June 19, 2026 • 43 mins
Cardio Obstetrics: What is it? | MedStar Health DocTalk
Pregnancy is often described as a natural stress test for the body, and especially for the heart. In this episode of MedStar Health DocTalk, host Debra Schindler sits down with cardiologist and cardio-obstetrics specialist Dr. Minhal Makshood to explore the growing field of cardio obstetrics and why pregnancy can reveal important clues about a woman’s long-term cardiovascular health.
Dr. Makshood explains how conditions such as preeclampsia, gestational hypertension, gestational diabetes, and peripartum cardiomyopathy can affect both mother and baby, and why these pregnancy-related complications may increase a woman’s risk of future heart disease, heart failure, stroke, and other cardiovascular conditions.
The conversation also highlights the importance of prenatal counseling for women with existing heart conditions, the role of multidisciplinary care teams, and why the postpartum period—sometimes called the “fourth trimester”—is a critical time for monitoring heart health.
In this episode, you'll learn:
• What cardio obstetrics is and why the specialty is rapidly growing
• How pregnancy can uncover previously undiagnosed heart conditions
• The warning signs of heart complications during and after pregnancy
• Why preeclampsia and gestational diabetes are more than temporary pregnancy complications
• How pregnancy history can help predict future cardiovascular risk
• The importance of coordinated care between cardiologists, obstetricians, and maternal-fetal medicine specialists
• What every woman should know about protecting her heart before, during, and after pregnancy
Whether you're planning a pregnancy, currently expecting, recently delivered a baby, or simply interested in women's heart health, this episode provides valuable insights that could have lifelong implications.
If you have a heart condition, experienced complications during pregnancy, or want to learn more about protecting your cardiovascular health before, during, or after pregnancy, schedule an appointment with the Women's Health and Cardio Obstetrics Clinic at MedStar Health. Call 301-570-7404 to learn more or make an appointment.
Guest: Dr. Minhal Makshood, Cardiologist and Cardio-Obstetrics Specialist
Host: Debra Schindler
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:02):
Comprehensive, relevantand insightful conversations about health
and medicine happen here.
When MedStar Health Doc talk,these are real conversations
with physician experts fromaround the largest
healthcare system in theMaryland DC region.
Pregnancy is really oneof the most transformative
times in a woman's life,but it can place extraordinary
(00:23):
demands on the body,especially the heart.
During a healthy pregnancy,blood volume increases
dramatically, heart rate rises,and the cardiovascular
system works over timeto support both mother and baby.
In many ways, pregnancy actsas a natural stress test for the heart.
For some women that stresstest can reveal previously
(00:44):
undiagnosed heart conditionsor trigger new complications
such as high blood pressure,pre-eclampsia,
or even heart failure, that'swhere cardio obstetrics comes in.
Cardio obstetrics is a rapidlygrowing new field of medicine
that brings together cardiologyand maternal-fetal medicine.
It focuses on protecting thecardiovascular health of women
(01:06):
before, during, andafter pregnancy
through a highly coordinatedteam-based approach.
This specialized careis designed for women
with preexisting heart conditions, suchas congenital heart disease,
valve disorders, arrhythmias,and cardiomyopathies, as well as women
who develop pregnancyrelated complications
that can affect long-term heart health.
(01:28):
Today we're joined by Dr.
Minhal Makshood, a cardiologistand cardio obstetrics
specialist at MedStar Health,to discuss how this emerging
field is improving outcomesfor mothers and babies
and why pregnancy canoffer critical insights
into a woman's future.
Cardiovascular health. I'm yourhost, Debra Schindler. Dr. Makshood,
(01:49):
Thank you so much for having me.
Yeah. I didn't tell you this before,but this topic is a
little close to my heart.
My father's mother, now we'regoing back to the forties,
she had something calledrheumatic heart, which we now know
to be a valve disorderfrom having rheumatic
fever as a child.
And after she carriedmy dad in her pregnancy
and the untreated valveproblem took its toll
(02:11):
and at 25 years old, she died.
And I was surprised to readas I researched this topic
for this discussion today,that they only started really
looking at rheumatic heartand cardio obstetrics in the nineties.
So why now is it surfacing?
Great question. So I'm sorry aboutthat personal experience,
(02:31):
but this is actually, you know,still the reality for a lot of women.
So the truth is that maternal mortalityand morbidity has been
rising in the United States.
And if you look at the reasonwhy the primary driver of
that is actually iscardiovascular disease.
So then the questionremains, why is that so?
Well, a couple different reasons.
We are seeing more and morewomen become pregnant with
(02:53):
other comorbidities such asadvanced maternal age, obesity,
diabetes, high cholesterol.
So PA patients are havingpreexisting conditions
and choosing to havechildren at an older age.
We are also seeing women whohave preexisting heart disease,
such as prior congenitalheart disease, get pregnant
'cause they're living longenough to go through pregnancy
(03:14):
because of the advancementof medical care, which is fantastic.
And then we are also learning that womenwho have adverse pregnancy
outcomes such as preeclampsia,gestational diabetes, preterm
labor, these are thingsthat can happen during pregnancy
as complications of pregnancy.
