September 4, 2024 • 36 mins
Join our special guests, Drs. Lauren Lastinger from The Ohio State University and Sharon Roble from OhioHealth, as we review common issues in cardio-obstetrics for the cardiac practitioner. We will review pearls for managing common cardiovascular conditions during pregnancy, evaluation of cardiac symptoms during pregnancy, common medication pitfalls, and new concepts in peripartum cardiomyopathy.
For more information, see:
Lastinger et al :Diagnostic and Management Considerations in a High-Risk Pregnant Patient With Ischemic Cardiomyopathy
Cardio-Obstetrics Essentials: Team-Based Management of Cardiovascular Disease and Pregnancy (ACC course)
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kanny (00:11):
So welcome back to the Cardio Ohio podcast.
This is Canny Graywall inColumbus, your host, and I'd
like to welcome again a co hostI think you're familiar with,
our current president of theOhio chapter of the ACC, Dr.
Ellen Sabic, who's checking infrom Cleveland.
Ellen, welcome.
Ellen (00:30):
Thank you so much, Canny.
Kanny (00:32):
So we're really excited today to be able to talk about a
field we haven't had theopportunity to address so far in
our series, which is the growingfield of cardio obstetrics.
You know, this is something allof us in general cardiology deal
with, as a consultant or on ourinpatient wards.
But it is a growing field andwe're forced luckily today to
(00:54):
have a couple of cardiologistsfrom here in central Ohio who
amongst their various interests,specialize in, in cardio
obstetrics.
I'd like to first welcome Dr.
Lauren Lassinger.
She's here in Columbus at OhioState University.
She's part of the adultcongenital heart disease program
(01:14):
there.
Lauren, welcome.
And do you mind just taking aminute to kind of talk about
your career path that led you toyour current position and this,
you know, the breakup of yourcurrent practice.
Lauren (01:25):
Yeah, sure.
Thank you so much, first of all,for having us on.
And I'm excited that you'vechosen Cardio Obstetrics to talk
about, because it's definitely agrowing field, although it's not
a new field.
It's something that, as youmentioned we've been doing for a
very long time, even precedingme.
But it's becoming much more of aformal field.
And I think anybody getting moreeducation, this can only only be
(01:46):
helpful.
So I kind of, I wouldn't say I,I went into cardiology training
thinking this was something Iwas going to do, but got exposed
to it just through my trainingin adult congenital heart
disease, because a lot of ourpatients, as you know, are
younger women of childbearingage, and a lot of them have have
pregnancies successfully, evenin the most complex things.
(02:07):
cases, but also as part of that,our program at Ohio State the,
the cardio obstetrics programhas really existed for a long
time under the umbrella of adultcongenital heart disease.
And so as part of that, I gottraining in taking care of women
with cardiomyopathy andaortopathy and other things.
And really I came out offellowship not thinking it would
be a big part, but I realizedwhat as a fellow sitting at a
(02:29):
table during these meetings wehave, and I recognize at the
time that I was the only womanin the room having conversations
about these women and their careplan who had actually given
birth to a baby.
And so I felt very connected tothese women.
You know, both professionally,but also personally because I've
been through what they weregoing through and so that really
(02:51):
has been a part of my careerthat has evolved.
I'm now the director of thecardio obstetrics program at
Ohio State, and it's somethingthat I'm really passionate about
both, care wise and thenteaching others.
Kanny (03:04):
Well, that's great.
And we're certainly happy tohave you on the program and
happy to have you as a resourcehere in Central Ohio.
I'd like to also introduce oursecond guest, and this is
someone I've had the pleasure ofworking with since 2016 when you
joined OhioHealth, and that'sDr.
Sharon Robel, who is based inMansfield, Ohio, with
(03:24):
OhioHealth, but also works herein Columbus as well, and is well
known at Ohio State as well foryour training.
Sharon's a cardiac imagingspecialist, but also runs the
adult congenital heart clinichere at Riverside Hospital.
Sharon, welcome and can you letus know a little bit about your
path as well that led to you toCentral Ohio and your current
(03:45):
position?
Sharon (03:47):
Thanks.
Thanks, Kenny.
And thank you for having me ontoday.
I appreciate the opportunity totalk about this is this is my
favorite group of patients totake care of.
So I have been a cardiologistnow for 19 years, and it's been
(04:10):
a great journey to see how adultcongenital heart disease
training has evolved.
When I first started we had todo both adult and pediatric
training.
So as we did that there was someexposure to pregnancy, and
that's really where I gotinterested in the field.
(04:32):
It was very interesting becausefor a long time, women were told
by their pediatric cardiologistto not even have children.
And it wasn't uncommon that theywere actually told to undergo
permanent sterilization becauseit was just too risky for them
to have children.
And it really shocked me in mytraining to hear that.
(04:55):
So when I went through mytraining, that was sort of when
things were starting to change,and we realized that even some
of the highest risk patients whonever thought they could have
children were given theopportunity to actually have
children and to consider thatopportunity.
And it was just, An amazingexperience having been med
(05:19):
Pete's trained into see that andactually help be a part of that.
So when I finished my training,I actually came back to central
Ohio and and joined the adultcongenital program at OSU and
really helped with that programand it just really took off
there and and we continue todevelop that program and.
(05:41):
When the opportunity came overhere to help develop an imaging
program with another colleagueof mine, I, I took that, but
still wanted to be a part of thepregnant population and, and it
was certainly a need here aswell as many patients wanted to
deliver in the Ohio healthsystem.
So, I, I was a good opportunityto come here and continue with
(06:03):
that patient population.
And Lauren and I continue toshare patients when they.
Want to deliver one place andthey're followed another place.
So, so it's just a greatpopulation to work with.
Lauren (06:16):
It should also be stated that the program that I, I'm
currently involved with isreally built by Dr.
Robles.
So I have the benefit of just.
Kind of taking over everythingthat she built, which is it's
it's an amazing and robustprogram at Ohio State.
Thanks to her.
Kanny (06:33):
Yeah, it's great to have both these resources here.
Now, of course, in a in a systemlike Ohio State or here at Ohio
Health, we're fortunate to have,multidisciplinary specialists in
so many fields, including, adultcongenital disease and also
cardiac obstetrics, but ofcourse.
And a lot of our practicesettings around Ohio, where our
audience is listening, that'snot necessarily the case.
(06:55):
So, we thought the discussionwould kind of be framed more
from the standpoint of a generalcardiologist or cardiac
practitioner, like an advancedpractitioner, who may not, have
immediate access tosubspecialists.
So I think that's where Ellenand I want to kind of, you know,
address some of these Thesecommon issues that come up,
Ellen (07:14):
So Lauren and Sharon, we are so lucky to have you here
today for this discussion.
And I'd like to start off thediscussion thinking about.
We have a lot of common generalcardiology conditions we see in
our young patients, particularlyin this instance, young women,
fabular heart disease,hypertrophic cardiomyopathy.
We more likely deal with thesimple adult congenital heart
(07:36):
disease and aortic actasia, butwhich of these conditions, you
know, are well tolerated inpregnancy and which ones raise
the red flags when we reallyshould refer to sort of the high
risk cardio OB people.
And also, can you give us somemanagement.
And so we're going to talk alittle bit about how we can
(07:57):
manage these people throughtheir pregnancies, sure.
Lauren (08:02):
Yeah, you're right.
It's a very wide spectrum ofwomen who.
With heart disease who getpregnant, you know, I think the
some of the simplest things arethe patients who have
palpitations or history of PBCsor history of SVT or something
like that.
The simpler arrhythmias tend tobe really well tolerated in
pregnancy.
And I don't have too manyconcerns about those patients.
(08:22):
The rest of the cardiomyopathiesand that sort of thing are
really very dependent on what'sgoing on.
And I think the, the trickiestones are the ones that you don't
see coming that probably give methe most positive.
You mentioned aortic ectasia.
So one of the patientpopulations that, you know, that
I think maybe get missed forthose patients who have Marfan
(08:43):
syndrome or Loewy's disease orsome of those connective tissue
disease that, that wherepregnancy can really be.
