February 26, 2024 • 29 mins
Cardiovascular Complications make motherhood unsafe for African American women. This episode of MEternal with Kenya Gipson @coachkenya, Dr. Elizbeth Cherot of @marchofdimes, and Dr. Joseph Puma of @sorinmedical uncovers what women of color can do to protect themselves and their babies from severe complications during and after pregnancy. Access directly affects health outcomes in communities of color compared to other races. This conversation brings forth these cultural barriers to the forefront.
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Episode Transcript
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(00:00):
We've been having some great conversations sofar, and we are like really smack
in the middle of Heart Health Month, which is pretty incredible because it just
seemed like it was January yesterday.Yes, it was. We're halfway through
and this is a big month toreally amplify. I'm so excited to be
here today to talk about it andtalk about not just moms but women in
general and really how we should beamplifying this. Yes, and we have
(00:24):
a very special guest with us heretoday, doctor Joseph Puma of Soren Medical,
who is one of our partners hereat iHeart and has been doing a
lot of great work in communities ofcolor in terms of getting the messaging out
about heart health, the importance ofpreventative care, and why it's important for
us to be taking those steps towardsunderstanding what's going on with our heart health.
(00:46):
So welcome to the Maternal Thank you, Kenya, thanks for inviting me
again, and doctor Chiro, it'sa true pleasure to be here with you.
Thank you you too. Yeah.So we're talking about pro clemsia,
yeah, on our last episode,which I feel like sometimes goes very underdiagnosed
in a lot of certain cases,I was underdiagnosed with proclemsias. So can
(01:07):
you just explain to us what proclemsyais and how that relates to heart health.
Yeah, so, gosh, that'sa loaded question. Loaded, that's
like, okay, how long dowe have? So preclamsy is a state
that you can be spilling a lotof protein in your urine. You can
have symptoms like headaches or visual changes, strange upper right upper quadrant pain,
(01:30):
a lot of swelling and that couldbe fast. Now in pregnancy, you
can have swelling but really fast ongoingswelling, visual changes where you have a
hole in your vision, and thenyou have high blood pressure the spilling of
this protein. And it's a stateof either before pregnancy, during or after.
We talk about this happening a thirdof the time before you deliver,
(01:51):
a third of the time while you'rein labor, and a third after that
you become ill. And the cureis unfortunately delivery. We don't have a
lot of treatment. We try andprotect moms from seizing because that can be
the ultimate sequale. Swelling in thebrain can be the ultimate sequality that often
doesn't happen, but is what weprotect against happening. The scary part is
(02:13):
once you deliver, you still hormonallyare transitioning in the last you know,
the last six weeks after you deliver, and so that has been when I've
seen it as well. And thebig thing that I always like to talk
about with preclamsy is understanding the warningsigns, asking about them way before it
happens, and really it usually happensafter the twentieth week. But also realizing
(02:38):
that when we talked a little bitabout this, that's a stress test.
Pregnancy is a stress test because ultimatelyyou may end up with chronic hypertension after
preclamsy or pregnancy, but you areat risk if you've had preclamsya for cardiovascar
disease for the future. So I'llleave it there because I have a feeling
someone else might want to time.Yes, So what do you see when
(03:01):
it comes to people who may beexperiencing proclemsia or anything preventative before pregnancy that
you see in some of your patients. So preclams here is probably the most
serious and most common complication of pregnancy. And you know you've had prior speakers
here that the birthing experience, theentire experience should be a beautiful experience and
(03:23):
it shouldn't be an experience of fear. And if we have addicate healthcare systems
and processes in place, excuse me. If we have adequate systems and processes
in place, we should be ableto capture patients who are at risk for
pre eclamsy and follow them closely.The challenge of pre clamsy is is it's
(03:46):
primarily driven around high blood pressure,okay, and it's kind of like high
blood pressure on steroids in a sense. It's just a dramatic increase in pressure,
very difficult to control. But itdoesn't just affect the mother. It
affects the child as well, andthat's a challenge. I think. The
other good point that doctor Cherro makesis pre eclamsy is not just a pregnancy
(04:11):
disorder or a birthing disorder. Weneed to have systems in place to follow
these mothers and children for a yearafter the pregnancy because the complications can significant
complications during that time can occur upto them. And let's face it,
when often when the mother dies duringpregnancy or a child dies during pregnant,
(04:31):
it is often related directly to preeclamsy and so so we really need to
be way more proactive, find outwhat the understand better, what the risk
factors are, raise awareness, education, and have systems in place to help
care for people so they can havea beautiful birthing experience. Yeah yeah,
(04:53):
I So talk to me a littlebit about what you see with black women.
Do you see it worse with blackwomen? Do you see the cardiovascar
disease? We know right that moreblack women have complications from pre eclamsy.
I'm just curious, right, I'mthe one catching the baby and then taking
care of that mom for a shorttime afterwards, and then I'm looking at
(05:15):
you going help. Well. Ithink if you look at worldwide, over
ninety percent of cases of pre eclamsiaare occurring in underserved communities women that are
black or brown. So this isthis is not a white problem. This
is a black and brownblem In theUnited States, it's pretty much it's pretty
(05:38):
much the same. But this isnot a biologic issues. It's not that
biologically or something in our DNA makesbrown or black women have higher incidences of
pre eclampsia and complication. It's actuallya number of other factors many of them
are social factors, some of themare economic factors, poverty factors, and
(06:01):
so there's a lot that we canand should be doing. It is.
I know today I'm with people whoshare my outrage that such a wealthy country
can have such a high infant mortality. I don't want to I know doctor
Schurou knows it better, but Ithink we're like number forty six in the
(06:24):
world. I know I'm with peopletoday that share my outrage. And if
you're a black woman, your riskof complications from pregnancy or death from pregnancy
are more than twice as high asyour white counterparts. And just as a
physician, and this is one ofthe reasons I think it's so amazing that
the March of Dimes has a physicianas a chief executive, someone who has
(06:47):
cared for patients, delivered children,understands all the on the ground factors for
over twenty five years that doctor Schrurouhas done. That we should be work
working as our primary goal to meetunmet needs for our patients in our communities
and in the healthcare system. Forsure. Yeah, no, listen,
(07:10):
you just thank you. First ofall, that was kind, but also
it is absolutely a spectrum of thingsthat we see, and we absolutely see
pret climsy and white women as well, but women black women are dying more,
right, So that and if wesolve for that, we solve for
all women. I guess I'd loveto know or really talk about. I
(07:33):
mean mostly because I deliver right,I'll take care of mom. She may
come back year over year or skipseeing me after she delivers her last patient.