And we are learningthat these complications
of pregnancy actually havelong-term effects on your
(03:36):
cardiovascular system.
Well, you know, many listenersare probably hearing cardio
obstetrics for the first time.
And I heard you reference it as cardio B,which I thought is very clever.
How do you explain that to patients?
What exactly is cardio obstetrics?
So cardio obstetrics is afield that was born as a result
of that data that I just toldyou, that maternal mortality
and morbidity is primarily drivenby cardiovascular complications.
(03:59):
It is the care of womenwith heart conditions
before, during, and after pregnancy.
So this could include womenwho already have preexisting
heart disease, such as womenwith congenital heart disease,
valvular heart disease,like the example you gave
of your own family member,abnormal heart rhythms or
existing heart failure.
And these women, prettystraightforward, right?
They have preexisting heart disease.
(04:21):
So they're high risk during pregnancy,but it also includes taking care of women
who de develop heartrelated problems, such as,
like I mentioned before, hypertension,preeclampsia heart failure
or abnormal heart rhythms.
We need to understandthat pregnancy places an
extraordinary demand on thecardiovascular system.
As you mentioned, your blood volume rises,the heart rate increases,
(04:44):
and the heart now has to work much harderto support both mother and baby.
So pregnancy like is a naturalstress test to the body.
So cardio obstetrics is reallyabout anticipating that risk,
recognizing problems earlyand creating a coordinated
care plan so women can movethrough pregnancy and postpartum
as safely as possible.
(05:07):
And this is how we decreasethat maternal mortality
and morbidity that is drivenby cardiovascular disease.
So cardio obstetrics iswhere maternal health
and heart health meet.
So you mentioned these,these conditions pre-eclampsia,
explain what that one is.
So when we think ofcomplications of, you know,
pregnancy related complications, we thinkof hypertensive disorders of pregnancy.
(05:32):
High blood pressure,High blood pressure, correct.
So you can either develophigh blood pressure,
there are very diff strictdefinitions for each of these.
You can develop gestational hypertension,which simply means you have
elevated blood pressureduring pregnancy, or an extreme form of
that is preeclampsia or eclampsia.
Preeclampsia essentiallyis not just elevated blood
pressure, but now you'reseeing consequences of
(05:54):
that elevated bloodpressure to the vasculature
that results in end organ damage.
So patients can starthaving kidney dysfunction,
heart dysfunction, retentionof fluid in their lungs, in their legs.
So what you're seeing is thatelevated blood pressure is now
causing an inflammatory responseand causing destruction to the
vascular endothelial systemthat then results in through
(06:15):
this cascade of complicationsthat cause end organ dysfunction.
So patients will startdeveloping protein in the urine
as a complication of kidney dysfunctionand then they can start having,
like I said, fluid retention.
So it's an extreme form of hypertension,belated complications.
And that's always an emergency,Typically.
(06:35):
Yes. So been patients at preeclampsia,usually the treatment primarily
for preeclampsia other thandecreasing blood pressure
and treating them withother ME medications,
including magnesium, isdelivery to save mom.
Of course. I know some womenwho have been through that
and they've had emergencycesarean sections.
But what if the preeclampsiastarts earlier in the pregnancy?
Does that happen? Is it treatable?
(06:56):
Would that be when thepatient would come to you?
So that's a very good question.
So oftentimes preeclampsiawe see closer later on in
pregnancy, but it patientscan have hypertension related
complications, particularlypreeclampsia earlier on,
particularly in the secondtrimester and so on and so forth.
So that is why it's very importantto identify patients at risk
and make sure that they'reon the best management in
(07:18):
terms of their blood pressure.
But if they do developpreeclampsia, to your point,
the treatment unfortunately is delivery.
Okay. So it's treating theblood pressure and delivering
because mom needs tobe healthy for baby to Survive.
Absolutely. So when these changes happento the cardiovascular
system during pregnancy,do they usually revert
back to, to normalcyafter the pregnancy?
(07:40):
And does it reveal anythingabout the woman's future health?
This is a really, really good questionand a very important one.
You know, oftentimes all theseconditions that I mentioned,
and I'm gonna repeat them again'cause they're important
to know, preeclampsia,gestational hypertension,
gestational diabetes,and preterm labor, they're
often all just treatedas pregnancy complications, right?
(08:01):
So oftentimes you'll talkto women, they'll say,
I had preeclampsia during my pregnancy,I delivered baby, and everything's done.
But they're actuallycardiovascular warning signs.
They tell us that a woman'sblood vessels may be more
vulnerable to high blood pressureand vascular disease later in life.
And we've actually lookedat this and studied this.
Patients with gestationaldiabetes also tell us about their
future risk of diabetesand cardiovascular disease.
(08:23):
So oftentimes, if you havean adverse pregnancy outcome,
which is one of thoseconditions that I mentioned,
this is a great clue aboutyour long-term cardiovascular
risk, because we know that patientswith adverse pregnancy
outcomes are at increased riskof heart failure, coronary disease,
and overall bad outcomes,cardiovascular one.