A risk factor for aorticenlargement.
Rarely aortic dissection, but ithappens.
And and then thecardiomyopathies, like the
hypertrophic cardiomyopathy canreally be a mixed bag, and it
(09:04):
kind of depends on what you'restarting with.
But those, those that give mepause or sort of those
aortopathy, anybody with asignificantly reduced EF and a
cardiomyopathy and some of thosehypertrophic cardiomyopathies,
depending on what the underlyingsubstrate is.
Ellen (09:22):
And as far as the different valvular heart
disease, regurgitant versusstenotic, are there particular
ones who you worry about a bitmore than others?
Lauren (09:33):
Right.
You know, anybody that doesn'thave severe valve disease, tends
to do okay in pregnancy.
hemodynamic changes ofpregnancy, the, the, the The
extra volume that you have onboard, the increase in heart
rate, the change in yoursystemic vascular resistance.
So, you know, anything that'smild, moderate, anything right
sided tends to do fine.
We see a lot of women withsevere tricuspid regurgitation
(09:56):
from a history of endocarditis.
They tend to do just fine.
It's a left sided obstructivelesions that can get you into
trouble.
And then So aortic stenosis,mitral stenosis can definitely
get you into trouble.
And oftentimes even reallysignificant mitral
regurgitation.
If you have a sort of primarymitral valve disease, just
because of the hemodynamicchanges of pregnancy after
(10:18):
delivery, there's a lot ofchanges that happen.
And so some of those, butanything that's kind of mild,
moderate, anything right sidedtends to be pretty well
tolerated.
Ellen (10:27):
Wonderful.
Thank you,
Sharon (10:28):
I think it's important to also think about the
symptoms, not just or theconditions, not just during
pregnancy, but during labor anddelivery as well as after.
So we have a problem in thiscountry with maternal mortality
(10:48):
in pregnancy, and it has to doboth with acquired and as well
as congenital heart disease.
But, but certainly we need tothink about those things.
So whenever I assess.
patients patient that comes tome, I think about, okay, how do
we manage them during thepregnancy, during the labor and
then afterwards as well?
And I make sure that as Ioutline a plan for them, I
(11:12):
address all those issues.
Because My biggest nightmare isthat they go home and something
catastrophic happens after theydeliver too.
So we're not done after theydeliver.
We have to think about how do wemanage them afterwards as well.
Because as Lauren pointed out,there are a lot of hemodynamic
changes that happen afterdelivery.
(11:33):
The biggest risk is not thepregnancy and it's not the
delivery.
It's actually the it may be theweek or two after they deliver
as they go through thepostpartum changes.
So some may need to stay longerin the hospital for that.
So I think it's thinking aboutall those things when we talk
about yeah.
managing these patients.
(11:53):
And, and I think that the otherthing we need to think about is
maybe they only have to see thecardio V physician once or twice
just to help kind of outlinethat it may not be that they
necessarily need managedthroughout the whole pregnancy
by that person.
But I think it's helpful to say,well, let's at least have one
assessment and figure out wheredo we go from there?
(12:14):
Because it is candy pointed outto, it's a multidisciplinary
team.
So we have to find out what the.
OBs are comfortable with two atthose local hospitals because
sometimes what I think could bemanaged at a local hospital, the
OBs don't feel comfortable withthis either.
So I think open lines ofcommunication are also
important.
Kanny (12:34):
So on that note, Sharon in a patient, a pregnant
patient, say with mild tomoderate valve disease, for
example, or perhaps mild aorticectasia in terms of imaging
during pregnancy, are you,usually relying on a change or
in symptoms to warrant imaging?
Or is there a role for any kindof routine monitoring?
(12:54):
Because I know there arechallenges, of course, with
imaging and pregnancy.
Sharon (12:59):
I routinely monitor my patients during pregnancy.
So for example, aortic ectasiapatients get monitored once a
trimester.
Current guidelines for Marfian'spatients actually recommend
imaging every four to five weeksbecause they are at a high, such
a high risk for dissection.
And if there's a significantchange, C sections are
(13:22):
recommended.
The nice thing about.
Some of our imaging modalitiesso non contrast MRIs can be
performed during pregnancy andwe get very nice imaging of the
aorta.
It's no contrast, no radiation,and so that gives us a lot of
information.
So that's a very useful tool.
(13:43):
That we can use the biggestissue that I have had with MRAs
actually is trying to do them inthe third trimester and I've had
a few women that have supinesyncope from obstruction of the
IBC with the gravid uterus, butimaging wise, you usually get
beautiful images and we can dothose pretty quickly.
Ellen (14:04):
Wonderful.
You you also talked a little bitabout sort of mode of delivery
when C sections.
Lauren, could you touch basewith us as far as when do you
all get involved as part of theplanning of, can patients push?
Do they, do they do a vaginalbirth?
When do we recommend C sections?
And at what point do we, atwhich patients do we step in and
(14:25):
sort of try and specify that tothe OB?
Lauren (14:29):
Yeah, this is one of those, I would say, cardio
obstetrics myths or myths hasbeen floating around cardiology
and still does in amongproviders that don't have much
experience taking care ofpregnant women, but I have
patients that come to me all thetime saying, Oh, my pediatric
cardiologist said I would haveto deliver by a C section or it
tends to happen more in thecongenital population or women
(14:52):
who have, you know, Marfansyndrome say, Oh, I'm definitely
been told I have to deliver viaC section and that, Really
across the board, there arealmost no cardiovascular
indications for a C section.
And that includes patients withpulmonary hypertension, most
patients with connective tissuedisease, aortic disease.
You know, most patients withheart failure.
(15:14):
And because really the risk, therisk of C section, even in those
patients where you're worriedabout pushing is greater than
vaginal delivery just due to therisk of anesthesia, analgesia,
the anorexial analgesia.
a higher risk of bleeding,disrupting your hemodynamics
with C section.
And so the times that Irecommend C section, I think
Sharon mentioned, you know, ifyou were showing rapid aortic
(15:36):
growth you might consider it theone slam dunk is if you're
somebody who comes in on fulldose anticoagulation.
So maybe somebody with amechanical valve whose INR is
therapeutic that's a slam dunk Csection just because of the risk
of fetal intracranial hemorrhagewith vaginal delivery.
(15:56):
But by and large, for mostpatients, there's not a cardiac
indication for C section becausewe can get away with things like
an assisted second stage, sothat would be like a vacuum or a
forceps delivery where thepatient doesn't actually have to
push.
They let them labor down untiluntil the baby's, you know,
pretty close to delivered andthen just assist the baby out
(16:17):
and that helps decrease, youknow, that increase in afterload
with pushing that we might beconcerned about.
The other indication, obviously,is somebody who's crashing and
burning, cardiogenic shock, thatsort of situation, obviously, if
the mom is unstable, we for surego for C section, or if there
are obstetrics reasons.
But from a cardiac standpoint,very few.
Kanny (16:38):
Yeah, thanks, Lauren.
I thought maybe we could turnour attention now, not to
patients like we've been talkingabout with known cardiovascular
or congenital disease who getpregnant, but some of the common
symptoms we encounter during apregnancy, maybe in a patient
with no prior cardiac history.
Of course, anybody who does.
general cardiology consultationsin the clinic, or even in the
(16:59):
hospital, knows that, it's very,very common to see patients who
report things like palpitationsor near syncope, sometimes
atypical chest discomfort.
We obviously can't talk aboutall those in detail, but I
thought, Sharon, maybe you couldjust give us a few of your
pearls, for example, in apatient, say, with palpitations
or episodic tachycardia, maybe afew things in the history that
(17:22):
would Kind of set off a redlight in your mind that the
patient might need furtherevaluation versus the more
common run of the millnonspecific things we tend to
see.
Sharon (17:31):
Sure, so it's very challenging sometimes because
many of the symptoms that peoplehave can be just normal
pregnancy.
But I think history taking isvery important and listening to
what their symptoms are.
