Chapters Transcript Video Pregnancy & Heart Disease Click here to view presentation deck Back to Symposium Once again. Good morning. Uh My name is Gloria Tu. I'm one of the maternal fetal medicine specialists at Eastern Virginia Medical School. Uh Now at O Dod U or Old Dominion University, it's a new partnership that we're very excited about. Um Thank you again for coming today and listening about what we consider or what I consider a very important topic, um which is pregnancy and heart disease. Um The goals of today will be to discuss what cardiovascular changes happen in pregnancy and why this makes pregnancy challenging or potentially dangerous for pregnant women. Um normal and abnormal cardiopulmonary symptoms and signs um and then risk stratification for these patients. Um as well as kind of what kind of assessment tools we have um in our wheelhouse to help understand what the risk is for the pregnancy and postpartum period. Most of my content will come from the American Heart Association as well as the European Society of Cardiology, uh guidelines on cardiovascular diseases in pregnancy. Um So cardiovascular disease can affect up to 4% of pregnancies and it may be difficult to differentiate from normal pregnancy symptoms. Um So it's of the utmost importance that we understand kind of what the difference is, however subtle and refer to uh the appropriate providers. Um As you can see here, uh The chart represents CDC data from 2024 showing the that cardiovascular disease is the leading, is a leading cause of pregnancy related mortality in the United States. It represents up to 40% of um of pregnancy related deaths. And they say that four in five of these pregnancy related deaths in the US were preventable. Uh So this is a call to action to us to find solutions for this. Though, you can see a significant portion of pregnancy related deaths occur in the pregnancy um period or the um immediate postpartum period, up to half of them will occur after delivery. And so when we say uh as obgyns, we follow patients in the postpartum period, we consider that the fourth trimester and ours usually extends to about 6 to 12 weeks after delivery. And then after that, we hand them back to you uh to see patients um understanding that um you know, the risks still exist afterwards. This is from one academic center in New York where they released the data on their patient population, what the characteristics were um of the patients with cardiovascular disease. Um There were a couple of interesting findings here. Um one that congenital heart disease patients accounted for about a quarter of their patients. Um You know, we consider CHD um limiting before uh but now that patients are becoming healthier living longer, um they are now entering pregnancy and that itself poses a risk. Um You can see about 75% of the patients had Medicaid. Um and Medicaid is can, is uh may represent a group of patients who had limited health care access prior to pregnancy. And so it's not uncommon for us to see patients uh in pregnancy for the first time and diagnose them with sometimes one or multiple chronic medical conditions that have been um undertreated. Um You can also see that some of the patients here came into pregnancy with uh pregnancy with chronic medical conditions such as diabetes, hypertension, but some of them develop it over time during the pregnancy itself. And so you may actually have what you would consider an otherwise healthy person um who is still at risk for cardiovascular disease and they don't list it here, but advanced maternal age is another uh group of patients who's at fairly high risk for complications in pregnancy. Um if you take a look at patients who are 40 years and above, they have almost a 4 to 5 risk, 4 to 5 fold risk of mortality in pregnancy uh than other patients. So, why does this occur? Why do we um have concerns about cardiovascular changes in pregnancy? Well, we know that there are pretty significant hemodynamic and physiologic changes that happen to support just normal pregnancy. Um and there's an increased cardiac demand right around the time of delivery. Um, there's also limited safety data on medications. Um, so it's not uncommon for either patients and, or practitioners to stop otherwise necessary medications. Um, it happens both in cardiovascular disease and almost every other, um, every other specialty very, very commonly psychiatry as well. So, this chart shows kind of the significant changes um, in pregnancy physiology that occur in the, um, as early as the first trimester and it becomes most pronounced right at the time of delivery. Um and then in the third trimester, now, the majority of patients with healthy cardiac function coming into pregnancy overall tolerate this fine. Um but it's the patients that have um the pre-existing heart disease that may potentially have a challenge with this. Um We used to talk about pregnancy as a 9 to 10 month stress test and you can see your heart is doing this for the course of 9 to 10 months. It's usually gonna uncover some sort of um disease. Um And we also consider pregnancy a window to future health. So if there are things that