With me, I always worry aboutthat cardio of vascular risk. They
don't get it's further, you know, downstream. I think about the we
know very well that diabetes, ifyou have justtational diabetes, your risk for
(07:56):
diabetes over your lifetime. And Ithink we do a good job of information.
I'm not sure we do a greatjob. Most moms will come back
to me, believe it or not. They come to me more than they
come their primary care provider. SoI would love to have that conversation of
really talking to I don't want toterrify somebody who just had preclamps Yeah,
but how do we make sure thatthey over their lifetime come in and get
(08:20):
seen and what do they really need? So that's a great question, doctor
Schrow. Women who have preclampstery inpregnancy, regardless of color, of socioeconomic
status, actually have a much higherincidence of chronic hypertension, high blood pressure,
diabetes, cardiovascil disease, high cholesterol. So their long term risk is
(08:45):
worse. So, you know,if you're if you're pregnant in your thirties,
but you had pre eclamsya getting you. You know, I like to
tell people, my job is tomake you an old person, right,
That's what I do, right.My job is to help people live longer,
right, Okay, But if you'vehad these conditions in your thirties,
it's much harder for us to workto make you an old person. Okay.
(09:09):
So the risks of all these associatedfactors is significant. That risk in
the first year is much higher,Okay. Connecting them though, it's it's
a long term care issue, isn'tit right, It's a long term care
issue. It's it's a matter ofbringing the services to the patient. How
do you tell a young mother,for instance, that has to travel from
(09:31):
their community to go to a hospitalcenter if there's no no health care in
their community. So access to meis probably the hardest thing. I think
we need to stop blaming people,yes, for their health care problems,
that it's you know, it's it'sall on them. It's not all on
them. We're you know, we'rea country where a community that should be
(09:54):
working to help help each other.The March is done, the March of
Dimes. Is this incredibly innova procorrect. Thank you. There's you know,
mobile healthcare bringing it into the community. You know, I live in
New York City, and if youlook around New York City, when we
lived through the COVID crisis, whichyou know, we're all traumatized from the
(10:16):
big challenge there was, there wereno hospital beds. And yet just in
the last several months, can youBeth Israel is closing has announced as closing.
That's a thousand bed hospital in Brooklynin an underserved area. The State
University of New York has announced it'sgoing to close downstate. So where are
(10:37):
people supposed to go for healthcare?So I think it's a combination of issues.
If if you have, first ofall, up to eight percent of
pregnancies have pre acclamsy or regardless ofcollege. So let's identify with the actual
problem is. But we can identifyhigh risk women just by doing a history,
(11:00):
a five minute history, asking afew questions, we can identify which
which of these women are going goingto be high risk and then have a
process to follow them more closely andif they do develop pre eclamsia, we
should have programs to follow these patientslongitudinally and connect them into a healthcare system.
Yeah. So if you you're apregnant woman and you have high blood
(11:22):
pressure, right, how can youmanage that? Yeah? I mean that.
So, first of all, ifyou have chronic hype pretension, So
there's a couple of things. Youcould have chronic hype pretension, just stational
hypertension, so chronic you had itbefore pregnancy, gestational it's happening during your
pregnancy, and then preclamcy being thisaquality. Both of those are risk factors
for pre eclampsia. Really, it'sabout getting a blood pressure cuff and start
(11:43):
monitoring yourself. It's about asking,reviewing and knowing the symptoms and really diving
in. So again, it's theswelling, it's rapid weight gain, it's
about nausea, vomiting, it's aboutheadache, visual changes, and if you're
not sure, you need to act. Yeah, right, and a provider
should be bringing it up. Dependingon the stage of where you are and
your pregnancy, you may be seenweekly or you meet every other other two
(12:07):
weeks. But if that's happening,you need to get in sooner right as
the provider. But blood pressure isreally the key. And we have now
much more or recommendations for much moretighter control than we ever did, which
is fantastic because we actually see theoutcomes for babies being better because oftentimes we
have to deliver prematurely because of thepre aclampsia. Knowing that that's getting work.
(12:28):
We also have biomarkers now, whichis so exciting. This is something
that's more in Europe. It wasjust FDA approved here in the United States,
and I get super excited to thinkabout the future. So it's a
blood draw, so if you're inthe hospital, and this is where you
know if you're in the hospital andor have been, really this is preeclampsia
or is it not preeclampsick? Ifyou could have other disorders, kidney,
(12:50):
we could go through other things,but how do we differentiate whether this is
really preeclampsia or not. We havesome standard blood work. We have kind
of a mealieu of signs and symptoms. But truly, now we have a
blood test that helps us decide whatdo we do? And I love it.
I think it's finally moving forward.As I said, they're using it
(13:13):
in Europe more readily than we are, and I'm excited to see us coming
really moving forward with the blood testto help us with the algorithm on what
to do next. That's great.I would just adds to that doctor show.
You know, you make a keypoint monitoring the blood pressure closely.
We have such technology now that inour practice in patients that have high blood
(13:35):
pressure that we're having in challenge controlling, we have blood pressure cuffs that I
don't understand the technology have kind ofa cellular chip or something in it like
your cell phone, and we justasked them to take their pressure at home
once a day. Yeah, andit automatically comes, you know, through
the clouds somehow into our computer andwe have our nurses and staff. We
(13:58):
have a group of nurses and staffthat monitor hundreds of patients blood pressures on
a regular basis. So there arehigh tech ways and actually low tech ways.
