The chest pain started early in Ashley LaSerra’s second pregnancy. At 12 weeks, she felt like she did at 30 weeks with her first daughter.
As she’d done her entire life, she went to her cardiologist: “I said to him, ‘I just don’t feel right. Something’s off.’”
LaSerra was born with a ventricular aneurysm, a bulge in the wall of her heart’s lower pumping chambers. When the heart beats, the bulge swells like a water balloon; if it bursts, she could die. Pregnancy exacerbates that risk.
Under the supervision of medical providers across health networks, LaSerra and her daughters, born 18 months apart, survived.
Many women do not: Heart disease is the No. 1 reason mothers die during or within a year of pregnancy. Nearly 70% of those deaths are preventable, according to a 2018 report from nine maternal mortality review committees.
Layers of protection, like the team-based approach LaSerra received, can help.
“You actually feel with this group, ‘Hey, I can get through nine months with a safe pregnancy,’” she said.
In pregnancy, the heart works a double shift, pumping an increasing volume of blood to nourish not one, but two bodies. Over the course of gestation, blood supply increases by 30-50%.
“Pregnancy is like a nine-month stress test for the heart,” said Dr. Aiyanna Anderson, a maternal-fetal medicine physician in Fort Worth. “If you already have a heart condition, you’re putting more stress on something that is already not in the best shape.”
Heart conditions, under the umbrella of heart disease, can be acquired or congenital, meaning the issue is present from birth. In the U.S., the most common form of heart disease is coronary artery disease, which develops over time and restricts blood flow to the heart.
In pregnancy, however, the story shifts. Congenital heart disease, like LaSerra’s aneurysm, is most common. Cardiomyopathy, a disease of the heart muscle that can be congenital or acquired, causes the most serious problems, according to the Cleveland Clinic.
The consequences are manifold. For example, heart disease in pregnancy can lead to high blood pressure, including preeclampsia, which can lead to seizures; and irregular heart beats, which can cause blood clots, which can lead to stroke and heart attack.
At LaSerra’s one-year check-up, her heartbeat sounded abnormal. An echocardiogram revealed the aneurysm.
In the nearly three decades since, she’s experienced a cavalcade of screenings and treatments: Heart monitors, MRIs, more echocardiograms. At 16, she started beta blockers, medicines to lower her blood pressure. When she was 18, her cardiologist told her she’d never have children. “It was a lot for an 18-year-old to grasp,” LaSerra said.
Years passed. LaSerra married her high school boyfriend, who had supported her through the cardiologist’s bad news. When they moved to Fort Worth in 2016, LaSerra sought a second opinion from Dr. Scott Pilgrim, a pediatric cardiologist at Cook Children’s Medical Center.
Pilgrim runs the adult congenital heart disease program at Cook Children’s, a lesser-known department among the trappings of a children’s hospital. Some of his patients, he told LaSerra, are 80 years old.
His specialty, adult congenital heart disease, grew alongside advances in care. In the past, babies born with heart disease didn’t survive past childhood. As medical care and treatments improved, more than nine in 10 babies born with a minor heart condition, and roughly seven in 10 with a serious heart condition, live until they’re at least 18.
Most of those children can go on to have children of their own, Pilgrim told the Fort Worth Report.
“There’s really no reason that the majority of congenital heart patients cannot have babies,” Pilgrim said. “Most of them can, in fact, have successful, safe pregnancies with proper oversight and care.”
For his pregnant patients, Pilgrim collaborates with Maternal-Fetal Medicine of Texas, a team of maternal-fetal medicine physicians, including Anderson, with Texas Health Resources. Pilgrim gave LaSerra the green light.
“It was kind of like a, ‘Here’s the group of people that are going to be following you if you do,’” LaSerra remembers he told her. “‘Whenever you’re ready, go ahead.’”
Every month, the team of providers from Cook Children’s and Texas Health Fort Worth meet to discuss shared patients.
For each patient, the team considers if any issues have developed during pregnancy, whether vaginal or cesarean delivery makes most sense, what kind of heart monitoring a patient might need, what postpartum care could look like, among other questions. By meeting’s end, the team has an updated delivery plan in place.
“(The providers) always knew what was going on with each other,” LaSerra said. “They would all touch base and get on the same page.”
In 2018, both the American Heart Association and the American College of Obstetricians and Gynecologists recommended “enhanced collaboration” between cardiologists and OBGYNs to bridge gaps in care.
The same year, the European Society of Cardiology described something even more specific: the use of multidisciplinary, pregnancy heart teams to help curb deaths before, during and after delivery.
The care model can only do so much. Pilgrim worries that patients at risk for heart complications during pregnancy aren’t getting the care they need before they get pregnant. Roughly 30-50% of child heart patients fall out of cardiology care before they reach adulthood, he said.
“I am fearful that there are hundreds, if not thousands, of adults in the Fort Worth area that had some form of heart problem as a child that are not being followed,” he said.
In another corner of Fort Worth, a separate multidisciplinary team of providers is working to meet people in their own homes.
Healthy Start provides home health visits to women and families before, during and after pregnancy. The program, funded by the government and operated by The University of North Texas Health Science Center, launched in 2014 to help diminish Tarrant County’s death rate for babies.
Tania Lopez, a nurse midwife with Healthy Start, calls the program “another layer of surveillance.”
Historically, Tarrant County’s rate has been one of the highest in Texas, as well as higher than the national average. Most babies who don’t survive their first year die from birth defects, the most common of which is heart-related.
The heart health of the baby is inextricably linked to the heart health of the mother. For most people, the risk of having a baby born with congenital heart disease is around 1%. For parents with congenital heart disease, the risk jumps to at least 3%, according to a 2020 review from Cold Spring Harbor Perspectives in Biology.
When Lopez meets with patients, she tells them to look for signs of a heart issue: pronounced shortness of breath, wild heart beats, chest pain or pressure, a cough when lying down. Mostly, she’s emphatic: Know your history and your family’s history, and ask questions about your condition.
During both her pregnancies, LaSerra kept a pulse oximeter, which measures the blood’s oxygen level, blood pressure cuff and notepad on hand. When questions cropped up, she wrote them down. At her medical team’s next monthly meeting, she asked them.
The chest pain she felt early in her second daughter’s pregnancy eased when Pilgrim increased her dosage of beta blockers. Both deliveries — by caesarian section — were smooth, and in the 24 hours afterward, LaSerra’s providers monitored her heart for disruptions. Afterward, she and her daughters were cleared to go.
LaSerra herself is a nurse. She now works with the pregnancy heart team on the Texas Health Fort Worth side. She’s open to telling patients her story.
Neither of her daughters were born with heart disease. Maybe, one day, she and her husband will try for one more.
“Don’t let anybody tell you no,” she said. “We have great doctors that pave a path for you. It is possible. I was told no at 18 and now I can say I’ve done it twice. There are physicians, and we’ve got good technology, and we have the resources in Fort Worth.”
Editor’s note: This story was updated to clarify which complications heart disease in pregnancy can cause.
Alexis Allison is the health reporter at the Fort Worth Report. Her position is supported by a grant from Texas Health Resources. Contact her by email or via Twitter. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here.