are uncovered during pregnancy, um hypertensions, diabetes, thyroid disease, cardiomyopathies, patients are at higher risk for these after pregnancy as well, even if it resolves in that immediate postpartum period. So what are normal symptoms um that we may see in pregnancy um for those of you who have been pregnant or no pregnant people, you know, it's pretty common for people to have some sort of dyspnea, orthopnea. Um, and that's usually due to the gravid uterus pushing up on the diaphragm. Um, it's just very common to have easy fatigability. Um, if anyone's been pregnant and you know what I'm talking about, just afternoon naps every single day. Um, and then presync and syncopy are pretty common from IVC compression as well as kind of orthostatic hypotension. Um, you know, as a person who works in an operating room, if there's ever a woman of childbearing age and all of a sudden she passes out. First thing we do is of course, help pick her up. And the second thing we do is offer her a pregnancy test. Now, things that are abnormal, um severe dyspnea, hemoptysis, practicism, nocturnal dyspnea and anything that gets worse with exertion, these would not be consistent with normal pregnancy and these all require some sort of evaluation or follow up. Um in terms of signs of pregnancy that can be normal edema, increased JVP, cardiomegaly. All these things are secondary usually to the fluid accumulation in pregnancy. And then we can hear oftentimes a soft like systolic flow murmur that can be pretty normal, but what's not abnormal are sustained, arrhythmias, anything that causes cyanosis, um clubbing, harsh uh systolic murmurs or any sort of diastolic murmurs and those would all warrant kind of some sort of further follow up. Um because patients have these identifiable risk factors prior to pregnancy. Um and there's continued risk of morbidity mortality after pregnancy. It's important for us to kind of use this as an opportunity to evaluate and optimize the health of all patients of childbearing age, whether, you know, before during or after pregnancy. Um And the American Heart Association thinks about this as a continuum oops um where it's a cycle because we oftentimes will get repeat customers. So we optimize things um for one pregnancy and they enter the next pregnancy once again, they're not optimized again, uh we may have complications. So we offer um something called a preconception consult. So, prior to entering into pregnancy, how can, how can we optimize not only your cardiovascular health but all health. Um And so that in uh pregnancy specifically, we talk about identifying and screening for cardiac history and cardiac disease including medications, what previous surgeries they've had and if they've had a history of cardiac events. Um And then when we talk about planning for the actual pregnancy itself, we like to spend time updating imaging, uh mo doing additional monitoring. Um And then educating patients on how their cardiac disease might affect both maternal and fetal health. Um It's also important that we identify any genetic ideologies for their heart disease because that potentially can be passed on to future generations as well. And, and people want to hear a little bit about that. Um We also assess the barriers um to achieving appropriate care uh and then try to optimize their modifiable risk factors um during the pregnancy or prior to pregnancy. And we have multiple tools to kind of estimate what an individual person's risk is of having a complication in pregnancy. Um One thing that we look at is something called the modified who classification, which looks at the type of heart disease or type of lesion that that person has. Um And as you can see here they go from class one to class four, which is on the next slide. Um Class one being the most benign with the lowest risk of morbidity mortality and class four being the highest risk. Um So for the most common conditions that we talk about are we, you may see are things like metro valve prolapse uh which is a class one, no increased risk of mortality and potentially a small risk of morbidity. Um and things like successfully repaired shunts like um A SDS V SDS, those are overall well tolerated. Um But as you see here, getting higher and higher up in the classes, um we can potentially increase to people who have uh systolic dysfunction and class four, everything that's class four area are considered contraindications to pregnancy. Um We would say that class four represents the highest risk conditions um with the highest risk of mortality. And in these instances, we would recommend either repair um or optimization of the condition prior to pregnancy. And if it's something that can't be optimized, then recommending not getting pregnant at all and considering things like gestational carriers. Um We also do talk about um if these patients do inadvertently get pregnant, um and they show up on our doorsteps, we have to have a conversation about what this truly means for maternal and fetal health and whether it's safe to continue pregnancy or not. We also have a couple of scales that we can use or a couple of um systems that we