Cardiovascular-Related Maternal Mortality

Abstract

Cardiovascular disease (CVD) is the leading cause of pregnancy-related death in the United States and disproportionately affects Black women. In this review, we address the major contributors to cardiovascular-related maternal deaths, focusing on the importance of both prepregnancy and postpartum care. Risk factors such as hypertension, diabetes, dyslipidemia, and obesity contribute to cardiovascular risk during and after pregnancy. As prepregnancy optimization of these factors has been shown to mitigate this risk, we discuss evidence-based approaches to cardiovascular risk management in reproductive-aged women. Women with pre-existing CVD should undergo prepregnancy counseling and risk assessment using validated tools such as the modified World Health Organization 2.0 classification. We review common presenting symptoms of CVD in pregnancy, such as shortness of breath, and we discuss how tools such N-terminal pro-B-type natriuretic peptide testing can help distinguish dyspnea of pregnancy from symptoms of heart failure. We also review the evidence-based management of the leading causes of cardiovascular-related maternal deaths, including cardiomyopathy, myocardial infarction, and hypertensive disorders of pregnancy. Importantly, the implementation of standardized care, such as perinatal CVD risk assessment algorithms, and postpartum remote monitoring programs may improve disparities in cardiovascular risk assessment and diagnosis.

The United States has the highest maternal mortality rate among wealthy nations, with rates steadily increasing since the early 1990s.^1–3 There are large racial and ethnic disparities in pregnancy-related mortality; non-Hispanic Black Americans have at least three times higher risk of mortality than White Americans.^1–5 Cardiovascular disease (CVD) is the leading cause of pregnancy-related death and is highest among Black women, who experience higher mortality rates from cardiomyopathy and preeclampsia or eclampsia compared with White women.^3–9 Social determinants of health likely contribute to a large portion of these disparities.⁴

Although maternal mortality rates were once driven by complications such as hemorrhage and thromboembolism, current rates are mostly due to cardiovascular causes, which include cardiomyopathy, hypertensive heart disease, coronary artery disease, congenital heart disease, valvular disease, and arrhythmias.^6,7 These occur in patients with known cardiovascular risk factors (eg, obesity, hypertension and diabetes) even in the absence of cardiac disease; in patients with existing underlying cardiac disease (eg, cardiomyopathy or congenital heart disease); and as new, acute events in patients with no underlying risks.^1,6,7,10

There are multiple cardiovascular changes that occur during pregnancy, including an increase in plasma volume, heart rate, and cardiac output, as well as a decrease in systemic vascular resistance and blood pressure.¹⁰ These changes can unmask or worsen underlying CVD and can also contribute to new onset pregnancy-related cardiac events.

PREPREGNANCY CARE TO PREVENT PREGNANCY-RELATED CARDIOVASCULAR COMPLICATIONS

The growing prevalence of pre-existing medical comorbidities contributes to cardiovascular-related maternal mortality. Thus, the importance of focusing on the prepregnancy time period, when known medical comorbidities can be optimized, is critical. Cardiovascular complications in pregnancy are more likely to occur among those with cardiometabolic risk factors (Fig. 1).¹¹ Improving hypertension and glycemic control, losing weight, and quitting smoking before pregnancy have been shown to improve pregnancy outcomes and could directly influence overall cardiovascular risk.^11,12 Although optimizing health would ideally be done before pregnancy, the central tenets about counseling, medical management, and lifestyle modification can be used during a pregnancy, even if the patient did not receive prepregnancy care. Understanding how best to optimize the health of patients with medical comorbidities affecting pregnancy is critically important for successful counseling and interventions. Recommendations for prepregnancy management of cardiovascular risk factors are outlined in Box 1.

Fig. 1.

Association between cardiovascular (CV) risk factors and cardiovascular complications of pregnancy. Percentage of patients with and without CV complications for each cardiometabolic risk factor. Cardiovascular complications are defined as maternal death, major adverse CV event, or hypertensive disorders of pregnancy, as defined in Lau et al.¹¹ CVD, cardiovascular disease.

Levine. Cardiovascular-Related Maternal Mortality. Obstet Gynecol 2026.

Box 1. Prepregnancy Counseling for Cardiovascular Risk Factors*.