So this is why it's importantto identify these patients early
(08:46):
and in the postpartumperiod, intervene early
and help with lifestyle modificationsand risk assessment so
that these things can beprevented in the future
and that patients don't presentin their forties, fifties
with heart attacks or heartfailure or other conditions
because they weren't adequately screenedor thought about in more detail
or intervened upon earlier.
(09:09):
Who are some of the patientsthat you see who's typically a patient
who needs cardio obstetric specialty care?
So it's a whole host of patients.
So if I were to describethe typical patient
with preexisting heart disease, right?
So someone that already has aheart condition, like I said,
that's a straightforward one.
Typically I would see thatpatient for prenatal counseling,
which is before they become pregnant.
(09:31):
So these patients who arepreexisting cardiac conditions
should plan pregnancy, right?
So they should go see their OBand also see a cardio obstetric
specialist or a cardiologistand make sure that they're
on the right medications,make sure that they're
optimized cardiovascular wise,if they need further imaging
or testing to understandtheir disease process further,
(09:51):
that needs to be completed.
If they have conditions thatrequire surgical intervention
or anything like that,that needs to be handled
before pregnancy, thosethings need to be discussed.
So the prenatal counselingentails taking care of women
of preexisting cardiacdisease like heart failure
or you know, valvular dysfunctionor underlying arrhythmias,
and essentially risk stratifying themor even chronic hypertension and diabetes
(10:14):
and making sure that allthese factors are optimized.
So they're going inwith their best foot
forward into pregnancy.
So that's the typical patientwith preexisting cardiac disease.
The second layer of patientsI see is risk factors
or prior pregnancy related complications.
So if you have had preeclampsiain your first pregnancy
or gestational diabetesin your first pregnancy
(10:35):
or any of these other adversepregnancy outcomes, it's good
to have a prenatal counselingwith a cardio obstetric
specialist to make surethat these things are optimized prior
to getting pregnant againand making sure we are on top of it
and controlling blood pressure,controlling other risk factors,
making sure for example,that you're on an aspirin for
preeclampsia pro prophylaxis,and then making sure they're
frequently followed throughoutpregnancy so they can meet the demands
(10:59):
of pregnancy without complication.
So that's the second flavor of patients.
Then the other flavorof patients are patients
who are pregnant and thenstart having problems.
So when you are pregnant, ifyou have severe chest pain,
worsening shortness ofbreath, you're passing out,
you're dizzy, you're feelingsignificant palpitations,
(11:19):
then you should absolutely see a cardioobstetric specialist.
A lot of people will say,well wait a minute, a lot
of pregnant women get shortof breath during pregnancy,
they'll get a little dizzy.
Do we panic every timewe have these symptoms?
Well, yes and no.
So for example, it's veryimportant to pay attention
to trends and listen to your body.
If something feels off,you are more short of
breath than expected.
(11:41):
You're noticing your legsare getting more swollen,
your passing out is never normal,chest pain is never normal, right?
Then you should immediatelyseek evaluation, right?
Early intervention here is key.
So those are patientswho develop heart issues
during pregnancy that thencome and see me at that time,
and then we follow them through pregnancyand then we transform into
the third trimester postpartumphase where patients are more vulnerable,
(12:08):
pregnant patients are morevulnerable at that time
because of all the changesthat occur at that time
and can develop heart conditions then.
And then I'll see a host of patientsthat either develop things
like peripartum cardiomyopathythat typically occurs at the
end of pregnancy or postpartum.
What exactly is that?
So peripartum cardiomyopathyis heart failure
that occurs from pregnancy.
(12:29):
And there's a whole host ofreasons as to why that happens.
You know, during the post thethird trimester going into the
postpartum phase, yourbody is going through a lot
of hormonal changes.
There's a lot of changes inthe inflammatory pathways,
the metabolic pathways and delivering inand of itself is a huge
stressor to the body,specifically vaginal delivery.
So patients goingthrough these changes can
develop heart failure.
(12:51):
And there are some patientsthat are more prone to that.
Like for example, patientswho already have elevated
blood pressure, right?
They already have somethingthat's vulnerable about their vasculature
that increases their riskfor endothelial dysfunction
and dysfunction of their vascular systemthat can then down the
line lead to heart failure.
So for some reason, we see thismost in the third trimester
(13:11):
to the postpartum phase for that reason.
Okay? And we are hypervigilant about thisbecause a lot of times women
can come in, they're shortof breath, they'll have
swelling in their legsand they'll be diagnosed with this, right?
And they can even developpreeclampsia postpartum,
you can be completelyfine during your pregnancy
and then you deliver a baby.
Oh, and then your bloodpressure is elevated
and you're having swollen legsand it could just be from preeclampsia
(13:32):
that develops postpartumAnd, and the risk for that is stroke.
So yeah, it's, yes ifpreeclampsia is untreated,
but the risk for that isalso heart failure, right?
So preeclampsia is also on a spectrumwhere it can end up causing
destruction to the heart too.
And you can end upleading to heart failure,
which is the extreme form of that.