can use for patients with either congenital acquired heart disease and or arrhythmias. And this is the Carreg um predictor. And so what they do is they take a look at some characteristics of the patient or a history of cardiac events or complications. Um and using these points um over on the right, if you have, you know, uh one point on, you know, of these risk factors, you have about a 5% risk of having some sort of cardiac event during pregnancy. And when they say cardiac event during pregnancies, most commonly, they were talking about pulmonary edemas, sustained arrhythmias, um requiring treatment, stroke, um cardiac arrest and or death. Um as you can see here, there are conditions um like pulmonary hypertension opathy, coronary artery disease where you can have four points or higher and that represents over a 40% risk of having a cardiac event. Now, there's another scale that we can use for patients with congenital heart disease called the Zahara uh scale. Um And we predominantly look at the history of arrhythmia is kind of what their functional classes are. And once again using this, you can assess the risk of a patient for having a cardiac event in pregnancy, taking a look at patients who are already on some sort of active medication. Um, we uh the American Heart Association, uh created these really great diagrams that show, um, which medications are considered safe in both uh, pregnancy, which is kind of that top icon. Um And then breastfeeding, which is the bottom icon. Um, red is uh a higher risk for having um either tragic in the city or is not considered compatible with pregnancy. Um And then green is considered green is go, I don't know if anyone watches paw patrol, but green means go safe to take in pregnancy totally fine. Um And then you can see here that um Aces and Arbs generally not recommended in pregnancy because they're considered Travis do have a higher risk for the fetus um for complications. Um But you can see that aces ace inhibitors are lime green for the postpartum period and for lactation. And so some of them are considered safe. Um in terms of beta blockers, calcium channel blockers and vasodilators. All of these are considered um considered safe and to have better uh data in pregnancy. Um some of them are preferred more than others, which is why they're lime green and some of them still come with risk, but they're acceptable risks in a lot of cases because of um the possibility of untreated disease. Same thing for antithrombotic agents. Um You can see all the way to the left aspirin is the full spectrum of uh green to red. And we consider low dose aspirin to actually be a fairly standard medication that we use in all of pregnancy for things like preeclampsia risk. Um And now we're thinking more about kind of complications of pregnancy. Um that may also be mitigated by taking aspirin. We generally don't recommend high dose aspirin. So if you have anyone who's on a aspirin on a regular basis, we recommend cutting back on that um because it does have a higher risk of um premature uh ductal arteriosus closure for the fetus and that can lead to structural heart changes as well. Um You could take a look here for anyone who needs anticoagulation. The most common thing we're gonna be using is unfractionated heparin and low molecular heparin because it doesn't cross the placenta. Um If you did need to use um Coumadin, we use that in very limited circumstances. Um The most common thing that we're gonna be talking about is mechanical valve disease just because of the risk of thrombosis without it. Um And so we weigh the risk and benefit of these medications um in pregnancy, but say for postpartum and then we don't have enough data on a direct oral anticoagulants in general. We don't use those in pregnancy, we do know they cross the placenta and they cross into breast milk, but we have no um no long term data on the effects. So when we talk about this, we talk about, you know, our partnership within this room of preconception, pregnancy and postpartum care. Um and as doctor Lynch had alluded to, we have started a um cardi obstetric center here um both with the support of Centa and EV MS. Um and it takes a village to, you know, care for these patients. Um So definitely we see the patients, but, you know, in addition to us, it's, you know, other forms of cardiology like structure, heart failure, um E PC T surgery have all been involved in our patients. Our anesthesia groups, both anesthesia, um with ob and uh cardiac anesthesia, um nursing, um our genetic counselors, um L and D our heart hospital partners, all of these people together um are needed to take care of a single patient. Um You know, we discuss patients on a regular basis. We provide joint counseling and I think this is of the utmost importance because we aren't, if we're not working together, then the pier can get clouded or sometimes, you know, we may not fully understand um what a patient is um is going through. Um And as Petra has alluded to our program was, uh we saw about 100 and 19 patients either either acquired or congenital heart disease. Last year and our numbers are just rising. Um So, absolutely, if