Yes, you can get the fanciestof blood pressure cuffs, but truly
you just need a blood pressure cuffthat you can monitor yourself, excuse me,
And that has been really well provenafter you go home to not to
decrease readmissions and actually identify those thatneed to be seen. So and you
(14:24):
know, our guidelines aren't like thatwe should be. We do actually hand
out blood pressure cuffs. In WestTexas, we hand out a lot of
blood pressure cuffs because the miles todrive. Do I need to come in
or not? I'm feeling dizzy,lightheaded. I don't know about you,
but it happens when I stand up. So what right? So what is
that real? Is that not real? What do I add? I now
have some data points? Yeah,and you're absolutely right, we can do
(14:45):
it remotely and doing telemedicine is right. I mean, that's one thing out
of COVID that's probably the only thingthat I really get excited about that it
advanced. As a practitioner at thetime telemedicine was like, we're never gonna
be able to do this in obsesstricks, and we can do it,
and we can do it for realproblems and issues, and I see as
this is one that gets me reallyexcited about thinking about it's new and innovative,
(15:09):
not so new really, right,and so it's just we can make
the fanciest of ones using bluetooth andhow fantastic it could drop into your MR
and alarm you. But a patientcould take control of that too of getting
a blood pressure. Yeah, haveyou treated people or women with proclemsia at
your practice before? Yes, weoften get asked to see high risk pregnancies.
(15:30):
The ob guy n's often you knowyou have high risk ob gyn physicians,
but the majority of the complications areoften cardiovasqued and interestingly, sometimes the
ob gyn physicians aren't the ones thatwant to treat the high blood pressure because
there are I love, Yeah,there are some high blood pressures, and
there are only certain medications that youcan use. Even if someone at high
(15:54):
blood pressure before and they were perfectlywell controlled on a medication for years,
once they're pregnant, you need toswitch them to different medications. So we
often see high risk pregnancies, getthem through their pregnancy. Unfortunately, can
discharge them from the practices on oneof the few times we can actually discharge
(16:17):
your patient from a cardiovascular practice,but they'll have to come back at some
point, right, Yeah, butthey and and that partnership is really important
from an obsttrition standpoint because fun reallythe patient has to be at the center
sure, so that they're really takingcare of on all aspects and really,
you know, there's a certain levelof comfort I'm going to have that I
want an expert to come in andhelp with. Yeah, for sure,
(16:40):
what are some of the signs andthe symptoms. So so I mentioned some
swelling. So swelling can be likeyour face can swell, your hands or
feet can swell. Lots of pregnancies, lots of people swell. But this
can be dramatic headache that doesn't goaway, and it's not the typical tension
band headache. You're really talking abouta global headache. There's something called skatoma
(17:03):
or visual change, which is ablack hole in the visual of vision.
And I always think about any visualchange you should be asking your provider.
And then there's the high blood pressure. There's the the spill. You can
spill a lot of protein in yoururine, which is obviously a symptom that
you'll see. But you'll see somenauch of vomiting, some write up or
quadrant pain that isn't kind of thebaby moving up there. All of that
(17:27):
can happen at once. None ofthose could happen and that's the scary thing.
You could have high blood pressure andnot have those symptoms, right,
but those are the most difficult forprey climbs. Yeah. I love the
synergies that both of you are doingin the community with the mobile health units
and the accessibility that you're creating incommunities of color with people being able to
(17:49):
get scanned right for preventive healthcare reasons. So I just I commend you both
for taking that step towards accessibility becausethat's the biggest solved to moving the needle
for us. Well, you talkedabout maturnity care deserts. We see maturnity
care. It's why we really focusedin New York because that there are maturnity
care. Everybody thinks of the rural, it's not always rural. Right,
(18:11):
as you're talking about hospital closures,we've seen four percent of labor and delivery
units closed across this country and thatyou know, what we call maturnity care
desert is when you don't have accessto a labor and delivery, a birth
center, a midwife, excuse me, family practitioner, anybody to do or
doc to do prenatal care, andwe're seeing those across this whole country.
(18:33):
By play, six million women livein those areas, and it can be
as to your point, in thatinner city where they're you know, you
don't just take an ober right there. They can't afford it, right,
They can't afford it even the subwayride. So getting it out comfortable getting
on the subway when you're pregnant,going up and down those stairs, and
so really getting into the community wherethey are is why we launched the mobile
(18:53):
unit in New York and so wepartnered with the Presbyterian Hospital because even though
I'm a provider, not right,so the March of Dimes isn't but being
that convener to bring the partners inand bring the other partnerships to really get
care where moms are. I thinkabout old school docs who used to have
a doctor's bag and go into thehouses to see I mean, that's right,
(19:15):
and then all of a sudden wemoved everything into the hospital, which
we know right, and then becameoutpatient, and we've got to figure out
how to get back into those communities. Sounds like you're doing it. I
would educt to show that the Marchof Dimes, in addition to the mobile
units and convening care, the otherkey thing, which especially in the black
community, which is a risk factorfor preocclempsia, is social isolation, social
(19:41):
support. And you know, kindof this renaissance now of the use of
duelists, Yes, may have asignificant impact, you know, because the
midwife, for instance, traditionally providedthe medical care for a birthing person,
but you know, duelis provide thesocial support, the you know, the
(20:02):
the other type of care that's required. And I know the March of Dimes,
under doctor Schuro's leadership, has starteda program with doulas in the community.
And you're right, just because we'rein a city, you know,
and you know, only a coupleof miles right separates us from you know,
the amazing buildings and wealth and structuresand poverty. But that's a long
(20:29):
distance in an urban environment, asopposed to you know, your work in
Appalachia where miles and miles separates you. Yeah, no, I think you
brought up the dual work. Thankyou for highlighting. We're really proud of
the work we're doing with the CBSFoundation, and I you know, we
see preterm birth declining and women whohave a doula, and we know that
(20:49):
we can have better outcomes using csection rates other things, and we know
that that really has to be amplified. The supplying demand is a little bit
right, needs to be I wantto say corrected, but it needs to
be balanced. But also the integrationwithin those huge buildings you talk about,
(21:10):
right, And we know that sometimesa doula it can be like a community
worker, right, who's really helpingalong those lines as well. So there's
many structures that we're trying to thinkabout. We know burnout is big within
providers. We're asking providers to doa lot. You're one, I'm one,
right, if it's not our trainingor getting updated, it's just doing
(21:30):
more and asking more. I'm thrilledthat I have specialists to help me,
But thinking about it, we can'tanswer. I can't do everything. So
relying on a doula or a communitywork to help support these moms, I
think is really the next It's anit's funny you say it's sort of the
revolution of it. You're absolutely right, it's the next iteration of it and
(21:52):
really amplifying them and really getting themreimbursement. We're now advocating for that as
well. Yeah, good stuff,good stuff. So managing medical conditions before
and during pregnancy are super important,right, what's your messaging to people who
are pregnant or thinking about getting pregnantone day and how they can reduce the
risk for themselves and their babies.So, from a cardiovascular standpoint, diet,
(22:18):
exercise, I should always start withdiet and exercise. Sometimes I forget
because it's kind of my background noisein life, right, salt, and
it's and funny what is biologic isthere are sex differences and race differences into
our response to salt, and inblack women salt they're more sensitive increases hypertension,
(22:42):
high blood pressure. So diet,exercise, obesity is a risk factor
for preclampsia. A BMI of overthirty is one of the risk factors.