So understanding that these are all thingsthat cardio obstetrics takes care
(13:55):
of in a collaborative fashion.
So it's either preexistingheart disease, heart disease
that you develop during pregnancyor someone that has risk factors
to develop heart disease in pregnancy.
So that's the entire hostof patients we care for.
And once you are a patient,you should be our patient forever.
And now, if a woman hasany of these conditions,
pre-eclampsia, gestational hypertension,gestational diabetes, is the baby at risk,
(14:19):
is there any impact to the baby's health?
Yeah, so that's a great question.
So for, for example,gestational diabetes can lead
to large babies because ofuncontrolled sugars, you know,
because blood sugar is a toxin, right?
So that can lead to LAlarge for gestational age.
Preeclampsia itself, like I said,it's an issue with the vasculature.
So it can result in the babynot getting enough perfusion.
(14:40):
So when mother is not doing well,baby naturally won't be doing well.
'cause the baby depends on mom to do well.
Is is a large baby a risky baby?
I mean, is that a danger to the baby?
Yeah. So a large babytypically, so I'm not an OB GYNI
Understand. So,But I would say that, you know,
gestational diabetes can thenlead to large gestational age
(15:02):
that can then lead to laborand delivery related complications, right?
Larger babies are harderto deliver, sometimes need
to do C-sections, whichIm important to know.
And knowing that, youknow, babies that are born
with macrosomian who arelarger, also an increased score
of obesity and diabetes in thefuture and things like that.
So there are obviously fetalimplications for this as well.
But it's important to understandthat in, when you think
(15:24):
of pregnancy, mom needs to be healthybecause whatever mom is
experiencing baby's invariablyexperiencing the consequences of that too.
I have seen babies bornwhen their moms were
with gestational diabetes andthey're fat and they're cute.
They're just so cute. Yeah,they look pretty healthy,
but they, they look just little chubby.
(15:44):
Yes. Yeah, yeah, yeah, yeah.
I think it's more important tosort of think of these things
as a lens into the future, right?
And I think that's kind ofwhere the narrative sort
of shifts a little bit,where we need to understand
that pregnancy is not just anexperience a woman has once in
her lifetime, whatevercomplications she develops,
she develops and then we forget about it.
These are not just memories,these have long-term
(16:06):
cardiovascular consequences.
So the pregnancy historyshould be a huge part
of a woman's history interms of her health history.
I tell women, know yourhealth history really well.
Know your pregnancy history.
Oftentimes I will speak to patientsand I'll ask them about
their pregnancies, you know,even when they're in their fifties
and they'll say, I thinkI had high blood pressure.
(16:28):
I remember my legs were quite swollen.
I think my sugars weren't great.
It's just almost likeit becomes this memory
and it's, it's only Ithink a human response
to sometimes shieldthings that are negative.
And most people remember,you know, holding their baby
for the first time andhow that made them feel.
And that's all beautiful.
But it's important to remember the stuffthat didn't go well too,
because that stuff is reallya clue into the future, right?
(16:50):
It's telling you, you know,this is a window into your future.
It's telling you howyou may have issues 10,
20 years down the line.
And I think that's really keybecause it's so valuable, that information
and it really gives us that opportunityto intervene earlier on.
So we can save women from a lotof cardiovascular complications later on.
So cardiologists should be askingtheir female patients about
(17:11):
their pregnancy history.
They should be asking them,did you develop preeclampsia?
Did you develop gestational diabetes?
Did you have preterm labor?
These things are important.
Did you ever have uncontrolled bloodpressure during pregnancy?
Right? And if, and if theanswer to that is yes,
that changes how theyrisk stratify that patient
and how they think about that patient.
(17:32):
I mentioned my grandmotherhaving had rheumatic heart
and she delivered my dad, butsubsequently was weakening
and she knew that she was going to die.
Sad story. But it was,you know, 1940. Yeah, one.
Nowadays, if a woman camein with the same problem,
we know now to be a valvularproblem, what would they do
(17:52):
with a situation like that?
Could the woman undergo surgery forthat? Yeah, while she's pregnant.
Great question. In fact, Iactually had an experience
during fellowship where of a womanwith mitral stenosis in the setting
of rheumatic heart disease.
And she got operated on, had it fixed,and then she went through pregnancy
and we were able to carryher through that pregnancy.
(18:13):
So this is where thatprenatal counseling is really
key, right?
So then the question is, whoneeds prenatal counseling?
If you know that youhave a cardiac condition,
then it's pretty easy to justgo see a cardiologist, right?
Because you have a cardiac condition,but you also need to be on top of it
and make sure you talk to thembefore you decide pregnancy
to make sure it is safefor you to get pregnant.
'cause not all cardiacconditions are created equal
in her situation.
(18:34):
We were able to fix her mitral valvebefore she could go into surgery.
But there are some cardiac conditionswhere pregnancy is truly contraindicated,
where you shouldn't consider pregnancybecause it is too high risk.
But then there are conditionswhere you know, you have mild
to moderate disease,you're pretty optimized
and we can safely carry you through them.