anyone has any patients who you feel would benefit from either a preconception consult or just pregnancy care, we're here to uh to take care of the patients. But as we talked about pregnancy, you know, pregnancy still poses a risk even in the postpartum period. Um So with that, um the journal of uh the American College of Cardiology uh released this which hopefully you guys can see which is a way for us to assess pregnancy and postpartum risk factors for um active cardiac disease. And so what they did is said, you know, if the person has symptoms um or vital sign abnormalities or risk factors, at least one of each or cumulatively, four of any of these, um they really should um be considered for cardiac imaging, cardiac testing as well as referred to an MFM um or a primary care doctor or a cardiologist. Um And as we talked about before patients have risk um in pregnancy that can be assessed prior to pregnancy to give them a better understanding of what the, what their pregnancy will look like going forward. The best time to do all of this is going to be in the um in the prepregnancy period. So, in the preconception period to optimize um and cardiac conditions, I think uh do the best if there's a multidisciplinary approach to it, especially since these patients can be complicated. Um delivery doesn't cure everything though. Uh, so make sure that we continue to screen for cardiovascular disease after pregnancy as well. Ok. Any questions or questions at the end? Yes, ma'am. Oh, we do the questions. Yeah. Yeah, I can show that medic patient experience about sure. And it's not necessarily that they're the, um, 75% of all Medicaid patients have some sort of baseline heart disease. I think they're just at highest risk because they have a lot of the risk factors. Yeah. So they may develop one of these, um, during pregnancy and I think the most common, um, acquired to disease that happens during pregnancy is usually going to be some sort of cardiomyopathy. Um, and cardiomyopathy, the periard of cardiomyopathy go hand in hand with things like hypertension, um, obesity, um, African American or, or Black race. There's a lot of things, um, that I think are uncovered during pregnancy because of lack of long term health care that could have screened for and optimize some of these conditions prior to. She said that that's the reason. Do you see the page that cardio? A Yeah, that's a good, good question. And I, I was, um, debating whether I spent some time on that because it is. Oh, no, no, you're fine. It's just such a large topic. So I wanted to make sure, um, that it was adequately covered, but it is, uh, definitely a risk. There are patients who have, um, cardiomyopathies that developed during the pregnancy itself and we consider it a um peripartum cardiomyopathy if there's no other source for it and it happens right around the time of delivery. Um The good news is that with, you know, guideline, directed therapy and with kind of the right um care, a lot of these women will have recovery, but there is a small population within that group that don't recover. Um and they actually end up having, um they end up actually end up being who classification. Sorry, let me get to it, do classification. Um three where they have this persistent uh uh systolic dysfunction and when they enter that next pregnancy, they're at higher risk. Um you know, even women with recovered function do have a higher risk of having recurrence of it. It's just not as significant and it, it's not as morbid, no problem. And there's a threefold increased risk if you ever had pregnancy induced um complications on developing later on in life. Um cardiovascular disease. So it counts for women as a risk factor. Um when you screen them for their cardiovascular risk score. Yes. Mhm. Definitely a higher risk as you have delayed uh delayed childbearing. So, um the statistic that I last saw was, you know, the risk of maternal mortality. It has been anywhere from 20 to 30 per 100,000 live births. Um which sounds fairly small. But if you think about kind of the significance of it, it's high and it's definitely higher, highest in the countries. Um It is something that increases to almost 100 and 40 per 100,000 life births if you're above the age of 40. And that may be because you have, you know, increased comorbidities. It may be that you have underlying heart disease. Um And it's actually a debate right now within maternal fetal medicine. If you have a person who's coming for preconception consult, that seems otherwise healthy. Um When you do screening for things like chronic hypertension and diabetes, should we be offering everyone a screening echocardiogram too? Some senators say yes, some senators say there's not enough uh evidence to suggest that the cost has actually um borne any fruit to, to decrease the risk for um future moms. But it is definitely something that's concerning the consideration for us. Any other questions? Ok. Thank you very much. I just Published Created by Related Presenters Gloria T.. Too, M.D Maternal & Fetal Medicine, Obstetrics & Gynecology View full profile
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