Regular exercise. You know, itdoesn't have to be everyone preparing to run
a marathon, but moving, butjust getting off the couch. That's what
(23:03):
I'd like to just you know,how about we all take a brisk walk
around the block. You know,let's just start with something simple or even
low impact exercise. Tai Chi isactually there's some data now that tai chi
can reduce hypertension, reduce the amountof meds that you need, and it
keeps you, you know, itstretches you. It's very mobile. So
(23:25):
all the kinds of things that yourmother told you to do when you were
a kid, what you need tobe doing, right as we get older,
my mother was right, she getssmarter we ought to be doing.
But then diabetes, you know,checking getting your sugar checked, having your
blood pressure checked by a professional,by a physician, kidney function, these
(23:45):
are all again risk factors, higherincidents in the black community. More importantly,
almost a fifty percent higher incidence inthirty to forty year olds in the
black community than the white community.So at a baseline, a thirty five
year old woman who gets pregnant,if they're black and a baseline they're underlying
(24:07):
risk factors are going to be higher, which is going to contribute to potentially
a higher risk pregnancy. So thereare a lot of factors before you get
pregnant that you should be considering toget yourself prepared. Yeah, I would
only add getting on full of acidat a time, you know, reviewing
family history because that pulls in birththe facts and really talking about other things
(24:32):
like smoking and alcohol and illicit druguse, all of those and actually not
illicit drug use, but all ofthose things you know, can impact a
pregnancy in a lot of ways.And the last I'm going to say it,
I always check lipids. I checklipids on my patients before if they're
coming in for a prenatal appointment,because that's really like their baseline is.
And we don't check in pregnancy becausecholesterol is used for the basis of a
(24:57):
lot of hormones and so that's notthe time to check lipids. But I
try and do that, and thenwe talk about the signs and symptoms,
and prevention is really talking about areyou a candidate for lodos aspirin, And
that's once you're pregnant, roughly aroundthe twelfth week, and so it's important
to get in and get care andget to creatal care. I always say
(25:18):
this is preventative care. People thinkof it as not that, and it
is absolutely preventive care. So it'ssetting you up for the best success for
your pregnancy, and so that that'sspecifically for pre clamcy. The bist thing
we have right now is lodos asproin. Right, Yeah, lodos aspirin is
a great point, and it's interestingto see the obstetricians now talking about LOO.
(25:41):
It's great. As a cardiologist,it's the most prescribed medicine in my
entire career, and even people say, well, I can bite over the
counter. I like to write theprescription. I want to make sure they
understand that it is important. Butlow dose aspirin can lower blood pressure,
reduces the risk of pre acclaimed toyou by about five percent. The American
(26:03):
College drops etricians and gynecologists. Thishas been a guideline recommendation for them now
for at least the last five ormore years. And so that is a
simple thing we can do. Andthe reason it's important to talk about that
is because once women get pregnant,it becomes the stigma about taking anything.
(26:26):
You're so you're afraid, right,well, right, you're you're worried on
so many lives, yeah, right, and so that and your child,
right, your maternal instincts are startingright from the beginning. So the safety,
especially after twelve weeks, has reallybeen well well established. But it's
also you have to take it everyday. Yeah, compliance issue with it,
which I love that you write theprescription. I always recommend, and
(26:47):
I've had pharmacists call me saying youcan't, and there are signs that say
you can't take asperin in pregnancy.It's lotos aspirin. So it's that baby
aster, the one malgrim like that. We really push in that sense of
making sure that people under stand exactlywhat it is. So yeah, I
find it funny that that's the mostprescribed. So we the American College of
Obijan, the Society of MFM,the US Preventative Task Force all support lodo
(27:11):
sasprin. So just to reemphasize thatit is. It becomes a trust factor
that how is this impacting my child? Actually, it's impacting your percenta the
way I like to talk about it, And that's the cause of your preclipse.
Yeah and so and what and againit's sort of what you know.
I don't want to call them badhumors because that might take us back many
(27:32):
years, right, But it's it'sreally thinking about what is being produced by
the placenta and what can we reducewith that Loto saspron and talking about it
and really having that conversation with thepatient is super important to have really early
on, because we know it canmake a difference and if you start it
later, it's not going to havethe same impact, right, So,
and that may be the difference betweenpre term birth and all the signs and
(27:55):
symptoms we went over and having youknow, a high risk pregnancy. It's
amazing to think about all great resourcesand information. So where can more people
find out about what March of Dimesis doing? So Marshadimes dot org And
if you want to look up ourpre term birth report card, you want
to look at our Maturity Care desertsthere. You want to donate, you
(28:15):
can donate there. But it alsohas tons of information just on education.
One of our biggest things that haslooked at on our website is pretty clams
down. Yeah, and then whatabout you, doctor Pumo. Where can
folks connect with you? Oh,they can find me on the web,
on Instagram, on the breakfast club. But I think the most important thing
though, is the conversations you're creating. Can you me Eternal podcast? I
(28:38):
think it's really important the awareness andeducation. I'm inspired by the work March
of Dimes is doing supporting me Eternal, and I totally inspired by the dedication
and the just the overall understanding ofthese issues by doctor Chiau, and I
think the March of Dimes as wellserved which is amazingly readership. So I
(29:00):
just think it's important to keep havingconversations. Yeah, yeah, I appreciate
it very much. Thank you somuch. Well, thank you both.
Right, this was great and Ihope it's going to help a lot of
moms that are out there who werekind of uncertain about a lot of things
before they started listening. And youcan learn more at me eternal dot info.