Hypertension

• Treat to target prepregnancy blood pressure lower than 130/80 mm Hg^†

• Refer for secondary hypertension screening, if applicable

• Counseling

  • Lifestyle counseling for blood pressure control
  • Aspirin prophylaxis for preeclampsia prevention
  • Risk of preeclampsia and fetal growth restriction
• Medication adjustment

  • Stop ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists
  • Nifedipine and labetalol have best safety data in pregnancy

Diabetes

• Treat to target prepregnancy Hb A_1c less than 6.5%

• Screen for diabetic complications, including creatinine, urinary albumin-to-creatinine ratio, and dilated eye examination if applicable

• Counseling

  • Lifestyle counseling for glycemic control
  • Risk of congenital malformations
• Medication adjustment

  • Transition antiglycemic medications to metformin or insulin
  • Stop ACE inhibitors and ARBs

Dyslipidemia (elevated LDL-C)

• Lipid panel if not done within past year

• Screen for family history of premature ASCVD

• Counseling: healthy lifestyle

• Medication adjustment

  • Risk–benefit discussion about statin continuation
  • Most lipid-lowering therapy should be stopped; bile acid sequestrants are safe in pregnancy but usually poorly tolerated

Obesity

• Stop GLP-1 RAs (ideally 2 mo before pregnancy)

• Counseling

  • Rebound weight gain (for those stopping weight-loss medication)
  • Lifestyle counseling

ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; Hb A_1c, hemoglobin A_1c; LDL-C, low density lipoprotein cholesterol; ASCVD, atherosclerotic cardiovascular disease; GLP-1 RA, glucagon-like peptide-1 receptor agonist.

*Recommendations adapted from the American College of Obstetrics & Gynecology prepregnancy counseling and the National Lipid Association guidelines.

† Recommendation from the multi-society blood pressure guidelines to prevent risk of developing ASCVD.⁷³

Hypertension

Elevated blood pressure is a potent risk factor for hypertensive disorders of pregnancy (HDP), which are leading causes of maternal morbidity and mortality. An estimated 16.4% of women aged 18–39 years have stage 1 (systolic 130–139 mm Hg or diastolic 80–89 mm Hg) or stage 2 (systolic 140 mm Hg or higher or diastolic 90 mm Hg or higher) hypertension. Among this population, 34.6% are aware of their diagnosis and only 7.2% have well-controlled hypertension.¹³ The blood pressure treatment goal in nonpregnant adults is a measure of 130/80 mm Hg or less. Reaching this target has been associated with lower long-term risk of myocardial infarction, heart failure, and stroke. Identifying secondary causes of hypertension before pregnancy may lead to potentially curative interventions. Therefore, an evaluation should be considered for all patients with stage 2 hypertension before 30 years of age or in the presence of other risk factors.¹⁴ For individuals with hypertension who are pregnant or planning pregnancy, long-acting nifedipine and labetalol are the preferred medications.³ However, many additional antihypertensive and cardiac medications can be used in pregnancy, with the exception of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, and aldosterone antagonists, given their known teratogenicity.^3,10

Diabetes

Rates of pregestational diabetes are increasing in the United States. Both type 1 and type 2 diabetes are associated with up to a 3.8-fold increased risk of maternal mortality, and both increase the risk of all-cause mortality.¹⁵ Women with diabetes have higher rates of chronic conditions, including hypertension and CVD, and are also more likely to develop preeclampsia and other adverse pregnancy outcomes. These factors all contribute to increased risk of cardiovascular death. Improved prepregnancy glycemic control (hemoglobin A_1c less than 6.5%) is associated with lower risk of severe maternal morbidity and maternal death.¹⁶ Thus, the importance of optimizing diabetes control should be a focus of prepregnancy counseling in patients with diabetes.