I have a a low threshold to docardiovascular testing in my
(17:56):
patients.
So patients are getting pregnantat older ages.
They have more cardiovascularrisk factors.
So I take shortness of breathseriously.
because we don't want to missthings like peripartum
cardiomyopathy.
(18:17):
Obesity is obviously anepidemic.
We see a lot of patients withdiastolic dysfunction.
They come in with risk factorswith chronic hypertension.
And so, so I have a lowthreshold to get an echo during
pregnancy, if they complain ofshortness of breath
palpitations, I really try totease out what's going on.
(18:39):
And you know, I see a lot ofwomen where if you get a good
history, you can tell thatthey're just premature atrial or
ventricular complexes and Iwon't necessarily monitor those
patients and I try to providereassurance.
patients who give me a littlebit better history of what
(19:01):
sounds like arrhythmias, theymay get a monitor.
We see a lot of tachycardiacomplaints nowadays.
And, and I think there's beenmore in the lay press about
dysautonomia or POTS.
And so I see a lot of thosepatients come in.
My biggest concern when theycome in with tachycardia is to
(19:21):
make sure that they have normalheart rate variability.
So, If patients have normalheart rate variability, then I
just provide them reassurancethat the that the fast heart
rate is not going to bedangerous and that that's a
normal part of pregnancy.
So again, a 24 hour Holtermonitor just to show them that.
So, so we do provide a lot ofreassurance to people.
Ellen (19:46):
Wonderful.
If we turn a little bit moretowards sort of mundane things
we deal with, with our everydaycardiovascular patients, a lot
of our patients havecardiovascular medications.
And I guess one question I haveis, how should we counsel our
younger women patients?
Are there certain medications wewarn them ahead of time saying,
(20:07):
well, if you're on thismedication, it's not great in
pregnancy, you need to stop itor contact us before you decide
to get pregnant.
Lauren (20:15):
So usually the women that we're seeing who are on
these medications are women whohave pre existing heart disease.
So a couple of commonpopulations are like our
morphine population who areoften on atenolol.
Which is a beta blocker that isfelt to be contraindicated in
pregnancy or angiotensinreceptor blockers.
(20:35):
The other population would bepatients who have heart failure,
who are on similar medicationsand spironolactone.
And then the third populationthat I see where we're usually
talking about medications thatmight be dangerous, at least
cardiac medications are patientswho are on systemic
anticoagulation with warfarinor, or DOACs.
So that might be a patient whohas a mechanical valve.
(20:58):
And so when we, this issomething I talk about, any
woman that comes into my clinicat the childbearing age, we have
conversations about pregnancyand what are you using for
contraception and, and if theyare using durable contraception
and they're on medications thatcan be triatogenic and just to
name a few of those, so Imentioned that those few, but
spironolactone is another one wehave conversations about, well
(21:23):
Even if you're on durablecontraception, if you're going
to get pregnant or you decide tostop your contraception, these
are the medications that youneed to stop.
So you need to call me if youhave Marfan syndrome and you're
on atenolol and losartan, and Iwill switch you to metoprolol or
cravetolol, which have bettersafety profiles in pregnancy.
Warfarin in particular is atricky one because obviously if
(21:44):
you have a mechanical valve youneed to stay therapeutic.
And so if you're trying to getpregnant, we don't want to mess
around with your anticoagulationuntil you're confirmed to be
pregnant.
But Warfarin, if you are on morethan five milligrams a day in
the first trimester isteratogenic.
And so.
What I typically tell thosepatients to do is to take
(22:06):
pregnancy tests regularly ifthey're off contraception.
So maybe once a week, check fora pregnancy test if they're
actively actively trying to getpregnant.
And the second that pops uppositive, call and we'll switch
you to Lovenox.
It can be tricky in thatparticular situation, but
usually we give thoserecommendations.
And most of our patients arepretty good about calling when
they come off birth control ifthey're trying to conceive and
(22:27):
we switch around themedications.
Sharon (22:29):
I think one other medication to talk about is
statins.
Because that recently changed.
So with all the hyperlipidemiathat we have nowadays, so
familial hyperlipidemia, we doput some younger patients on
statins, which used to be abigger deal.
(22:49):
They do need to stop them oncethey become pregnant, although
there is some data that forthese very significant
hyperlipidemic patients, youcould potentially continue it.
I stop it, but I, I don't get asconcerned.
So it used to be, you know, veryIt was really bad if they got
(23:09):
pregnant on it.
It was almost up there withCoumadin.
Nowadays, if they get pregnanton it, we obviously stop it, but
just because of how significantsome of these familial
hyperlipidemia patients can beit, it, I think we're a little
bit more liberal in startingthese patients on them and
continuing them in certaincases.
(23:30):
Now, again, I would have thatdiscussion with a cardio
obstetrics patient and, and notjust leave that up to the
general cardiologist, but thereis newer data out there about
using statins in women ofchildbearing age and being a
little bit more liberal withthat use.
Lauren (23:47):
And our MFM department here at Ohio State is doing a
whole lot of research on this.
But paravastatin, if you'regoing to use a statin, is the
one that seems to have beengetting more of the green light.
These days, even duringpregnancy.
Sharon (23:59):
It would really be the familial hyperlipidemia patients
that you either have havegenetic testing or you have a
strong family history of earlyatherosclerosis that I would, I
would put Pravastatin on duringthe pregnancy.
Kanny (24:15):
Thanks.
I think a lot of us in generalcardiology, that's not the first
thing we would think of when wesee a patient who's on a statin.
So that that's very helpful.
One condition we wanted to takea little more of a deep dive
into because I think veryinteresting and really hits on
all the key aspects between,high risk OB and cardiology is
peripartum cardiomyopathy.
(24:38):
Now, most general cardiologists,I think, are familiar with how
it presents clinically and, youknow, the, the nuts and bolts
of, of initiating therapy, butwe were wondering there's any
updated information about theincidence of PPM, or if there's
anything that stands out the ageand history of the patient
themselves.
I would lead you more to lead,to a higher suspicion of that
(25:00):
when someone presents with,dyspnea, for example.
Lauren (25:04):
Yeah, I think, you know, the news, I wouldn't say a whole
lot new in the incidents.
It's still pretty rare.
And I would say that anybodypresenting during pregnancy or
within a five months postpartumcoming in to the ER with new
shortness of breath andswelling.
It's always up there.
We've actually talked about andin our statewide, you know,
maternal mortality reviewcommittee.
(25:26):
It should we should we have abracelet on somebody who's given
birth to people take themseriously when they come to the
ER shortness of breath and thatpostpartum period, because a lot
of times that gets missed.
But you know, I think one of thenew things that's popped up is.
That are at least that are beinginvestigated are a couple of
things.
One, how does, how does thingslike preeclampsia play into
(25:47):
this?
Because there seems to be anassociation there.
We see a ton of preeclampsia,fortunately, not as much
peripartum cardiomyopathy, butthere seems to be a potential
link there.
And so some of the researchwe're doing is looking into
things like echo strain.
Is there something that we canpick up on all these women with
preeclampsia that might predictthat they might be at higher
risk for developing peripartumcardiomyopathy.
(26:08):
And the other new thing that Ithink is interesting is that
there seems to be in somepatients with peripartum
cardiomyopathy, when theyactually go through the genetic
testing, they are finding higherincidences of pre existing Gene
mutations like in a Titan gene.
And some of these patients.
So is there a crossover betweenmaybe a familial dilated
cardiomyopathy syndrome andpatients who develop peripartum
(26:29):
cardiomyopathy?
So I think we will continue tolearn a lot more about it.
Keeping an eye out for, youknow, symptoms in that
postpartum period is keyperipartum cardiomyopathy.
Anybody that's taking care ofthese patients, whether it's in
primary care clinic or the E.
R.
when they present.
Ellen (26:48):
That's actually really quite interesting.
So 1 question is for patientswho have a family history of.
A cardi, a dilatedcardiomyopathy.
Are those patients, are thosepeople at a higher risk, you
think?