Right, there's a lot of informationup there, March of Dimes.
(29:21):
You have content up there that yousupply for us, so we've got all
the moms here well covered. Right. Yeah, thank you so much,
Kenya. Yeah, thank you,thank you. Until next time, thank you.
We've been having some great conversations sofar, and we are like really smack
in the middle of Heart Health Month, which is pretty incredible because it just
seemed like it was January yesterday.Yes, it was. We're halfway through
and this is a big month toreally amplify. I'm so excited to be
here today to talk about it andtalk about not just moms but women in
general and really how we should beamplifying this. Yes, and we have
(00:24):
a very special guest with us heretoday, doctor Joseph Puma of Soren Medical,
who is one of our partners hereat iHeart and has been doing a
lot of great work in communities ofcolor in terms of getting the messaging out
about heart health, the importance ofpreventative care, and why it's important for
us to be taking those steps towardsunderstanding what's going on with our heart health.
(00:46):
So welcome to the Maternal Thank you, Kenya, thanks for inviting me
again, and doctor Chiro, it'sa true pleasure to be here with you.
Thank you you too. Yeah.So we're talking about pro clemsia,
yeah, on our last episode,which I feel like sometimes goes very underdiagnosed
in a lot of certain cases,I was underdiagnosed with proclemsias. So can
(01:07):
you just explain to us what proclemsyais and how that relates to heart health.
Yeah, so, gosh, that'sa loaded question. Loaded, that's
like, okay, how long dowe have? So preclamsy is a state
that you can be spilling a lotof protein in your urine. You can
have symptoms like headaches or visual changes, strange upper right upper quadrant pain,
(01:30):
a lot of swelling and that couldbe fast. Now in pregnancy, you
can have swelling but really fast ongoingswelling, visual changes where you have a
hole in your vision, and thenyou have high blood pressure the spilling of
this protein. And it's a stateof either before pregnancy, during or after.
We talk about this happening a thirdof the time before you deliver,
(01:51):
a third of the time while you'rein labor, and a third after that
you become ill. And the cureis unfortunately delivery. We don't have a
lot of treatment. We try andprotect moms from seizing because that can be
the ultimate sequale. Swelling in thebrain can be the ultimate sequality that often
doesn't happen, but is what weprotect against happening. The scary part is
(02:13):
once you deliver, you still hormonallyare transitioning in the last you know,
the last six weeks after you deliver, and so that has been when I've
seen it as well. And thebig thing that I always like to talk
about with preclamsy is understanding the warningsigns, asking about them way before it
happens, and really it usually happensafter the twentieth week. But also realizing
(02:38):
that when we talked a little bitabout this, that's a stress test.
Pregnancy is a stress test because ultimatelyyou may end up with chronic hypertension after
preclamsy or pregnancy, but you areat risk if you've had preclamsya for cardiovascar
disease for the future. So I'llleave it there because I have a feeling
someone else might want to time.Yes, So what do you see when
(03:01):
it comes to people who may beexperiencing proclemsia or anything preventative before pregnancy that
you see in some of your patients. So preclams here is probably the most
serious and most common complication of pregnancy. And you know you've had prior speakers
here that the birthing experience, theentire experience should be a beautiful experience and
(03:23):
it shouldn't be an experience of fear. And if we have addicate healthcare systems
and processes in place, excuse me. If we have adequate systems and processes
in place, we should be ableto capture patients who are at risk for
pre eclamsy and follow them closely.The challenge of pre clamsy is is it's
(03:46):
primarily driven around high blood pressure,okay, and it's kind of like high
blood pressure on steroids in a sense. It's just a dramatic increase in pressure,
very difficult to control. But itdoesn't just affect the mother. It
affects the child as well, andthat's a challenge. I think. The
other good point that doctor Cherro makesis pre eclamsy is not just a pregnancy
(04:11):
disorder or a birthing disorder. Weneed to have systems in place to follow
these mothers and children for a yearafter the pregnancy because the complications can significant
complications during that time can occur upto them. And let's face it,
when often when the mother dies duringpregnancy or a child dies during pregnant,
(04:31):
it is often related directly to preeclamsy and so so we really need to
be way more proactive, find outwhat the understand better, what the risk
factors are, raise awareness, education, and have systems in place to help
care for people so they can havea beautiful birthing experience. Yeah yeah,
(04:53):
I So talk to me a littlebit about what you see with black women.
Do you see it worse with blackwomen? Do you see the cardiovascar
disease? We know right that moreblack women have complications from pre eclamsy.
I'm just curious, right, I'mthe one catching the baby and then taking
care of that mom for a shorttime afterwards, and then I'm looking at
(05:15):
you going help. Well. Ithink if you look at worldwide, over
ninety percent of cases of pre eclamsiaare occurring in underserved communities women that are
black or brown. So this isthis is not a white problem. This
is a black and brownblem In theUnited States, it's pretty much it's pretty
(05:38):
much the same. But this isnot a biologic issues. It's not that
biologically or something in our DNA makesbrown or black women have higher incidences of
pre eclampsia and complication. It's actuallya number of other factors many of them
are social factors, some of themare economic factors, poverty factors, and
(06:01):
so there's a lot that we canand should be doing. It is.
I know today I'm with people whoshare my outrage that such a wealthy country
can have such a high infant mortality. I don't want to I know doctor
Schurou knows it better, but Ithink we're like number forty six in the
(06:24):
world. I know I'm with peopletoday that share my outrage. And if
you're a black woman, your riskof complications from pregnancy or death from pregnancy
are more than twice as high asyour white counterparts. And just as a
physician, and this is one ofthe reasons I think it's so amazing that
the March of Dimes has a physicianas a chief executive, someone who has
(06:47):
cared for patients, delivered children,understands all the on the ground factors for
over twenty five years that doctor Schrurouhas done. That we should be work
working as our primary goal to meetunmet needs for our patients in our communities
and in the healthcare system. Forsure. Yeah, no, listen,
(07:10):
you just thank you. First ofall, that was kind, but also
it is absolutely a spectrum of thingsthat we see, and we absolutely see
pret climsy and white women as well, but women black women are dying more,
right, So that and if wesolve for that, we solve for
all women. I guess I'd loveto know or really talk about. I
(07:33):
mean mostly because I deliver right,I'll take care of mom. She may
come back year over year or skipseeing me after she delivers her last patient.