Dyslipidemia

Familial hypercholesterolemia is an autosomal dominant genetic disorder that occurs in 1 of 250 individuals.¹⁷ Heterozygous familial hypercholesterolemia is characterized by elevation of low-density lipoprotein cholesterol and a markedly increased risk of premature atherosclerotic CVD. Familial hypercholesterolemia is often underdiagnosed and may therefore be an unknown cardiovascular risk factor during pregnancy. Prepregnancy screening may be an important opportunity to identify women who have familial hypercholesterolemia and may be at risk for atherosclerotic CVD during and after pregnancy. Statins are first-line treatment of familial hypercholesterolemia. Historically contraindicated in pregnancy, they are now considered safe to use in high-risk women, such as those with known atherosclerotic CVD or familial hypercholesterolemia with high-risk features (eg, coronary calcifications or prior cardiac event). Therefore, continuation of statins can be considered in this population.^17,18 Although current guidelines do not recommend specific statins, pravastatin has previously been studied during pregnancy for the prevention of preeclampsia and has the most safety data.¹⁷

Obesity

Obesity is increasingly prevalent in the United States and is associated with rising rates of adverse pregnancy outcomes and CVD. Obesity is also a risk factor for CVD complications such as venous thromboembolism and peripartum cardiomyopathy (PPCM). Women with obesity are at threefold to fourfold higher risk of pregnancy-related death, with recent reports noting that obesity contributed to approximately 30% of maternal deaths.¹⁹ Weight loss improves control of cardiovascular risk factors, including elevated blood pressure and poor glycemic control.²⁰ Successful prepregnancy weight-loss strategies include lifestyle interventions, bariatric surgery, and medications. In nonpregnant adults, glucagon-like peptide-1 receptor agonists are associated with significant weight loss and improved cardiovascular outcomes, including lower rates of myocardial infarction, stroke, and cardiovascular death.²¹ Although data are limited, current recommendations are for glucagon-like peptide-1 receptor agonists to be discontinued 2 months before pregnancy.²² Patients should be advised that weight gain is common after stopping medication.

Diet and Exercise

Healthy diet and routine exercise are recommended for nonpregnant and pregnant adults to promote cardiovascular health. Prepregnancy counseling is an opportunity to provide tailored nutritional guidance to reduce the burden of cardiovascular risk factors. The DASH (Dietary Approaches to Stop Hypertension) diet can reduce systolic blood pressure by 5–8 mm Hg, and a diet low in saturated fat can lower low-density lipoprotein cholesterol by as much as 30%. Counseling to increase or maintain moderate-intensity activity in pregnancy is warranted, as exercise during pregnancy is associated with lower risk of gestational diabetes and HDP.²³

Known Cardiac Disease

There is a growing population of reproductive age women with either congenital or acquired cardiac conditions who are becoming pregnant. These patients have different counseling and monitoring needs before and during pregnancy, depending on their inherent risk. Several risk-stratification tools have been developed to assess risk of cardiovascular complications during pregnancy and to guide treatment and delivery decisions. These include ZAHARA (Zwangerschap bij Aangeboren Hartafwijking); CARPREG II (Cardiac Disease in Pregnancy Risk Index); and the modified World Health Organization (WHO) classification, the most commonly used and well-validated measure to risk stratify patients with known CVD.^3,10,18 The most recent European Society of Cardiology guidelines on Pregnancy and Heart Disease¹⁸ recommend using the modified WHO 2.0 classification in conjunction with the CARPREG II risk score to risk stratify patients with congenital or acquired heart disease. The management of specific acquired and congenital cardiac conditions is beyond the scope of this manuscript; we refer readers to recent guidelines and review articles on this topic.^10,18 Existing guidelines highlight the importance of a Pregnancy Heart Team in caring for anyone who is modified WHO risk class II or higher. This care team typically includes obstetricians, maternal-fetal medicine subspecialists, cardiologists, and additional subspecialists as needed for those with higher risk conditions. The frequency of follow-up in pregnancy and location of delivery are also individually tailored on the basis of overall risk. There are many prepregnancy and early-pregnancy interventions that can improve outcomes for pregnancy in cardiac patients. These include optimizing medication and performing screening or diagnostic imaging to better risk stratify patients.