And should we have a higherlevel of suspicion when they're
going through pregnancy thatthey might end up developing a
peripartum cardiomyopathy?
Lauren (27:09):
I do watch them closer.
I mean, we see a fair number ofthose in our clinic and I keep
an eye on them usually once atrimester with an echo, which
sometimes can be difficult toget insurance to cover.
But, I, I mostly counsel them,so a lot of the counseling is
for them to be able to educateother providers who might
encounter them on how to whatthey have going on and what
(27:31):
they've been counseled on as faras risk.
Sharon (27:34):
There's also a subset of patients who may not meet full
criteria for preeclampsia, butthey have volume overload and.
Those are a subset of patientswhere they may incorrectly get
labeled as peripartumcardiomyopathy, and they get
referred to us for, you know,pre pregnancy counseling, they
(27:56):
had peripartum cardiomyopathy.
But when you really dig intowhat happened, it is more, they
didn't tolerate these postpartumfluid shifts for some reason.
And I think, you know, they're.
technically didn't have systolicdysfunction, but it may have
been a component of diastolicdysfunction.
And I don't think we quite knowyet what that means.
(28:19):
And it would be interesting tolook at genetic testing in those
patients to see if they do havesome sort of mutation or what
happens with these patients downthe road.
But that's another subset ofpatients that we see a lot of
that come to us.
For pre pregnancy counseling,and I think the counseling for
those patients is a little bitdifferent than it might be for
(28:42):
somebody who has a trueperipartum cardiomyopathy.
But I also think that thosepatients need to be monitored
closely through pregnancybecause they are at risk for
volume overload in thatperipartum period again,
Kanny (28:55):
Sharon, I'm glad you brought that up because, in my
experience on the consultservice, that's actually a more
common scenario than actualconfirmed peripartum
cardiomyopathy, which is apatient maybe either in the
third trimester or even soonafter delivery who develops,
pulmonary congestion that's notsevere but enough to warrant,
diuretics, and everyone isexpecting, a low EF and of
(29:16):
course the echo looks fine ormaybe impaired diastolic
filling.
So I'm glad you brought that upbecause I think a lot of times
we don't know what to do withthose patients or what we should
label them as.
And it sounds like they mightstill be a higher risk group is
what you're saying.
Lauren (29:31):
But that label is so important.
And that was the point I wasgoing to bring up because as far
as counseling on subsequentpregnancies, there is a big
difference in how you counselsomebody who has true peripartum
cardiomyopathy with a reducedcompared to somebody.
who had volume overload, becausewe don't have any data showing
that those patients with, youknow, just the volume overload,
(29:52):
the diastolic dysfunction, yeah,they're probably at risk for
having similar problems, but notthat they are going to suffer,
you know, a drop in their EFagain, or in the case of
peripartum cardiomyopathy, if itdoesn't recover their EF, you
know, There's some studies,studies show a 20 percent
mortality with subsequentpregnancy.
So that, that label is hugebecause the patient that didn't
(30:15):
have true peripartumcardiomyopathy who gets labeled
with it often, and I see thisall the time, they come to me
and they're saying, I was told Ishould never get pregnant again,
or I got my tubes tied becausethey told me I had peripartum
cardiomyopathy and gettingpregnant again would kill me.
And that's where I think a lotof this education is very
important because for, you know,anybody out in the community
seeing these patients, the labelmatters because of the
(30:38):
counseling and subsequentpregnancies.
Ellen (30:41):
So, could you actually go over, how do you counsel
patients with postpartumcardiomyopathy and what do you
do with, what is their durationof heart failure medications?
Sharon (30:51):
So to, to Lauren's point people who are, are a true
peripartum cardiomyopathy haveAn increased risk of recurrent
systolic dysfunction withsubsequent pregnancies and, and
some centers, some physicianswill counsel them against future
(31:13):
pregnancies due to the risk ofRecurrent LV dysfunction.
And some studies have said thatthat can be as high as 20 to 50
percent depending on what studyyou look at.
And depending on the recovery ofthe LV function with with the
first pregnancy where you had LVdysfunction.
The other thing is that.
(31:35):
medical therapy for the LVdysfunction.
So years ago it was you couldstop after six months if there
was recovery of function.
some studies have suggested thatyou actually should not stop
medical therapy.
So the question I think has comeup, you know, with heart
failure, if you have recovery offunction, should you stop goal
directed medical therapy or youshould continue it?
(31:56):
And I think there's been somepush to continue Goal directed
medical therapy indefinitely.
So, if it's a true peripartumcardiomyopathy, we do counsel
that there is an increased riskof of LV dysfunction with
pregnancy, subsequentpregnancies.
And I monitor their ejectionfraction very closely with
(32:17):
echoes each trimester.
And then beginning in the secondtrimester, they'll get echoes
every four to six weeks.
Once you see a decline in the LVfunction, it's really
recommended that you deliver.
So you're talking aboutpotential preterm delivery if
the LV function falls again.
So, so the implications of thatdiagnosis.
(32:40):
As Lauren said, it's verysignificant versus somebody who
had volume overload anddiastolic dysfunction and needed
a dose or two or Lasix.
So I frequently am sitting inthese visits trying to tease out
what really happened with theprevious pregnancy.
Was it, oh, you needed a dose ortwo of Lasix?
Or were you on goal directedmedical therapy for three to six
(33:03):
months after you delivered andyou really did have a decline in
your LV function because thecounseling and the treatment for
the subsequent pregnancy isgoing to be very different.
Kanny (33:13):
Thanks.
That's a, that's greatinformation.
Helpful to know.
Before we wrap up, I did thinkof one other topic that maybe I
can ask Lauren.
We podcast actually with Dr.
Heather Gornick, it was a greattopic, you know, covering
fibromuscular dysplasia andspontaneous coronary dissection.
But I just thought, just in a,very briefly if you could
(33:37):
address, you know, how often youactually see that initial
presentation of someone withFMD, or you actually see a
coronary dissection duringpregnancy, and is there any
pearls about, you know, thepresentation that would raise
the red flag that that could behappening?
Lauren (33:52):
Yeah, I mean, we do see it.
I would say a couple of times ayear.
We have a pregnant patient whopresents with spontaneous
coronary artery dissection ormaybe 23 times a year.
Somebody who comes in with alegitimate STEMI and STEMI, even
just do it a regular oldfashioned.
atherosclerotic cardiovasculardisease.
But this is, this is why I thinkeducation is important because
(34:14):
any woman who presents withchest pain, when they're
pregnant, you really kind ofhave to take it seriously and
take a history and do doadditional work up when, when
someone presents and you havesome indication that there's
something going on, whetherit's, a troponin elevation,
which can be like in any case,nonspecific or EKG changes.
(34:37):
The first thing to know is thatI think about is like, okay,
well, how stable is the patient?
if somebody is Really having abig STEMI, you, you don't have
any other option.
You don't sit there and say, Oh,you're pregnant.
We'll just treat this medically.
They, they go to the cath laband they get a coronary
angiogram one consideration justbecause you can, you know,
further propagate SCAD with byjust engaging the coronary is,
(35:00):
is there a role for just a rootshot before to get a kind of
look at the lay of the land?
In general, we don't intervene,if unless somebody has a very
high risk lesion or is unstable,but I, I would think about it.
And anybody that comes in withchest pain in a trip on
elevation, how you proceed a lotdepends on how significant that
elevation where they're ongoingsymptoms.
(35:22):
So, you know, it's especially inthat 1st month postpartum, the
vast majority of of pregnancyassociated scan actually happens
postpartum in that 1st month.
Kanny (35:34):
Well, I think that was a fantastic discussion.
I think in.
35 minutes, we covered a lot of,a lot of material.
And I think it kind of shows whythis is a growing field and why
we're fortunate to havespecialists in cardiopstetrics
and adult congenital disease andin our communities.
So I guess I want to thank youboth.
(35:55):
I want to put a quick plug infor our Ohio ACC annual meeting.
It'll be coming up on October19th, not too far from now here
in Columbus.