With me, I always worry aboutthat cardio of vascular risk. They
don't get it's further, you know, downstream. I think about the we
know very well that diabetes, ifyou have justtational diabetes, your risk for
(07:56):
diabetes over your lifetime. And Ithink we do a good job of information.
I'm not sure we do a greatjob. Most moms will come back
to me, believe it or not. They come to me more than they
come their primary care provider. SoI would love to have that conversation of
really talking to I don't want toterrify somebody who just had preclamps Yeah,
but how do we make sure thatthey over their lifetime come in and get
(08:20):
seen and what do they really need? So that's a great question, doctor
Schrow. Women who have preclampstery inpregnancy, regardless of color, of socioeconomic
status, actually have a much higherincidence of chronic hypertension, high blood pressure,
diabetes, cardiovascil disease, high cholesterol. So their long term risk is
(08:45):
worse. So, you know,if you're if you're pregnant in your thirties,
but you had pre eclamsya getting you. You know, I like to
tell people, my job is tomake you an old person, right,
That's what I do, right.My job is to help people live longer,
right, Okay, But if you'vehad these conditions in your thirties,
it's much harder for us to workto make you an old person. Okay.
(09:09):
So the risks of all these associatedfactors is significant. That risk in
the first year is much higher,Okay. Connecting them though, it's it's
a long term care issue, isn'tit right, It's a long term care
issue. It's it's a matter ofbringing the services to the patient. How
do you tell a young mother,for instance, that has to travel from
(09:31):
their community to go to a hospitalcenter if there's no no health care in
their community. So access to meis probably the hardest thing. I think
we need to stop blaming people,yes, for their health care problems,
that it's you know, it's it'sall on them. It's not all on
them. We're you know, we'rea country where a community that should be
(09:54):
working to help help each other.The March is done, the March of
Dimes. Is this incredibly innova procorrect. Thank you. There's you know,
mobile healthcare bringing it into the community. You know, I live in
New York City, and if youlook around New York City, when we
lived through the COVID crisis, whichyou know, we're all traumatized from the
(10:16):
big challenge there was, there wereno hospital beds. And yet just in
the last several months, can youBeth Israel is closing has announced as closing.
That's a thousand bed hospital in Brooklynin an underserved area. The State
University of New York has announced it'sgoing to close downstate. So where are
(10:37):
people supposed to go for healthcare?So I think it's a combination of issues.
If if you have, first ofall, up to eight percent of
pregnancies have pre acclamsy or regardless ofcollege. So let's identify with the actual
problem is. But we can identifyhigh risk women just by doing a history,
(11:00):
a five minute history, asking afew questions, we can identify which
which of these women are going goingto be high risk and then have a
process to follow them more closely andif they do develop pre eclamsia, we
should have programs to follow these patientslongitudinally and connect them into a healthcare system.
Yeah. So if you you're apregnant woman and you have high blood
(11:22):
pressure, right, how can youmanage that? Yeah? I mean that.
So, first of all, ifyou have chronic hype pretension, So
there's a couple of things. Youcould have chronic hype pretension, just stational
hypertension, so chronic you had itbefore pregnancy, gestational it's happening during your
pregnancy, and then preclamcy being thisaquality. Both of those are risk factors
for pre eclampsia. Really, it'sabout getting a blood pressure cuff and start
(11:43):
monitoring yourself. It's about asking,reviewing and knowing the symptoms and really diving
in. So again, it's theswelling, it's rapid weight gain, it's
about nausea, vomiting, it's aboutheadache, visual changes, and if you're
not sure, you need to act. Yeah, right, and a provider
should be bringing it up. Dependingon the stage of where you are and
your pregnancy, you may be seenweekly or you meet every other other two
(12:07):
weeks. But if that's happening,you need to get in sooner right as
the provider. But blood pressure isreally the key. And we have now
much more or recommendations for much moretighter control than we ever did, which
is fantastic because we actually see theoutcomes for babies being better because oftentimes we
have to deliver prematurely because of thepre aclampsia. Knowing that that's getting work.
(12:28):
We also have biomarkers now, whichis so exciting. This is something
that's more in Europe. It wasjust FDA approved here in the United States,
and I get super excited to thinkabout the future. So it's a
blood draw, so if you're inthe hospital, and this is where you
know if you're in the hospital andor have been, really this is preeclampsia
or is it not preeclampsick? Ifyou could have other disorders, kidney,
(12:50):
we could go through other things,but how do we differentiate whether this is
really preeclampsia or not. We havesome standard blood work. We have kind
of a mealieu of signs and symptoms. But truly, now we have a
blood test that helps us decide whatdo we do? And I love it.
I think it's finally moving forward.As I said, they're using it
(13:13):
in Europe more readily than we are, and I'm excited to see us coming
really moving forward with the blood testto help us with the algorithm on what
to do next. That's great.I would just adds to that doctor show.
You know, you make a keypoint monitoring the blood pressure closely.
We have such technology now that inour practice in patients that have high blood
(13:35):
pressure that we're having in challenge controlling, we have blood pressure cuffs that I
don't understand the technology have kind ofa cellular chip or something in it like
your cell phone, and we justasked them to take their pressure at home
once a day. Yeah, andit automatically comes, you know, through
the clouds somehow into our computer andwe have our nurses and staff. We
(13:58):
have a group of nurses and staffthat monitor hundreds of patients blood pressures on
a regular basis. So there arehigh tech ways and actually low tech ways.
Yes, you can get the fanciestof blood pressure cuffs, but truly
you just need a blood pressure cuffthat you can monitor yourself, excuse me,
And that has been really well provenafter you go home to not to
decrease readmissions and actually identify those thatneed to be seen. So and you
(14:24):
know, our guidelines aren't like thatwe should be. We do actually hand
out blood pressure cuffs. In WestTexas, we hand out a lot of
blood pressure cuffs because the miles todrive. Do I need to come in
or not? I'm feeling dizzy,lightheaded. I don't know about you,
but it happens when I stand up. So what right? So what is
that real? Is that not real? What do I add? I now
have some data points? Yeah,and you're absolutely right, we can do
(14:45):
it remotely and doing telemedicine is right. I mean, that's one thing out
of COVID that's probably the only thingthat I really get excited about that it
advanced. As a practitioner at thetime telemedicine was like, we're never gonna
be able to do this in obsesstricks, and we can do it,
and we can do it for realproblems and issues, and I see as
this is one that gets me reallyexcited about thinking about it's new and innovative,
(15:09):
not so new really, right,and so it's just we can make
the fanciest of ones using bluetooth andhow fantastic it could drop into your MR
and alarm you. But a patientcould take control of that too of getting
a blood pressure. Yeah, haveyou treated people or women with proclemsia at
your practice before? Yes, weoften get asked to see high risk pregnancies.