CARDIOVASCULAR RISK ASSESSMENT AND IMPORTANCE OF STANDARDIZATION OF CARE ON IMPROVING MATERNAL MORTALITY AND ASSOCIATED DISPARITIES

There are many plausible etiologies to explain the prevalence of cardiovascular-related deaths and the racial disparities that exist among them. Health system and clinician-level factors, including implicit bias, variation in care, and unequal access to care, are known to be leading contributors to maternal mortality.^5,24

In addition, delayed response and misdiagnosis are the leading contributors to pregnancy-related cardiovascular death. This is likely due to a number of factors, including the overlap of cardiac and pregnancy symptoms (eg, shortness of breath, edema, and fatigue) as well as implicit and explicit biases in patient assessment, treatment, and access to care that lead to discrepancies in treatment quality.^25–32 One method to reduce the effects of implicit bias and inequity in patient care is to standardize care management. The use of protocols to standardize care has been shown to decrease adverse outcomes in various fields, including obstetrics.^33–37 Standardization of care is also associated with a reduction in treatment disparities,³⁸ likely through targeting both conscious and subconscious differences in medical management by race.^39–41 The Centers for Disease Control and Prevention has advocated for standardized assessments of pregnant and postpartum patients as one plausible method to reduce overall rates of pregnancy-related cardiovascular mortality and to address the existing racial disparities in maternal mortality.⁴²

A standardized perinatal cardiovascular risk-assessment algorithm^43,44 is an intervention intended to standardize both the overall assessment of baseline cardiovascular risk and the evaluation of patients who present with cardiovascular-related symptoms. Prior work has demonstrated that use of this algorithm accurately predicted almost 90% of cardiovascular-related deaths.⁴⁵ This algorithm was developed by the California Maternal Quality Care Collaborative and has been adapted for use in different contexts. Figure 2 shows an example of an algorithm adapted for local city-wide use based on feedback from stakeholders and a community advisory board.⁴⁶ This algorithm can be used for outpatient screening of all obstetric patients to identify those at highest risk for developing CVD. It can also be used for standardized assessment of patients who present to an emergency room or obstetric triage unit with cardiovascular-related symptoms (eg, chest pain, shortness of breath, worsening lower extremity edema). The algorithm highlights the importance of measuring brain natriuretic peptide or N-terminal pro-BNP (NT-proBNP) and performing an electrocardiogram (ECG) in the initial evaluation of these patients.

Fig. 2.

Adapted and refined perinatal cardiovascular risk-assessment algorithm. Cardiovascular (CV) risk assessment algorithm adapted with feedback from stakeholders and a community advisory board for local city-wide context. HR, heart rate; BP, blood pressure; RR, respiratory rate; BMI, body mass index; EKG, electrocardiogram; NT-pro-BNP, N-terminal pro-B-type natriuretic peptide; CBC, complete blood count; CXR, chest x-ray; HF, heart failure; CMP, complete metabolic panel; TSH, thyroid stimulating hormone; VQ, ventilation and perfusion; CT, computed tomography; VS, vital signs; ER, emergency room; OB, Obstetrics; MFM, maternal-fetal medicine. Modified from Kumar NR, Davis I, Kamarajugadda S, Levine L, Mehta A. Developing an interdisciplinary community action team for reduction in maternal mortality related to cardiovascular disease. Progress in Community Health Partnerships: Research, Education, and Action 2026;20:77–84. doi: 10.1353/cpr.2026.a987074. Used with permission.

Levine. Cardiovascular related maternal mortality. Obstet Gynecol 2026.

CARDIOVASCULAR SYMPTOMS DURING PREGNANCY AND POSTPARTUM AND ACUTE CARDIOVASCULAR COMPLICATIONS

Shortness of breath and chest pain are not uncommon symptoms during pregnancy. Physiologic changes during pregnancy may lead to dyspnea and gastrointestinal reflux, which may cause chest pain. It is the overlap with normal pregnancy symptoms that often causes underestimation of concerning presentations with shortness of breath or chest pain underappreciated. Although they are uncommon, cardiomyopathy (including PPCM) and myocardial infarction (including spontaneous coronary artery dissection [SCAD]) are acute cardiovascular complications that are often misdiagnosed.