And we have many experts justlike Sharon, Lauren, and others
who are going to be sharingtheir knowledge.
with our practitionersstatewide.
So thank you both for joining usand we look forward to your
(36:17):
participation in future Ohio ACCactivities.
Sharon (36:21):
Thanks for
Lauren (36:21):
having us.
Really enjoyed it.
Thanks so much.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
So welcome back to the Cardio Ohio podcast.
This is Canny Graywall inColumbus, your host, and I'd
like to welcome again a co hostI think you're familiar with,
our current president of theOhio chapter of the ACC, Dr.
Ellen Sabic, who's checking infrom Cleveland.
Ellen, welcome.
Ellen (00:30):
Thank you so much, Canny.
Kanny (00:32):
So we're really excited today to be able to talk about a
field we haven't had theopportunity to address so far in
our series, which is the growingfield of cardio obstetrics.
You know, this is something allof us in general cardiology deal
with, as a consultant or on ourinpatient wards.
But it is a growing field andwe're forced luckily today to
(00:54):
have a couple of cardiologistsfrom here in central Ohio who
amongst their various interests,specialize in, in cardio
obstetrics.
I'd like to first welcome Dr.
Lauren Lassinger.
She's here in Columbus at OhioState University.
She's part of the adultcongenital heart disease program
(01:14):
there.
Lauren, welcome.
And do you mind just taking aminute to kind of talk about
your career path that led you toyour current position and this,
you know, the breakup of yourcurrent practice.
Lauren (01:25):
Yeah, sure.
Thank you so much, first of all,for having us on.
And I'm excited that you'vechosen Cardio Obstetrics to talk
about, because it's definitely agrowing field, although it's not
a new field.
It's something that, as youmentioned we've been doing for a
very long time, even precedingme.
But it's becoming much more of aformal field.
And I think anybody getting moreeducation, this can only only be
(01:46):
helpful.
So I kind of, I wouldn't say I,I went into cardiology training
thinking this was something Iwas going to do, but got exposed
to it just through my trainingin adult congenital heart
disease, because a lot of ourpatients, as you know, are
younger women of childbearingage, and a lot of them have have
pregnancies successfully, evenin the most complex things.
(02:07):
cases, but also as part of that,our program at Ohio State the,
the cardio obstetrics programhas really existed for a long
time under the umbrella of adultcongenital heart disease.
And so as part of that, I gottraining in taking care of women
with cardiomyopathy andaortopathy and other things.
And really I came out offellowship not thinking it would
be a big part, but I realizedwhat as a fellow sitting at a
(02:29):
table during these meetings wehave, and I recognize at the
time that I was the only womanin the room having conversations
about these women and their careplan who had actually given
birth to a baby.
And so I felt very connected tothese women.
You know, both professionally,but also personally because I've
been through what they weregoing through and so that really
(02:51):
has been a part of my careerthat has evolved.
I'm now the director of thecardio obstetrics program at
Ohio State, and it's somethingthat I'm really passionate about
both, care wise and thenteaching others.
Kanny (03:04):
Well, that's great.
And we're certainly happy tohave you on the program and
happy to have you as a resourcehere in Central Ohio.
I'd like to also introduce oursecond guest, and this is
someone I've had the pleasure ofworking with since 2016 when you
joined OhioHealth, and that'sDr.
Sharon Robel, who is based inMansfield, Ohio, with
(03:24):
OhioHealth, but also works herein Columbus as well, and is well
known at Ohio State as well foryour training.
Sharon's a cardiac imagingspecialist, but also runs the
adult congenital heart clinichere at Riverside Hospital.
Sharon, welcome and can you letus know a little bit about your
path as well that led to you toCentral Ohio and your current
(03:45):
position?
Sharon (03:47):
Thanks.
Thanks, Kenny.
And thank you for having me ontoday.
I appreciate the opportunity totalk about this is this is my
favorite group of patients totake care of.
So I have been a cardiologistnow for 19 years, and it's been
(04:10):
a great journey to see how adultcongenital heart disease
training has evolved.
When I first started we had todo both adult and pediatric
training.
So as we did that there was someexposure to pregnancy, and
that's really where I gotinterested in the field.
(04:32):
It was very interesting becausefor a long time, women were told
by their pediatric cardiologistto not even have children.
And it wasn't uncommon that theywere actually told to undergo
permanent sterilization becauseit was just too risky for them
to have children.
And it really shocked me in mytraining to hear that.
(04:55):
So when I went through mytraining, that was sort of when
things were starting to change,and we realized that even some
of the highest risk patients whonever thought they could have
children were given theopportunity to actually have
children and to consider thatopportunity.
And it was just, An amazingexperience having been med
(05:19):
Pete's trained into see that andactually help be a part of that.
So when I finished my training,I actually came back to central
Ohio and and joined the adultcongenital program at OSU and
really helped with that programand it just really took off
there and and we continue todevelop that program and.
(05:41):
When the opportunity came overhere to help develop an imaging
program with another colleagueof mine, I, I took that, but
still wanted to be a part of thepregnant population and, and it
was certainly a need here aswell as many patients wanted to
deliver in the Ohio healthsystem.
So, I, I was a good opportunityto come here and continue with
(06:03):
that patient population.
And Lauren and I continue toshare patients when they.
Want to deliver one place andthey're followed another place.
So, so it's just a greatpopulation to work with.
Lauren (06:16):
It should also be stated that the program that I, I'm
currently involved with isreally built by Dr.
Robles.
So I have the benefit of just.
Kind of taking over everythingthat she built, which is it's
it's an amazing and robustprogram at Ohio State.
Thanks to her.
Kanny (06:33):
Yeah, it's great to have both these resources here.
Now, of course, in a in a systemlike Ohio State or here at Ohio
Health, we're fortunate to have,multidisciplinary specialists in
so many fields, including, adultcongenital disease and also
cardiac obstetrics, but ofcourse.
And a lot of our practicesettings around Ohio, where our
audience is listening, that'snot necessarily the case.
(06:55):
So, we thought the discussionwould kind of be framed more
from the standpoint of a generalcardiologist or cardiac
practitioner, like an advancedpractitioner, who may not, have
immediate access tosubspecialists.
So I think that's where Ellenand I want to kind of, you know,
address some of these Thesecommon issues that come up,
Ellen (07:14):
So Lauren and Sharon, we are so lucky to have you here
today for this discussion.
And I'd like to start off thediscussion thinking about.
We have a lot of common generalcardiology conditions we see in
our young patients, particularlyin this instance, young women,
fabular heart disease,hypertrophic cardiomyopathy.
We more likely deal with thesimple adult congenital heart
(07:36):
disease and aortic actasia, butwhich of these conditions, you
know, are well tolerated inpregnancy and which ones raise
the red flags when we reallyshould refer to sort of the high
risk cardio OB people.
And also, can you give us somemanagement.
And so we're going to talk alittle bit about how we can
(07:57):
manage these people throughtheir pregnancies, sure.
Lauren (08:02):
Yeah, you're right.
It's a very wide spectrum ofwomen who.
With heart disease who getpregnant, you know, I think the
some of the simplest things arethe patients who have
palpitations or history of PBCsor history of SVT or something
like that.
The simpler arrhythmias tend tobe really well tolerated in
pregnancy.
And I don't have too manyconcerns about those patients.
(08:22):
The rest of the cardiomyopathiesand that sort of thing are
really very dependent on what'sgoing on.
And I think the, the trickiestones are the ones that you don't
see coming that probably give methe most positive.
You mentioned aortic ectasia.
So one of the patientpopulations that, you know, that
I think maybe get missed forthose patients who have Marfan
(08:43):
syndrome or Loewy's disease orsome of those connective tissue
disease that, that wherepregnancy can really be.
A risk factor for aorticenlargement.
Rarely aortic dissection, but ithappens.
And and then thecardiomyopathies, like the
hypertrophic cardiomyopathy canreally be a mixed bag, and it
(09:04):
kind of depends on what you'restarting with.