And and we do. So it's importantthat prenatal counseling
piece is important for womenwith pre-existing heart disease.
(18:57):
And if you are someone whois deciding to have a baby
and your advanced maternal age,and even if you're not
advanced maternal agent,know you have diabetes, obesity,
high blood pressure, go see someoneWhile a woman is pregnant,
can she be on blood pressure medications?
Absolutely. Or cholesterol me.
Yeah. It doesn't affect you. Well, bloodPressure you do cholesterol
is a little challenging.
So let's talk a little bit about that.
(19:17):
So blood pressure medications,there are safe medications
studied in pregnancy.
So that's another reasonwhy if you have chronic
hypertension, you needto make sure you see your
cardiologist before you consider pregnancybecause we need to ensure that
whatever medicines you're on,it is pregnancy safe
both for you and baby.
So if you're on somethingthat isn't pregnancy safe,
we will switch you prior to pregnancy.
So that's, that's one thing.
Cholesterol is a little tricky.
(19:40):
It's tricky because there's now newer datawith a statin called Pravastatin,
and we could use pravastatinin certain select high risk
cases, but statinsfor the longest time were
contraindicated in pregnancy.
So women who have had, youknow, issues with cholesterol,
typically if they've nothad a heart attack or stroke
and they're going intopregnancy, we're okay
(20:00):
with them staying off their statin.
But then there are afew subset of patients
who are high risk, who have hadpregnancies, have had stents
before, and in the past wewould never put them on a statin
because of high risk.
But then this patient shouldalso have a discussion
with their cardiologist andwhether pregnancy is truly safe,
if they have stents and other heartdisease, coronary disease.
However, in in this population,now we can consider pravastatin
(20:22):
if we need to use it.
We do have that tool.
What's important tounderstand is in pregnancy
and not all cardiac medications are safe.
So a cardio obstetrician is someonewho specialized in understanding
what medications can beused in pregnancy as well
to treat specific cardiac conditions.
So that's why it's importantto make sure you're on
all the right medicinesbefore pregnancy and
if you develop anythingduring pregnancy that you are treated
(20:46):
with medicines thatare safe. You and baby,
We know that black womenin the United States face
significantly higher ratesof pregnancy related death.
How can cardio obstetricshelp close the gap?
Yeah, so this is actually a very,very important topic when
it comes to maternal health.
And the disparities are actually quiteprofound and heartbreaking.
(21:08):
Black women have a higherrate of maternal mortality
and morbidity compared to other women.
This disparity is actuallytrue across income
and education as well, whichis what makes it shocking.
And it also sort ofhighlights the importance
of system level inequities.
A huge part of it is delayed diagnosisor that they present early
(21:28):
and their symptoms arenot taken seriously.
So there is a so sort ofsystemic inequity component here
as well that plays a role.
Cardio obstetrics can actually helpby creating earlier access
to specialized care,early recognition that is key.
Understanding the demographic,understanding the dis
disparity exists taking theirsymptoms seriously.
They have higher rates ofpreeclampsia knowing that,
(21:50):
and importantly, it's thiscare coordination piece with OB
and cardiology to make surethat these high risk women
are taken care of during pregnancyand are not lost after delivery.
So it's, it's aboutlistening, trust, access
and advocacy, which cardio B allows for.
So closing the gaps actuallystart with listening to women
(22:10):
and acting earlybecause we know that we
don't do a good job at that.
And that's another reason whywe're seeing this disparity.
Which makes me think of the casethat we were discussing
prior to our recordingwhere you have a mom who's
in her fifth pregnancy, neverbefore knew that she
had a hole in her heart.
Yeah. How is that possiblethat she has had four healthy
pregnancies, never knewthat she had this anomaly in her heart?
(22:36):
Yeah. So you know, that's,that's an interesting case
because she actually did notpresent with any symptoms
during her first few pregnancies.
And you know, when people say lotsof people are having
babies for years and yearsand years, not everyone
has a terrible outcome.
Pregnancy is a huge stressor to the body.
But you would be surprised byhow well your heart adapts to it.
(22:57):
And some people adapt sobeautiful in her situation.
Yes, she had a hole in her heartand she likely was born with this.
Right? And this is somethingthat progressed over time.
So interestingly, for whateverreason that I cannot explain,
for the first four pregnancies,she didn't have any symptoms.
She didn't have the shortness of breath,the swelling in her legs.
But her last pregnancy,she's a little older,
(23:18):
she's had the condition a little longer.
She likely had more stretch of her heart,increased shunting from the left to right
because of that hole inthe middle of her heart.
And eventually when shewent through pregnancy,
which was the ultimate stressor, it kindof tipped her over the edge.
And she's a great example of someonewho also presented in
the postpartum phase.
She didn't actuallypresent during pregnancy.
(23:40):
She presented towards the endwhen her heart couldn't take
the stressor anymore,particularly delivery.
And that's actually another great areawhere you could learn more
about a woman's heart.
Because when women gothrough vaginal delivery
and go through labor, there'sa lot of hemodynamic shifts
that occur there to your blood pressure,to the fluid shifts, right?