Cardiomyopathy, Including Peripartum Cardiomyopathy

Symptoms of heart failure or worsening cardiac function may occur in patients with pre-existing cardiomyopathy, (eg, hypertrophic cardiomyopathy or dilated cardiomyopathy) or may have an acute onset during pregnancy (eg, PPCM). Among all cardiomyopathy deaths, 68% occur between 7 days and 1 year after delivery, and as many as 77% are considered preventable.⁹ Among pregnancy-related deaths from cardiomyopathy in 2017–2019, 56% were attributed to PPCM.⁹

Occurring acutely toward the end of pregnancy or in the months after delivery, PPCM is defined as maternal heart failure with reduced ejection fraction (less than 45%) without another leading cause. Peripartum cardiomyopathy is the leading cause of peripartum-related cardiovascular deaths.^9,47 Risk factors include HDP (one third to one half of cases), multiple gestation, advanced maternal age, and anemia. Peripartum cardiomyopathy typically occurs in 1 of 2,000 births in the United States, and patients generally present with chest pain or dyspnea.^9,48 Mortality rates for PPCM vary on the basis of geographic location and patient characteristics. Among a contemporary U.S. cohort of 100 patients, the 1-year mortality rate was 4%; significantly higher mortality rates have been reported in other settings.⁴⁹

The majority of patients with PPCM are diagnosed in the first few weeks after delivery, though timing of diagnosis varies, especially by race (Fig. 3). Black women are diagnosed later in the postpartum period and have more severe disease at diagnosis.⁵⁰ Delayed diagnosis, defined as occurring later than 4–6 weeks postpartum, is associated with lower rates of myocardial recovery^49,51 and may result from lack of symptom recognition by clinicians or patients, difficulty accessing care, or poor care coordination. Clinicians may focus on more common medical conditions that cause shortness of breath, such as pneumonia, asthma, or pulmonary embolism. Early and accurate diagnosis of PPCM and other causes of heart failure may decrease maternal cardiovascular mortality.^7,9

Fig. 3.

Racial differences in timing of peripartum cardiomyopathy (PPCM) diagnosis. Represents timing of PPCM diagnosis among 220 patients treated at Penn Medicine. Data from Lewey J, Levine LD, Elovitz MA, Irizarry OC, Arany Z. Importance of early diagnosis in peripartum cardiomyopathy. Hypertension 2020;75:91–7. doi: 10.1161/HYPER-TENSIONAHA.119.13291.

Levine. Cardiovascular related maternal mortality. Obstet Gynecol 2026.

Echocardiogram is the gold standard for diagnosing PPCM. Testing of NT-proBNP can also be helpful, especially if echocardiogram is delayed. NT-proBNP is also an important test to triage pregnant or postpartum patients who present with any cardiac symptoms, including chest pain and shortness of breath. NT-proBNP levels are stable and valid during pregnancy.⁵²

Guideline-directed medical therapy is an important standard for medical management of heart failure and can be used with adaptations for pregnancy and the postpartum period to promote recovery. The components of guideline-directed medical therapy include beta blockers, renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors.⁵³ During pregnancy, beta blockers can be safely used. However, renin-angiotensin system inhibitors (eg, ACE inhibitors) should be avoided due to their nephrotoxic teratogenicity. Mineralocorticoid receptor antagonists are generally avoided due to fetal antiandrogenic effects, and sodium-glucose cotransporter 2 inhibitors are avoided due to inadequate evidence of their safety profile in pregnancy. In the postpartum period, specific ACE inhibitors (eg, enalapril) and mineralocorticoid receptor antagonists (eg, spironolactone) have favorable safety profiles and can be used in patients who are breastfeeding. For patients not breastfeeding and for those who have concluded breastfeeding, a full guideline-directed medical therapy regimen should be used.

Myocardial Infarction

Diagnoses of acute chest pain in pregnancy are broadly differentiated and range from benign conditions (eg, acid reflux) to life-threatening emergencies that can lead to maternal morbidity and mortality. Pulmonary embolism, acute myocardial infarction, and aortic dissection are uncommon during pregnancy; however, the risk of these events is higher in pregnant women compared with nonpregnant women.^54,55 Although these conditions can occur at any time during pregnancy, the first few weeks after delivery are the period of highest risk,⁵⁶ underscoring the importance of asking about recent pregnancy when reproductive-aged women are seen for care. Initial tests to evaluate acute chest pain include ECG and cardiac troponin levels. Computed tomography angiography with contrast is recommended if pulmonary embolism or aortic dissection is suspected.