But those, those that give mepause or sort of those
aortopathy, anybody with asignificantly reduced EF and a
cardiomyopathy and some of thosehypertrophic cardiomyopathies,
depending on what the underlyingsubstrate is.
Ellen (09:22):
And as far as the different valvular heart
disease, regurgitant versusstenotic, are there particular
ones who you worry about a bitmore than others?
Lauren (09:33):
Right.
You know, anybody that doesn'thave severe valve disease, tends
to do okay in pregnancy.
hemodynamic changes ofpregnancy, the, the, the The
extra volume that you have onboard, the increase in heart
rate, the change in yoursystemic vascular resistance.
So, you know, anything that'smild, moderate, anything right
sided tends to do fine.
We see a lot of women withsevere tricuspid regurgitation
(09:56):
from a history of endocarditis.
They tend to do just fine.
It's a left sided obstructivelesions that can get you into
trouble.
And then So aortic stenosis,mitral stenosis can definitely
get you into trouble.
And oftentimes even reallysignificant mitral
regurgitation.
If you have a sort of primarymitral valve disease, just
because of the hemodynamicchanges of pregnancy after
(10:18):
delivery, there's a lot ofchanges that happen.
And so some of those, butanything that's kind of mild,
moderate, anything right sidedtends to be pretty well
tolerated.
Ellen (10:27):
Wonderful.
Thank you,
Sharon (10:28):
I think it's important to also think about the
symptoms, not just or theconditions, not just during
pregnancy, but during labor anddelivery as well as after.
So we have a problem in thiscountry with maternal mortality
(10:48):
in pregnancy, and it has to doboth with acquired and as well
as congenital heart disease.
But, but certainly we need tothink about those things.
So whenever I assess.
patients patient that comes tome, I think about, okay, how do
we manage them during thepregnancy, during the labor and
then afterwards as well?
And I make sure that as Ioutline a plan for them, I
(11:12):
address all those issues.
Because My biggest nightmare isthat they go home and something
catastrophic happens after theydeliver too.
So we're not done after theydeliver.
We have to think about how do wemanage them afterwards as well.
Because as Lauren pointed out,there are a lot of hemodynamic
changes that happen afterdelivery.
(11:33):
The biggest risk is not thepregnancy and it's not the
delivery.
It's actually the it may be theweek or two after they deliver
as they go through thepostpartum changes.
So some may need to stay longerin the hospital for that.
So I think it's thinking aboutall those things when we talk
about yeah.
managing these patients.
(11:53):
And, and I think that the otherthing we need to think about is
maybe they only have to see thecardio V physician once or twice
just to help kind of outlinethat it may not be that they
necessarily need managedthroughout the whole pregnancy
by that person.
But I think it's helpful to say,well, let's at least have one
assessment and figure out wheredo we go from there?
(12:14):
Because it is candy pointed outto, it's a multidisciplinary
team.
So we have to find out what the.
OBs are comfortable with two atthose local hospitals because
sometimes what I think could bemanaged at a local hospital, the
OBs don't feel comfortable withthis either.
So I think open lines ofcommunication are also
important.
Kanny (12:34):
So on that note, Sharon in a patient, a pregnant
patient, say with mild tomoderate valve disease, for
example, or perhaps mild aorticectasia in terms of imaging
during pregnancy, are you,usually relying on a change or
in symptoms to warrant imaging?
Or is there a role for any kindof routine monitoring?
(12:54):
Because I know there arechallenges, of course, with
imaging and pregnancy.
Sharon (12:59):
I routinely monitor my patients during pregnancy.
So for example, aortic ectasiapatients get monitored once a
trimester.
Current guidelines for Marfian'spatients actually recommend
imaging every four to five weeksbecause they are at a high, such
a high risk for dissection.
And if there's a significantchange, C sections are
(13:22):
recommended.
The nice thing about.
Some of our imaging modalitiesso non contrast MRIs can be
performed during pregnancy andwe get very nice imaging of the
aorta.
It's no contrast, no radiation,and so that gives us a lot of
information.
So that's a very useful tool.
(13:43):
That we can use the biggestissue that I have had with MRAs
actually is trying to do them inthe third trimester and I've had
a few women that have supinesyncope from obstruction of the
IBC with the gravid uterus, butimaging wise, you usually get
beautiful images and we can dothose pretty quickly.
Ellen (14:04):
Wonderful.
You you also talked a little bitabout sort of mode of delivery
when C sections.
Lauren, could you touch basewith us as far as when do you
all get involved as part of theplanning of, can patients push?
Do they, do they do a vaginalbirth?
When do we recommend C sections?
And at what point do we, atwhich patients do we step in and
(14:25):
sort of try and specify that tothe OB?
Lauren (14:29):
Yeah, this is one of those, I would say, cardio
obstetrics myths or myths hasbeen floating around cardiology
and still does in amongproviders that don't have much
experience taking care ofpregnant women, but I have
patients that come to me all thetime saying, Oh, my pediatric
cardiologist said I would haveto deliver by a C section or it
tends to happen more in thecongenital population or women
(14:52):
who have, you know, Marfansyndrome say, Oh, I'm definitely
been told I have to deliver viaC section and that, Really
across the board, there arealmost no cardiovascular
indications for a C section.
And that includes patients withpulmonary hypertension, most
patients with connective tissuedisease, aortic disease.
You know, most patients withheart failure.
(15:14):
And because really the risk, therisk of C section, even in those
patients where you're worriedabout pushing is greater than
vaginal delivery just due to therisk of anesthesia, analgesia,
the anorexial analgesia.
a higher risk of bleeding,disrupting your hemodynamics
with C section.
And so the times that Irecommend C section, I think
Sharon mentioned, you know, ifyou were showing rapid aortic
(15:36):
growth you might consider it theone slam dunk is if you're
somebody who comes in on fulldose anticoagulation.
So maybe somebody with amechanical valve whose INR is
therapeutic that's a slam dunk Csection just because of the risk
of fetal intracranial hemorrhagewith vaginal delivery.
(15:56):
But by and large, for mostpatients, there's not a cardiac
indication for C section becausewe can get away with things like
an assisted second stage, sothat would be like a vacuum or a
forceps delivery where thepatient doesn't actually have to
push.
They let them labor down untiluntil the baby's, you know,
pretty close to delivered andthen just assist the baby out
(16:17):
and that helps decrease, youknow, that increase in afterload
with pushing that we might beconcerned about.
The other indication, obviously,is somebody who's crashing and
burning, cardiogenic shock, thatsort of situation, obviously, if
the mom is unstable, we for surego for C section, or if there
are obstetrics reasons.
But from a cardiac standpoint,very few.
Kanny (16:38):
Yeah, thanks, Lauren.
I thought maybe we could turnour attention now, not to
patients like we've been talkingabout with known cardiovascular
or congenital disease who getpregnant, but some of the common
symptoms we encounter during apregnancy, maybe in a patient
with no prior cardiac history.
Of course, anybody who does.
general cardiology consultationsin the clinic, or even in the
(16:59):
hospital, knows that, it's very,very common to see patients who
report things like palpitationsor near syncope, sometimes
atypical chest discomfort.
We obviously can't talk aboutall those in detail, but I
thought, Sharon, maybe you couldjust give us a few of your
pearls, for example, in apatient, say, with palpitations
or episodic tachycardia, maybe afew things in the history that
(17:22):
would Kind of set off a redlight in your mind that the
patient might need furtherevaluation versus the more
common run of the millnonspecific things we tend to
see.
Sharon (17:31):
Sure, so it's very challenging sometimes because
many of the symptoms that peoplehave can be just normal
pregnancy.
But I think history taking isvery important and listening to
what their symptoms are.
I have a a low threshold to docardiovascular testing in my
(17:56):
patients.
So patients are getting pregnantat older ages.
They have more cardiovascularrisk factors.
So I take shortness of breathseriously.
because we don't want to missthings like peripartum
cardiomyopathy.
(18:17):
Obesity is obviously anepidemic.
We see a lot of patients withdiastolic dysfunction.