(24:00):
That your heart has to adaptto and work well. Right?
And some women, when they showyou that they're not doing
that as well, that's another clueof something probably isn't.
Right. Right. So this is whereit's important to understand
that pregnancy unmasksor can unmask underlying
cardiovascular disease,which her case was a
phenomenal example of that.
(24:22):
Someone that has diseasedidn't know about it,
she gets pregnant, goesthrough that stress test
of increased blood volume,heart rate around delivery goes
through those hemodynamic shiftsand our heart says,
Hey, I can't take this.
And it starts retainingfluid and causes symptoms.
And then there she's diagnosed.
So sometimes pregnancyactually isn't the cause,
it's just showing youwhat your underlying
(24:43):
vulnerabilities already arethat were already there to begin with.
Well she attributes that pregnancyand that baby with saving her life.
Yes.
Just to finish off that story,she delivered the baby just fine
and she Yeah. And then what happened?
So I actually saw herin the postpartum phase.
That's when I was first introduced to her.
And you know, she was havingheart failure symptoms
(25:05):
and we ultimately diagnosedher with a hole in the heart.
And we had a phenomenalstructural heart team here.
And it was something thatwe were easily able to fix
through non-invasive surgeryor minimally invasive surgery.
She didn't need an open heart surgery.
So we were able to fix it witha minimally invasive surgery.
And I actually just saw her yesterdayand she's doing fantastic,
(25:25):
Wonderful, wonderful news. I mean, allHer symptoms have resolved
and she's already on thetrajectory of full recovery.
I think it does make sense that she can gofor pregnancies now that we
we're talking about it and,and not, not reveal
any issues in her heartbecause of the strain
that is constantly being puton her heart through all these,
(25:46):
the, the many pregnancies.
I mean, I can't imagine thesewomen who are 12, 13 babies,
what's going on withthem cardiovascular wise.
Yeah. And then also we needto understand that, you know,
the whole agent, advanced maternal agealso does play a role.
I mean, there are women whowill present in their early
twenties also with heart failure,but you're less likely
to have more complicationsif you don't have chronic
(26:09):
hypertension, diabetes, you'renot obese, you're young girl
with none, no other comorbidities.
Not that you can't, and it does happen,but typically most of those women do well.
But there's a reason why weworry more when women sort
of progress in ageand then start developing
other chronic conditionsbecause then you're sort
of piling on risk factorsand more stressors to the heart.
(26:29):
So when you put someone through pregnancy,they may not be able to
deal with that stress.
And a lot of women, you know,the really nice thing about this is a lot
of women do recover.
They do well, they go home to babyand they just live their lives.
And the truth is, Ican't tell you the number
of times women are shocked inmy office when I tell them,
oh, you had preeclampsiathat increases your risk of,
(26:51):
you know, cardiovasculardisease in the future, whether
that be heart failure or coronary disease.
They look at me just shockedlike, but I feel fine.
I went home, I feel fine, you know,but does that really increase my risk?
And then I try to explainto them like, yes,
because this is a clue aboutwhat things would be 10 years down the
line, 20 years down the line.
So if someone had an adversepre pregnancy outcome at the
(27:13):
age of 30 during a pregnancy,10, 20 years down the line,
they can come in with long-termcardiovascular issues if
they were not seeing a doctorand not caring for
themselves during that time.
And I think that time is so crucialbecause you can really intervene
and make sure their bloodpressure is well controlled
to make sure their blood sugars are not,or they don't develop diabetes
because all these thingsin the long run are
(27:33):
gonna affect their heart.
'cause women also thengo through menopause,
which is another hugeshift in their bodies
that also increases theirrisk of heart disease.
So it's important to kindof think about pregnancy
and pregnancy relatedcomplications as not just a clue,
but also just something thatyou have to think about deeply
for a patient in terms of howyou're going to manage them
(27:55):
and how you're going toprevent really, you know,
stroke heart attacksand things like that
early on in their lives.
Is it your suggestion thenthat anyone who's listening now
who had experienced preeclampsiaduring their pregnancy
have a cardiologist?
Yeah. Should they follow upwith a cardiologist even
if it's 10 years later?
I think they should see a doctor,whether it's a primary care doctor
(28:17):
or a cardiologist,depending on the situation.
So at at the least, see your PCP,make sure you're getting your blood
work, knowing all your numbers.
Make sure your bloodpressure's under control.
Know what a good bloodpressure is supposed to be.
Understand the cutoff of blood pressuresand make sure that you're below the cutoff
and you don't develop hypertension.
Pay attention to your cholesterol numbers.
So look at them, lookat the good cholesterol,
(28:37):
look at the bad cholesterol.
Make sure you're optimized.
Ask your doctor questions about that.
Look at your A1C, make sureyour diabetes is under control.
A primary care physicianis very much capable
of doing all of those things.
And yes, you can certainlyfollow with a cardiologist
as well, particularly if youhad more adverse complications.
But even for primary prevention, you know,either a cardiologist or a PCP,
(28:58):
but it has to be a physicianthat you need to see
for your routine careand that you're working on
lifestyle things, whetherthat be diet and exercise as well.