(15:30):
The ob guy n's often you knowyou have high risk ob gyn physicians,
but the majority of the complications areoften cardiovasqued and interestingly, sometimes the
ob gyn physicians aren't the ones thatwant to treat the high blood pressure because
there are I love, Yeah,there are some high blood pressures, and
there are only certain medications that youcan use. Even if someone at high
(15:54):
blood pressure before and they were perfectlywell controlled on a medication for years,
once they're pregnant, you need toswitch them to different medications. So we
often see high risk pregnancies, getthem through their pregnancy. Unfortunately, can
discharge them from the practices on oneof the few times we can actually discharge
(16:17):
your patient from a cardiovascular practice,but they'll have to come back at some
point, right, Yeah, butthey and and that partnership is really important
from an obsttrition standpoint because fun reallythe patient has to be at the center
sure, so that they're really takingcare of on all aspects and really,
you know, there's a certain levelof comfort I'm going to have that I
want an expert to come in andhelp with. Yeah, for sure,
(16:40):
what are some of the signs andthe symptoms. So so I mentioned some
swelling. So swelling can be likeyour face can swell, your hands or
feet can swell. Lots of pregnancies, lots of people swell. But this
can be dramatic headache that doesn't goaway, and it's not the typical tension
band headache. You're really talking abouta global headache. There's something called skatoma
(17:03):
or visual change, which is ablack hole in the visual of vision.
And I always think about any visualchange you should be asking your provider.
And then there's the high blood pressure. There's the the spill. You can
spill a lot of protein in yoururine, which is obviously a symptom that
you'll see. But you'll see somenauch of vomiting, some write up or
quadrant pain that isn't kind of thebaby moving up there. All of that
(17:27):
can happen at once. None ofthose could happen and that's the scary thing.
You could have high blood pressure andnot have those symptoms, right,
but those are the most difficult forprey climbs. Yeah. I love the
synergies that both of you are doingin the community with the mobile health units
and the accessibility that you're creating incommunities of color with people being able to
(17:49):
get scanned right for preventive healthcare reasons. So I just I commend you both
for taking that step towards accessibility becausethat's the biggest solved to moving the needle
for us. Well, you talkedabout maturnity care deserts. We see maturnity
care. It's why we really focusedin New York because that there are maturnity
care. Everybody thinks of the rural, it's not always rural. Right,
(18:11):
as you're talking about hospital closures,we've seen four percent of labor and delivery
units closed across this country and thatyou know, what we call maturnity care
desert is when you don't have accessto a labor and delivery, a birth
center, a midwife, excuse me, family practitioner, anybody to do or
doc to do prenatal care, andwe're seeing those across this whole country.
(18:33):
By play, six million women livein those areas, and it can be
as to your point, in thatinner city where they're you know, you
don't just take an ober right there. They can't afford it, right,
They can't afford it even the subwayride. So getting it out comfortable getting
on the subway when you're pregnant,going up and down those stairs, and
so really getting into the community wherethey are is why we launched the mobile
(18:53):
unit in New York and so wepartnered with the Presbyterian Hospital because even though
I'm a provider, not right,so the March of Dimes isn't but being
that convener to bring the partners inand bring the other partnerships to really get
care where moms are. I thinkabout old school docs who used to have
a doctor's bag and go into thehouses to see I mean, that's right,
(19:15):
and then all of a sudden wemoved everything into the hospital, which
we know right, and then becameoutpatient, and we've got to figure out
how to get back into those communities. Sounds like you're doing it. I
would educt to show that the Marchof Dimes, in addition to the mobile
units and convening care, the otherkey thing, which especially in the black
community, which is a risk factorfor preocclempsia, is social isolation, social
(19:41):
support. And you know, kindof this renaissance now of the use of
duelists, Yes, may have asignificant impact, you know, because the
midwife, for instance, traditionally providedthe medical care for a birthing person,
but you know, duelis provide thesocial support, the you know, the
(20:02):
the other type of care that's required. And I know the March of Dimes,
under doctor Schuro's leadership, has starteda program with doulas in the community.
And you're right, just because we'rein a city, you know,
and you know, only a coupleof miles right separates us from you know,
the amazing buildings and wealth and structuresand poverty. But that's a long
(20:29):
distance in an urban environment, asopposed to you know, your work in
Appalachia where miles and miles separates you. Yeah, no, I think you
brought up the dual work. Thankyou for highlighting. We're really proud of
the work we're doing with the CBSFoundation, and I you know, we
see preterm birth declining and women whohave a doula, and we know that
(20:49):
we can have better outcomes using csection rates other things, and we know
that that really has to be amplified. The supplying demand is a little bit
right, needs to be I wantto say corrected, but it needs to
be balanced. But also the integrationwithin those huge buildings you talk about,
(21:10):
right, And we know that sometimesa doula it can be like a community
worker, right, who's really helpingalong those lines as well. So there's
many structures that we're trying to thinkabout. We know burnout is big within
providers. We're asking providers to doa lot. You're one, I'm one,
right, if it's not our trainingor getting updated, it's just doing
(21:30):
more and asking more. I'm thrilledthat I have specialists to help me,
But thinking about it, we can'tanswer. I can't do everything. So
relying on a doula or a communitywork to help support these moms, I
think is really the next It's anit's funny you say it's sort of the
revolution of it. You're absolutely right, it's the next iteration of it and
(21:52):
really amplifying them and really getting themreimbursement. We're now advocating for that as
well. Yeah, good stuff,good stuff. So managing medical conditions before
and during pregnancy are super important,right, what's your messaging to people who
are pregnant or thinking about getting pregnantone day and how they can reduce the
risk for themselves and their babies.So, from a cardiovascular standpoint, diet,
(22:18):
exercise, I should always start withdiet and exercise. Sometimes I forget
because it's kind of my background noisein life, right, salt, and
it's and funny what is biologic isthere are sex differences and race differences into
our response to salt, and inblack women salt they're more sensitive increases hypertension,
(22:42):
high blood pressure. So diet,exercise, obesity is a risk factor
for preclampsia. A BMI of overthirty is one of the risk factors.