They come in with risk factorswith chronic hypertension.
And so, so I have a lowthreshold to get an echo during
pregnancy, if they complain ofshortness of breath
palpitations, I really try totease out what's going on.
(18:39):
And you know, I see a lot ofwomen where if you get a good
history, you can tell thatthey're just premature atrial or
ventricular complexes and Iwon't necessarily monitor those
patients and I try to providereassurance.
patients who give me a littlebit better history of what
(19:01):
sounds like arrhythmias, theymay get a monitor.
We see a lot of tachycardiacomplaints nowadays.
And, and I think there's beenmore in the lay press about
dysautonomia or POTS.
And so I see a lot of thosepatients come in.
My biggest concern when theycome in with tachycardia is to
(19:21):
make sure that they have normalheart rate variability.
So, If patients have normalheart rate variability, then I
just provide them reassurancethat the that the fast heart
rate is not going to bedangerous and that that's a
normal part of pregnancy.
So again, a 24 hour Holtermonitor just to show them that.
So, so we do provide a lot ofreassurance to people.
Ellen (19:46):
Wonderful.
If we turn a little bit moretowards sort of mundane things
we deal with, with our everydaycardiovascular patients, a lot
of our patients havecardiovascular medications.
And I guess one question I haveis, how should we counsel our
younger women patients?
Are there certain medications wewarn them ahead of time saying,
(20:07):
well, if you're on thismedication, it's not great in
pregnancy, you need to stop itor contact us before you decide
to get pregnant.
Lauren (20:15):
So usually the women that we're seeing who are on
these medications are women whohave pre existing heart disease.
So a couple of commonpopulations are like our
morphine population who areoften on atenolol.
Which is a beta blocker that isfelt to be contraindicated in
pregnancy or angiotensinreceptor blockers.
(20:35):
The other population would bepatients who have heart failure,
who are on similar medicationsand spironolactone.
And then the third populationthat I see where we're usually
talking about medications thatmight be dangerous, at least
cardiac medications are patientswho are on systemic
anticoagulation with warfarinor, or DOACs.
So that might be a patient whohas a mechanical valve.
(20:58):
And so when we, this issomething I talk about, any
woman that comes into my clinicat the childbearing age, we have
conversations about pregnancyand what are you using for
contraception and, and if theyare using durable contraception
and they're on medications thatcan be triatogenic and just to
name a few of those, so Imentioned that those few, but
spironolactone is another one wehave conversations about, well
(21:23):
Even if you're on durablecontraception, if you're going
to get pregnant or you decide tostop your contraception, these
are the medications that youneed to stop.
So you need to call me if youhave Marfan syndrome and you're
on atenolol and losartan, and Iwill switch you to metoprolol or
cravetolol, which have bettersafety profiles in pregnancy.
Warfarin in particular is atricky one because obviously if
(21:44):
you have a mechanical valve youneed to stay therapeutic.
And so if you're trying to getpregnant, we don't want to mess
around with your anticoagulationuntil you're confirmed to be
pregnant.
But Warfarin, if you are on morethan five milligrams a day in
the first trimester isteratogenic.
And so.
What I typically tell thosepatients to do is to take
(22:06):
pregnancy tests regularly ifthey're off contraception.
So maybe once a week, check fora pregnancy test if they're
actively actively trying to getpregnant.
And the second that pops uppositive, call and we'll switch
you to Lovenox.
It can be tricky in thatparticular situation, but
usually we give thoserecommendations.
And most of our patients arepretty good about calling when
they come off birth control ifthey're trying to conceive and
(22:27):
we switch around themedications.
Sharon (22:29):
I think one other medication to talk about is
statins.
Because that recently changed.
So with all the hyperlipidemiathat we have nowadays, so
familial hyperlipidemia, we doput some younger patients on
statins, which used to be abigger deal.
(22:49):
They do need to stop them oncethey become pregnant, although
there is some data that forthese very significant
hyperlipidemic patients, youcould potentially continue it.
I stop it, but I, I don't get asconcerned.
So it used to be, you know, veryIt was really bad if they got
(23:09):
pregnant on it.
It was almost up there withCoumadin.
Nowadays, if they get pregnanton it, we obviously stop it, but
just because of how significantsome of these familial
hyperlipidemia patients can beit, it, I think we're a little
bit more liberal in startingthese patients on them and
continuing them in certaincases.
(23:30):
Now, again, I would have thatdiscussion with a cardio
obstetrics patient and, and notjust leave that up to the
general cardiologist, but thereis newer data out there about
using statins in women ofchildbearing age and being a
little bit more liberal withthat use.
Lauren (23:47):
And our MFM department here at Ohio State is doing a
whole lot of research on this.
But paravastatin, if you'regoing to use a statin, is the
one that seems to have beengetting more of the green light.
These days, even duringpregnancy.
Sharon (23:59):
It would really be the familial hyperlipidemia patients
that you either have havegenetic testing or you have a
strong family history of earlyatherosclerosis that I would, I
would put Pravastatin on duringthe pregnancy.
Kanny (24:15):
Thanks.
I think a lot of us in generalcardiology, that's not the first
thing we would think of when wesee a patient who's on a statin.
So that that's very helpful.
One condition we wanted to takea little more of a deep dive
into because I think veryinteresting and really hits on
all the key aspects between,high risk OB and cardiology is
peripartum cardiomyopathy.
(24:38):
Now, most general cardiologists,I think, are familiar with how
it presents clinically and, youknow, the, the nuts and bolts
of, of initiating therapy, butwe were wondering there's any
updated information about theincidence of PPM, or if there's
anything that stands out the ageand history of the patient
themselves.
I would lead you more to lead,to a higher suspicion of that
(25:00):
when someone presents with,dyspnea, for example.
Lauren (25:04):
Yeah, I think, you know, the news, I wouldn't say a whole
lot new in the incidents.
It's still pretty rare.
And I would say that anybodypresenting during pregnancy or
within a five months postpartumcoming in to the ER with new
shortness of breath andswelling.
It's always up there.
We've actually talked about andin our statewide, you know,
maternal mortality reviewcommittee.
(25:26):
It should we should we have abracelet on somebody who's given
birth to people take themseriously when they come to the
ER shortness of breath and thatpostpartum period, because a lot
of times that gets missed.
But you know, I think one of thenew things that's popped up is.
That are at least that are beinginvestigated are a couple of
things.
One, how does, how does thingslike preeclampsia play into
(25:47):
this?
Because there seems to be anassociation there.
We see a ton of preeclampsia,fortunately, not as much
peripartum cardiomyopathy, butthere seems to be a potential
link there.
And so some of the researchwe're doing is looking into
things like echo strain.
Is there something that we canpick up on all these women with
preeclampsia that might predictthat they might be at higher
risk for developing peripartumcardiomyopathy.
(26:08):
And the other new thing that Ithink is interesting is that
there seems to be in somepatients with peripartum
cardiomyopathy, when theyactually go through the genetic
testing, they are finding higherincidences of pre existing Gene
mutations like in a Titan gene.
And some of these patients.
So is there a crossover betweenmaybe a familial dilated
cardiomyopathy syndrome andpatients who develop peripartum
(26:29):
cardiomyopathy?
So I think we will continue tolearn a lot more about it.
Keeping an eye out for, youknow, symptoms in that
postpartum period is keyperipartum cardiomyopathy.
Anybody that's taking care ofthese patients, whether it's in
primary care clinic or the E.
R.
when they present.
Ellen (26:48):
That's actually really quite interesting.
So 1 question is for patientswho have a family history of.
A cardi, a dilatedcardiomyopathy.
Are those patients, are thosepeople at a higher risk, you
think?
And should we have a higherlevel of suspicion when they're
going through pregnancy thatthey might end up developing a
peripartum cardiomyopathy?
Lauren (27:09):
I do watch them closer.
I mean, we see a fair number ofthose in our clinic and I keep
an eye on them usually once atrimester with an echo, which
sometimes can be difficult toget insurance to cover.