You mentioned those heart health numbersand I wanted to make sure that we,
we emphasize knowing thoseheart health numbers.
Are there any other ones thatpeople should be aware of?
I would say weight trends as well.
So blood pressure, cholesterol.
(29:19):
So know your lipid panel,what's your LDL, your A1C,
and then know how yourweights are trending.
I would say those are somebig ones that you should know
When you have a patient come inand you know that this
patient is high risk.
How does your care team and,and who makes up the care
team, how do you preparefor a case like that?
Yeah, so this is reallyvery, very important
(29:40):
because cardio obstetricsis primarily a collaborative
multidisciplinary team.
And that's what makes it amazing.
So it's a team that is acombination of cardiologists
for high risk pregnancies,maternal fetal medicine,
OB obstetrics, maternalfetal medicine, anesthesia
for delivery planning, nursing,and sometimes genetics if
patients have genetic conditions.
(30:03):
Advanced heart failurespecialists if patients already
coming in with heart failureor developing heart failure
or cardiothoracic surgery.
Even sometimes if patientsneed surgery before pre,
before pregnancy if they have valvularissues, so on and so forth.
So it is really a pretty large team.
But I would say the coremembers are cardiology, MFM,
which is maternal fetal medicine,obstetrics anesthesia, and nursing.
(30:24):
I think these are the core folksand we all work together to
take care of the patient.
Does that mean when the woman comes infor her monthly checkup
during her pregnancy,everybody is there
or is everyone talking abouther case at some point?
That's an excellent question.
So I would say it's acombination of both depending
on where you practice.
So where I trained, we hada cardio obstetrics clinic
(30:47):
where it was combined carewhere a patient would come
and see the cardiologist andthe OB person at the same time.
But that would only occur once a month.
And then sporadically,if they need to see each
of them individually, they will as well.
And then patients will also be discussedas part of meetings.
They'll go through differentpatients and delivery planning
and what's going on and updates.
(31:08):
In some places it's exclusivelymessaging, you know, you,
you make sure that all thepeople involved in the care
of the patient are talking to each other.
Right? And we constantlytalk to each other.
I can tell you when I'm takingcare of pregnant patients,
I'm talking to ob, you know,and if, if they're high risk
and we are worried about the deliveryand what their delivery plan is.
So most of the talking happensalso closer around delivery,
(31:28):
then we talk to anesthesia,we ask them about their concerns.
So this is something we constantly discussand mostly happens behind the
scenes in a lot of programswhere patients may not be
privy to those conversations,but they will know when
they come to visitsand we will tell them
about what we discussed.
And those things are repeated multipletimes at each of the visits.
So they know that everyoneis on the same page.
(31:49):
And I think patients deservecare where their doctors talk
to each other and we know thebest care comes from that.
Nothing is worse than when a patient comesto see multiple doctors
and they're all tellingthem different things
and they're just nottalking to each other.
Right, right.
And that's not gonna be effective.
Cardio OB is only effectivein doing its job of reducing,
(32:10):
you know, bad cardiovascular outcomes.
Only if you work as a team. Right?
I can see a patient in clinicand tell them to do something,
but if I'm not communicatingthat with the OB team,
the maternal fetal medicineteam, when they see the patient,
if not, probably more frequently than I dobecause especially towards
the end of pregnancywhere they're seeing them weekly and so on
and so forth, then they're not gonnabe looped into the care.
(32:31):
So none of that stuff is reallygoing to come to fruition.
So in order for all thisto work, well we all need
to come in 'cause weall bring very expertise
and we're all thinkingabout a different aspect.
OB thinks about a different aspect,cardiology thinks about the
cardiovascular consequences,anesthesia will, will think
about labor, delivery, sedation,that aspect of it, right?
(32:52):
So all of us come in withour own sort of, not agenda,
but our, our own concernsand our own plans.
And then we come together, put it togetherand come up with the best
plan for that patient.
And that's when we see this workingAnd then the baby is
born, everything goes welland we're in the, what
some people have called thefourth trimester.
(33:13):
And I love that you had mentioned beforeor I appreciate that you had mentioned
before that sometimeswomen get preeclampsia
after the delivery, which isa surprise to me actually.
Yeah. Tell me what thatfourth trimester is
and why is it such a criticaltime for heart health?
Yeah, so a lot of timeswhen women give birth,
you think the hardest part isover, no, I'm gonna go home
(33:35):
with my baby and everything's fine.
But unfortunately that'snot how it works in terms
of your just cardiovascular riskand overall just how your body works.
So towards the endof the third trimester
transitioning into delivery,your body is going through
a lot of changes, right?
We're seeing a hormonal shift,we're seeing changes in metabolic
(33:55):
and inflammatory pathways, right?
Which is huge. And then yougo through the whole process
of delivering labor, right?
Labor primarily.
And that itself is causing, you know,variations in blood pressure,
variations in fluid shiftsthat are going in the blood
vessel, outside the blood vesselthat can cause issues if they
have underlying preeclampsiaor underlying propensity
to develop heart failure.