Regular exercise. You know, itdoesn't have to be everyone preparing to run
a marathon, but moving, butjust getting off the couch. That's what
(23:03):
I'd like to just you know,how about we all take a brisk walk
around the block. You know,let's just start with something simple or even
low impact exercise. Tai Chi isactually there's some data now that tai chi
can reduce hypertension, reduce the amountof meds that you need, and it
keeps you, you know, itstretches you. It's very mobile. So
(23:25):
all the kinds of things that yourmother told you to do when you were
a kid, what you need tobe doing, right as we get older,
my mother was right, she getssmarter we ought to be doing.
But then diabetes, you know,checking getting your sugar checked, having your
blood pressure checked by a professional,by a physician, kidney function, these
(23:45):
are all again risk factors, higherincidents in the black community. More importantly,
almost a fifty percent higher incidence inthirty to forty year olds in the
black community than the white community.So at a baseline, a thirty five
year old woman who gets pregnant,if they're black and a baseline they're underlying
(24:07):
risk factors are going to be higher, which is going to contribute to potentially
a higher risk pregnancy. So thereare a lot of factors before you get
pregnant that you should be considering toget yourself prepared. Yeah, I would
only add getting on full of acidat a time, you know, reviewing
family history because that pulls in birththe facts and really talking about other things
(24:32):
like smoking and alcohol and illicit druguse, all of those and actually not
illicit drug use, but all ofthose things you know, can impact a
pregnancy in a lot of ways.And the last I'm going to say it,
I always check lipids. I checklipids on my patients before if they're
coming in for a prenatal appointment,because that's really like their baseline is.
And we don't check in pregnancy becausecholesterol is used for the basis of a
(24:57):
lot of hormones and so that's notthe time to check lipids. But I
try and do that, and thenwe talk about the signs and symptoms,
and prevention is really talking about areyou a candidate for lodos aspirin, And
that's once you're pregnant, roughly aroundthe twelfth week, and so it's important
to get in and get care andget to creatal care. I always say
(25:18):
this is preventative care. People thinkof it as not that, and it
is absolutely preventive care. So it'ssetting you up for the best success for
your pregnancy, and so that that'sspecifically for pre clamcy. The bist thing
we have right now is lodos asproin. Right, Yeah, lodos aspirin is
a great point, and it's interestingto see the obstetricians now talking about LOO.
(25:41):
It's great. As a cardiologist,it's the most prescribed medicine in my
entire career, and even people say, well, I can bite over the
counter. I like to write theprescription. I want to make sure they
understand that it is important. Butlow dose aspirin can lower blood pressure,
reduces the risk of pre acclaimed toyou by about five percent. The American
(26:03):
College drops etricians and gynecologists. Thishas been a guideline recommendation for them now
for at least the last five ormore years. And so that is a
simple thing we can do. Andthe reason it's important to talk about that
is because once women get pregnant,it becomes the stigma about taking anything.
(26:26):
You're so you're afraid, right,well, right, you're you're worried on
so many lives, yeah, right, and so that and your child,
right, your maternal instincts are startingright from the beginning. So the safety,
especially after twelve weeks, has reallybeen well well established. But it's
also you have to take it everyday. Yeah, compliance issue with it,
which I love that you write theprescription. I always recommend, and
(26:47):
I've had pharmacists call me saying youcan't, and there are signs that say
you can't take asperin in pregnancy.It's lotos aspirin. So it's that baby
aster, the one malgrim like that. We really push in that sense of
making sure that people under stand exactlywhat it is. So yeah, I
find it funny that that's the mostprescribed. So we the American College of
Obijan, the Society of MFM,the US Preventative Task Force all support lodo
(27:11):
sasprin. So just to reemphasize thatit is. It becomes a trust factor
that how is this impacting my child? Actually, it's impacting your percenta the
way I like to talk about it, And that's the cause of your preclipse.
Yeah and so and what and againit's sort of what you know.
I don't want to call them badhumors because that might take us back many
(27:32):
years, right, But it's it'sreally thinking about what is being produced by
the placenta and what can we reducewith that Loto saspron and talking about it
and really having that conversation with thepatient is super important to have really early
on, because we know it canmake a difference and if you start it
later, it's not going to havethe same impact, right, So,
and that may be the difference betweenpre term birth and all the signs and
(27:55):
symptoms we went over and having youknow, a high risk pregnancy. It's
amazing to think about all great resourcesand information. So where can more people
find out about what March of Dimesis doing? So Marshadimes dot org And
if you want to look up ourpre term birth report card, you want
to look at our Maturity Care desertsthere. You want to donate, you
(28:15):
can donate there. But it alsohas tons of information just on education.
One of our biggest things that haslooked at on our website is pretty clams
down. Yeah, and then whatabout you, doctor Pumo. Where can
folks connect with you? Oh,they can find me on the web,
on Instagram, on the breakfast club. But I think the most important thing
though, is the conversations you're creating. Can you me Eternal podcast? I
(28:38):
think it's really important the awareness andeducation. I'm inspired by the work March
of Dimes is doing supporting me Eternal, and I totally inspired by the dedication
and the just the overall understanding ofthese issues by doctor Chiau, and I
think the March of Dimes as wellserved which is amazingly readership. So I
(29:00):
just think it's important to keep havingconversations. Yeah, yeah, I appreciate
it very much. Thank you somuch. Well, thank you both.
Right, this was great and Ihope it's going to help a lot of
moms that are out there who werekind of uncertain about a lot of things
before they started listening. And youcan learn more at me eternal dot info.
Right, there's a lot of informationup there, March of Dimes.
(29:21):
You have content up there that yousupply for us, so we've got all
the moms here well covered. Right. Yeah, thank you so much,
Kenya. Yeah, thank you,thank you. Until next time, thank you.
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