But, I, I mostly counsel them,so a lot of the counseling is
for them to be able to educateother providers who might
encounter them on how to whatthey have going on and what
(27:31):
they've been counseled on as faras risk.
Sharon (27:34):
There's also a subset of patients who may not meet full
criteria for preeclampsia, butthey have volume overload and.
Those are a subset of patientswhere they may incorrectly get
labeled as peripartumcardiomyopathy, and they get
referred to us for, you know,pre pregnancy counseling, they
(27:56):
had peripartum cardiomyopathy.
But when you really dig intowhat happened, it is more, they
didn't tolerate these postpartumfluid shifts for some reason.
And I think, you know, they're.
technically didn't have systolicdysfunction, but it may have
been a component of diastolicdysfunction.
And I don't think we quite knowyet what that means.
(28:19):
And it would be interesting tolook at genetic testing in those
patients to see if they do havesome sort of mutation or what
happens with these patients downthe road.
But that's another subset ofpatients that we see a lot of
that come to us.
For pre pregnancy counseling,and I think the counseling for
those patients is a little bitdifferent than it might be for
(28:42):
somebody who has a trueperipartum cardiomyopathy.
But I also think that thosepatients need to be monitored
closely through pregnancybecause they are at risk for
volume overload in thatperipartum period again,
Kanny (28:55):
Sharon, I'm glad you brought that up because, in my
experience on the consultservice, that's actually a more
common scenario than actualconfirmed peripartum
cardiomyopathy, which is apatient maybe either in the
third trimester or even soonafter delivery who develops,
pulmonary congestion that's notsevere but enough to warrant,
diuretics, and everyone isexpecting, a low EF and of
(29:16):
course the echo looks fine ormaybe impaired diastolic
filling.
So I'm glad you brought that upbecause I think a lot of times
we don't know what to do withthose patients or what we should
label them as.
And it sounds like they mightstill be a higher risk group is
what you're saying.
Lauren (29:31):
But that label is so important.
And that was the point I wasgoing to bring up because as far
as counseling on subsequentpregnancies, there is a big
difference in how you counselsomebody who has true peripartum
cardiomyopathy with a reducedcompared to somebody.
who had volume overload, becausewe don't have any data showing
that those patients with, youknow, just the volume overload,
(29:52):
the diastolic dysfunction, yeah,they're probably at risk for
having similar problems, but notthat they are going to suffer,
you know, a drop in their EFagain, or in the case of
peripartum cardiomyopathy, if itdoesn't recover their EF, you
know, There's some studies,studies show a 20 percent
mortality with subsequentpregnancy.
So that, that label is hugebecause the patient that didn't
(30:15):
have true peripartumcardiomyopathy who gets labeled
with it often, and I see thisall the time, they come to me
and they're saying, I was told Ishould never get pregnant again,
or I got my tubes tied becausethey told me I had peripartum
cardiomyopathy and gettingpregnant again would kill me.
And that's where I think a lotof this education is very
important because for, you know,anybody out in the community
seeing these patients, the labelmatters because of the
(30:38):
counseling and subsequentpregnancies.
Ellen (30:41):
So, could you actually go over, how do you counsel
patients with postpartumcardiomyopathy and what do you
do with, what is their durationof heart failure medications?
Sharon (30:51):
So to, to Lauren's point people who are, are a true
peripartum cardiomyopathy haveAn increased risk of recurrent
systolic dysfunction withsubsequent pregnancies and, and
some centers, some physicianswill counsel them against future
(31:13):
pregnancies due to the risk ofRecurrent LV dysfunction.
And some studies have said thatthat can be as high as 20 to 50
percent depending on what studyyou look at.
And depending on the recovery ofthe LV function with with the
first pregnancy where you had LVdysfunction.
The other thing is that.
(31:35):
medical therapy for the LVdysfunction.
So years ago it was you couldstop after six months if there
was recovery of function.
some studies have suggested thatyou actually should not stop
medical therapy.
So the question I think has comeup, you know, with heart
failure, if you have recovery offunction, should you stop goal
directed medical therapy or youshould continue it?
(31:56):
And I think there's been somepush to continue Goal directed
medical therapy indefinitely.
So, if it's a true peripartumcardiomyopathy, we do counsel
that there is an increased riskof of LV dysfunction with
pregnancy, subsequentpregnancies.
And I monitor their ejectionfraction very closely with
(32:17):
echoes each trimester.
And then beginning in the secondtrimester, they'll get echoes
every four to six weeks.
Once you see a decline in the LVfunction, it's really
recommended that you deliver.
So you're talking aboutpotential preterm delivery if
the LV function falls again.
So, so the implications of thatdiagnosis.
(32:40):
As Lauren said, it's verysignificant versus somebody who
had volume overload anddiastolic dysfunction and needed
a dose or two or Lasix.
So I frequently am sitting inthese visits trying to tease out
what really happened with theprevious pregnancy.
Was it, oh, you needed a dose ortwo of Lasix?
Or were you on goal directedmedical therapy for three to six
(33:03):
months after you delivered andyou really did have a decline in
your LV function because thecounseling and the treatment for
the subsequent pregnancy isgoing to be very different.
Kanny (33:13):
Thanks.
That's a, that's greatinformation.
Helpful to know.
Before we wrap up, I did thinkof one other topic that maybe I
can ask Lauren.
We podcast actually with Dr.
Heather Gornick, it was a greattopic, you know, covering
fibromuscular dysplasia andspontaneous coronary dissection.
But I just thought, just in a,very briefly if you could
(33:37):
address, you know, how often youactually see that initial
presentation of someone withFMD, or you actually see a
coronary dissection duringpregnancy, and is there any
pearls about, you know, thepresentation that would raise
the red flag that that could behappening?
Lauren (33:52):
Yeah, I mean, we do see it.
I would say a couple of times ayear.
We have a pregnant patient whopresents with spontaneous
coronary artery dissection ormaybe 23 times a year.
Somebody who comes in with alegitimate STEMI and STEMI, even
just do it a regular oldfashioned.
atherosclerotic cardiovasculardisease.
But this is, this is why I thinkeducation is important because
(34:14):
any woman who presents withchest pain, when they're
pregnant, you really kind ofhave to take it seriously and
take a history and do doadditional work up when, when
someone presents and you havesome indication that there's
something going on, whetherit's, a troponin elevation,
which can be like in any case,nonspecific or EKG changes.
(34:37):
The first thing to know is thatI think about is like, okay,
well, how stable is the patient?
if somebody is Really having abig STEMI, you, you don't have
any other option.
You don't sit there and say, Oh,you're pregnant.
We'll just treat this medically.
They, they go to the cath laband they get a coronary
angiogram one consideration justbecause you can, you know,
further propagate SCAD with byjust engaging the coronary is,
(35:00):
is there a role for just a rootshot before to get a kind of
look at the lay of the land?
In general, we don't intervene,if unless somebody has a very
high risk lesion or is unstable,but I, I would think about it.
And anybody that comes in withchest pain in a trip on
elevation, how you proceed a lotdepends on how significant that
elevation where they're ongoingsymptoms.
(35:22):
So, you know, it's especially inthat 1st month postpartum, the
vast majority of of pregnancyassociated scan actually happens
postpartum in that 1st month.
Kanny (35:34):
Well, I think that was a fantastic discussion.
I think in.
35 minutes, we covered a lot of,a lot of material.
And I think it kind of shows whythis is a growing field and why
we're fortunate to havespecialists in cardiopstetrics
and adult congenital disease andin our communities.
So I guess I want to thank youboth.
(35:55):
I want to put a quick plug infor our Ohio ACC annual meeting.
It'll be coming up on October19th, not too far from now here
in Columbus.
And we have many experts justlike Sharon, Lauren, and others
who are going to be sharingtheir knowledge.
with our practitionersstatewide.
So thank you both for joining usand we look forward to your
(36:17):
participation in future Ohio ACCactivities.
Sharon (36:21):
Thanks for
Lauren (36:21):
having us.
Really enjoyed it.
Thanks so much.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
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