The incidence of acute myocardial infarction during pregnancy and the postpartum period is estimated to be 2.8–8.1 per 100,000 deliveries, with a cumulative mortality rate of 5%.⁵⁴ The most common etiologies of acute myocardial infarction in pregnancy include SCAD, which accounts for up to 40% of all myocardial infarctions during pregnancy and postpartum,^55,56 and atherosclerotic lesions.^18,54 It is estimated that about 50% of acute myocardial infarction cases associated with pregnancy occur in the postpartum period; the other half occur either in the antenatal period or surrounding delivery.⁵⁷ Acute myocardial infarction should be suspected in the setting of acute chest pain or dyspnea, ischemic changes on the ECG, or sudden increase in troponin levels. Coronary angiography is recommended and should be performed in the setting of acute coronary syndrome.¹⁸

Acute cardiovascular complications during pregnancy are significant contributors to morbidity and mortality. Therefore, it is important to consider the broad differential for shortness of breath and chest pain in pregnancy and the postpartum period, and to have a high suspicion for both PPCM and SCAD.

HYPERTENSIVE DISORDERS OF PREGNANCY

Several cardiovascular disorders, such as chronic hypertension during pregnancy, gestational hypertension, preeclampsia (both with and without severe features), and eclampsia, are included in HDP.⁵⁸ These disorders are estimated to complicate approximately 10% of pregnancies, and 16% of maternal deaths in developed countries are due to HDP.^59,60 Low-dose aspirin prophylaxis has been found to decrease the risk of developing preeclampsia in patients at moderate or high risk.⁵⁸ Importantly, prompt antihypertensive treatment of severely elevated blood pressure is critical in reducing maternal morbidity and risk of stroke.^58,61 Although HDP is most commonly diagnosed during pregnancy, the majority of deaths attributable to HDP occur during the first 6 weeks postpartum.⁶² Unfortunately, because postpartum care entails much less frequent surveillance compared with prenatal care, there are missed opportunities not only for detection of HDP, but also for prevention of HDP-associated morbidity and mortality. Therefore, it is prudent to consider postpartum blood pressure monitoring programs such as remote monitoring to mitigate this missed opportunity for intervention.^63–65

IMPORTANCE OF POSTPARTUM CARE ENGAGEMENT IN REDUCING CARDIOVASCULARV-RELATED MATERNAL MORTALITY

Prepregnancy counseling is critical to addressing maternal mortality risk, but the postpartum period is also a crucial time during which such risk often is overlooked or underassesssed.⁶⁶ In fact, the majority of cardiovascular events occur postpartum, when patients interact with the health care system much less frequently. For this reason, hospital systems, clinicians, and researchers are studying opportunities to increase interactions during this vulnerable period. Although expansion of Medicaid through 1 year postpartum is one component that will increase the ability to obtain and utilize care,^67,68 it is only one factor. Engagement in care in the immediate few weeks postpartum has the potential to identify early warning signs and allow for additional monitoring. Maternal deaths related to hypertension and acute cardiovascular events are most common during the first weeks to months postpartum. Remote monitoring programs have been shown to enhance postpartum care engagement and clinical outcomes while also reducing racial disparities. Remote monitoring interventions include the use of text-based messaging platforms and chatbots, with some monitoring only blood pressure and others monitoring all postpartum warning signs.^63–65,69 Although no one specific monitoring program has been shown to be superior, the key tenet is ensuring continued monitoring and engagement with clinicians in the postpartum setting. We therefore encourage all hospitals and facilities to implement a postpartum remote monitoring program tailored to their patient population.⁷⁰ Additionally, it is important to ensure efficient transition of care from obstetrics to primary care or cardiology, given the continuing risk of hypertension in the years after delivery and the known risk of chronic hypertension and future CVD in patients with a history of HDP.^66,71,72

CONCLUSIONS

The reasons CVD is the leading contributor to maternal mortality are multifaceted; therefore, the methods to improve outcomes are also multidimensional. However, emphasizing the importance of prepregnancy counseling, standardization of care, ongoing postpartum remote monitoring, and extending surveillance beyond the routine 6-week period are potentially effective interventions to combat this maternal health crisis.