.9 Risk Class 1 patients have no detectable increase in the risk of complications from their cardiac conditions, and the risk increases with each class up to Risk Class 4.
These are patients for whom pregnancy is contraindicated and termination of pregnancy is recommended due to the increased likelihood of severe maternal morbidity and high probability of maternal mortality. According to the CDC, from 2016 to 2018, cardiac conditions (cardiomyopathy, hypertensive disorders, and other cardiovascular complications) accounted for 35.5% of all maternal deaths.4
What are the implications specific to your institution, and how is your facility planning to prepare for and address these issues?
Dr Dragoman: We are privileged to live in a state that values bodily autonomy and honors that health care decisions are best made in partnership between patients and their doctors. New York is currently positioned to offer sanctuary for those who have the means to receive care in our state during this evolving medical crisis.
Unfortunately, we are already dealing with a national epidemic of maternal mortality that disproportionately affects communities of color. According to the Kaiser Family Foundation, 43% of women ages 18-49 living in states where abortion has been banned or likely will be banned are women of color.10 These women will face higher barriers to accessing abortion care in other states due to less access to financial resources for services, travel, and other logistical needs, exacerbating disparities in maternal morbidity and mortality. People of color also carry a disproportionate burden of CVD. These harmful bans will hurt a lot of people who are unable to access essential reproductive health care services, including abortion.
Mount Sinai’s OB/GYN department is home to world-class experts in complex family planning who work with patients with complex medical conditions to create individualized contraceptive management plans. Some goals include reducing the likelihood of unintended pregnancy and helping patients time any pregnancies to when their conditions are stable or optimized.
For patients who decide not to continue a pregnancy and for whom pregnancy presents an unacceptable health risk in the context of their condition, we offer pregnancy termination. Patients also work with maternal-fetal medicine specialists who provide care during high-risk pregnancies to support the best health outcomes for moms and babies.
How might the ruling on Roe v Wade affect medical education and future generations of clinicians?
Cassar: In higher education, abortion restrictions will impact the way that the curriculum is developed and presented in health education programs, including medical schools, nursing schools, physician assistant programs, and surgical tech training, just to name a few. In states where abortion is not permitted, appropriate training will not be provided to practitioners who would traditionally be providing this type of care.
These clinicians will move into practice unprepared to care for patients who need an abortion or may be suffering from the complications of one performed incorrectly. This does not just impact practitioners in an OB/GYN setting. It will have a ripple effect to emergency rooms, operating rooms, intensive care units, and primary care settings.
What are your recommendations for other clinicians in terms of providing optimal care and support to these patients in the context of tightened abortion restrictions?
Dr Dragoman: As a first step, it is important for clinicians caring for patients living with CVD to find out if they have a local complex family planning specialist to confer with regarding contraceptive management, pregnancy planning, and pregnancy termination. Complex Family Planning was just recognized by the American Board of Obstetrics and Gynecology as an official subspecialty in 2020, but fellowship training to cultivate physicians with this expertise has existed since the mid-1990s.
In addition, there are evidence-based guidelines produced by the US Centers for Disease Control and Prevention, the Medical Eligibility Criteria for Contraceptive Use, that offer recommendations on which contraceptive methods a given patient may be eligible to use safely.11 It is important that patients, especially those living with CVD and other medical conditions, are aware of the full range of effective contraceptive options available to best support decision-making and pregnancy planning.
If you live in a state with restrictions on abortion, make sure you are also clear on the limits of the law and whether or not there are health exceptions to accessing the procedure. Support your institution to provide safe and legal services to the full extent possible in your context. Be aware of resources available to connect patients to out-of-state services when necessary. In addition to the Abortion Finder, there is a national network of abortion funds that can assist patients with financial and logistical support, especially with out-of-state care seeking.
Cassar: All patients, but especially those with preexisting cardiac conditions, should receive preconception counseling to ensure an optimal state of health and assess the risks of pregnancy before moving ahead with any plans to conceive. For patients with lower risk cardiac conditions, there will likely be limited, if any restrictions on pregnancy, and their counseling may be as simple as ensuring optimal management of their disease prior to pregnancy and having more frequent doctor visits during the pregnancy to assess the health of the patient and fetus.
Patients with certain congenital cardiac anomalies or higher risk acquired cardiac disease will likely be counseled not to become pregnant, and reliable birth control methods should be discussed. In case of unintended pregnancy for these higher risk patients, a plan should be in place for how to proceed with the option that is safest for the patient and does not violate any laws for their state of residence.
What broader measures are needed to protect patients with CVD and other disabilities in light of the new restrictions?
Dr Dragoman: Abortion is essential health care. Patients don’t come to us with a political agenda when they are facing a pregnancy crisis – they need help. All clinicians involved in caring for reproductive-age people capable of pregnancy have a stake in reversing these harmful policies restricting comprehensive reproductive health care. Physicians and other clinicians have an important role to play in advocating for necessary policy change.
Cassar: The easiest option here is to amend the laws and allow practitioners to provide abortions to women who are medically in need of them – this would be the most ethical thing for states to do. Unfortunately, this may be a long and arduous uphill battle. In the absence of changes in the laws to allow this, networking between providers will be critical to optimize maternal health and outcomes. Developing networks of resources and practitioners to supplement the care that is allowed to be provided in states with severe restrictions or bans on abortion will be essential to having good outcomes for mothers with preexisting cardiac or other chronic conditions.