A new scientific statement from the American Heart Association (AHA) underscores the critical need for early detection and timely treatment of heart failure in pregnant and postpartum women to prevent serious complications, including irregular heartbeat, stroke, and death. Published today in the AHA's flagship journal, Circulation, the statement, “Heart Failure Occurring in the Perinatal Period,” highlights the challenges of recognizing heart failure when its symptoms—shortness of breath, fatigue, and swelling—often resemble common pregnancy experiences.
According to the AHA, nearly 1 in 4 women aged 20-44 currently has some type of cardiovascular disease, and heart disease is now one of the leading causes of pregnancy-related death in the U.S., based on data from the CDC’s Pregnancy Mortality Surveillance System. The true prevalence of heart failure during pregnancy and postpartum is unknown, but the statement notes that the postpartum period, extending through the first year after delivery, is a particularly high-risk time for women to develop heart failure.
“Heart failure during and after pregnancy is often hiding in plain sight,” said Demilade A. Adedinsewo, M.D., M.P.H., chair of the statement writing group and an assistant professor at the Mayo Clinic in Jacksonville, Florida. “By recognizing symptoms earlier and initiating appropriate treatment, especially in the postpartum period, clinicians and health systems have a powerful opportunity to prevent serious complications and save mothers’ lives.”
Heart failure, a condition where the heart cannot pump enough blood to meet the body’s needs, can affect the lungs, kidneys, and brain, leading to breathing difficulties, kidney issues, and increased stroke risk. Symptoms like labored breathing, fatigue, and leg swelling are also common in healthy pregnancies, often delaying diagnosis and treatment. Peripartum cardiomyopathy (PPCM), a form of heart muscle failure that develops late in pregnancy or months after delivery, is one specific manifestation.
Risk factors include high blood pressure, Type 2 diabetes, obesity, older maternal age, multiple gestation, and use of assisted reproductive technology. Among women with known heart disease, heart failure is the most common complication, affecting 11% during pregnancy and postpartum. Significant disparities exist: Black adults have about a 19% higher risk of developing heart failure than white adults, and Black women with PPCM are more likely to be diagnosed later. Heart failure contributed to 14.5% of pregnancy-related deaths among American Indian/Alaska Native women and 14.2% among Black women.
Delays in diagnosis can be life-threatening. Data from a national database indicate that pregnant women with heart failure are about 32 times more likely to die around delivery compared to those without heart failure. Risks for the mother include irregular heartbeat, stroke, worsening cardiac function, and poor mental health. For the baby, risks include restricted fetal growth, premature birth, low birth weight, stillbirth, or infant death.
Diagnosis involves electrocardiograms, blood tests for cardiac biomarkers, and echocardiograms to distinguish between normal pregnancy changes and heart failure. Management includes medications like beta blockers, diuretics, and vasodilators, which may be safe in pregnancy, along with a multidisciplinary cardio-obstetrics team. The AHA’s Life’s Essential 8 metrics—focusing on diet, physical activity, and other health factors—are increasingly recognized as important before, during, and after pregnancy.
The postpartum period is critical, with some women experiencing symptoms days or months after delivery. Referrals to cardiology or primary care beyond the traditional six-week postpartum visit are essential. Telemedicine and remote monitoring can support continued care. Contraception counseling is also important; long-acting reversible contraceptives, specifically hormonal intrauterine devices, are preferred for women with heart failure, while estrogen-containing methods are not recommended due to thrombosis risk.
“Improving postpartum care is essential to protecting maternal health,” Adedinsewo said. “Standardized screening, listening carefully to patient concerns, and improved access to care are crucial to help improve outcomes for mothers and their families.” The statement was prepared by a volunteer writing group on behalf of the AHA’s Women’s Health Science Committee and other councils, and it outlines what is currently known and what areas need additional research. More information is available in the full manuscript and on the AHA website.