(34:17):
So during this time it's reallycritical to pay attention
to the patient andunderstand that even well
after delivery daysand even up to weeks,
patients can still have faceconsequences of the pregnancy.
In fact, peripartumcardiomyopathy can be diagnosed up
to five months and even longer postpartum.
(34:38):
Wow. And some patients alsodevelop, it's very rare,
but can develop thiscondition called spontaneous
coronary artery dissection.
Which for some reason wesee happen closer to the end
of pregnancy in that postpartumperiod for all those changes
because of all those changes I justMentioned.
What, what is that? What happens?
So it's basically spontaneouscoronary dissection is the
(34:58):
blood vessel supplyingyour heart, the wall
of those blood vessels can dissectand it can lead to a heart attack
to patients will presentwith heart attacks.
And you know this, this is somethingthat is treated very
different differently from atraditional heart attack in some ways,
but it's nevertheless a heart attackand patients can present
with that and it's,and there's an entity
that's pregnancy associatedand that's something we also
(35:20):
think of if patients present,which crushing chest pain or
concerning symptoms, it's rarebut it can happen.
So it's important to understandthat preeclampsia can happen,
postpartum heart failurecan happen postpartum.
So many changes can happenbecause your body is still recovering.
And so, so important for womento pay attention to those symptoms.
(35:40):
What symptoms should a new mother neverignore after giving birth?
Yeah, definitely don't ignorechest pain that is severe.
You are having significantshortness of breath
with swelling in your legs andyou're not able to lay flat.
You have to sit up and sleepbecause you're having fluid
going into your lungs.
That's very concerning. You're dizzyand you're passing out alright,
these are all terrible symptoms.
(36:02):
And if, if you are noticingthat the swelling in your
legs are getting worse,that's never good because the
swelling in your legs shouldimprove right after delivery.
You will see more swellingimmediately after delivery
'cause of all the volume you get.
'cause you get a lot of fluidsand things like that during labor.
'cause women lose blood naturally whenthey, when they give birth.
So a lot of times, youknow, women will get fluids
(36:23):
and things like that so youcan feel a little more puffy
right after delivering.
But that should get better.
You should start noticingyour lengths kind
of shrinking back and you know,you're feeling like you're
holding onto less fluid than youdid towards the end of your pregnancy.
But if you're noticingthat that's getting worse,
your legs are puffier, I'm lying downand I just find it hard to breathe.
I can't breathe when I lay down.
(36:43):
I need like two or threepillows to prop myself up.
I wake up in the middle of the nightsometimes short of breath.
Those are all terrible signsI'm having crushing chest pain.
This is so strange. It's odd. Get checked.
I can't walk up a flight of stairsor two flights of stairs without
really getting short of breath.
That's, that's odd. I feellike I'm gonna pass out.
That's odd, right?
(37:04):
Is is this the purposeof a six week checkup
after the baby is born?
Yeah, so you know, the sixweek checkup happens with OB
and they're screening for many things,including postpartum depression
and other things thatthat women experience.
But it, this is also part of it, you know,checking the blood pressure, making sure
that you know the exam looks okay,that they're not having
any concerning symptoms.
Women with preexisting cardiac diseasewho have used cardio obstetrics
(37:27):
during their pregnancyshould also see their cardio
obstetrics specialistor their cardiologist
right after delivery.
I oftentimes will see women within weeksafter delivery just to make
sure that their trajectory is,you know, heading in the right direction.
Maybe there should bea three month checkup
as a routine routine.
And you know, that sometimesdoes happen depending on
what complications that they have.
(37:48):
So if they do, if they are high risk,I will see them a lot more
frequently in the first sixmonths postpartum just to make
sure that everything is goingas planned and making sure
their blood pressure is stable.
If, if there was preeclampsiainvolved, you know, if a lot
of women, you know, who alsohave preeclampsia end up
getting a heart ultrasound at some point,especially if they had
concerning symptoms to make surethat the heart's squeezing
(38:09):
and functioning normally,if there's ever a concern,
you know, we need to lookinto it with further workup.
So a lot of times I will seepatients in the immediate
couple weeks and then after that,a couple months out after that.
And if they're completely finethen I might see them in six
months and then go to a year after that.
And what steps are yourecommending to those women
that they take to reducelong-term cardiovascular risk?
(38:32):
So that's a good question.
I would say in general wouldstart out by saying
outside of even pregnancy,there are things that we all can do
to reduce our cardiovascular risk, right?
So that's weight management,making sure you're
exercising according to the,you know, guide guidelines.
We recommend at least 150 minutesof moderate intensity exercise per week.
That's roughly about 30 minutes a day.
(38:53):
So what is moderate intensity?
You can, you know, you cantalk, but you can't sing.
If you wanna do highintensity, you can, that's up
to 75 minutes per week aswell is what we recommend.
Adhering to a Mediterraneandiet that is, you know,
high in fruits and vegetables,low in saturated fats
and so on and so forth to make surethat you know your cholesterol is good.
(39:13):
Make sure you don't develop diabetes,do not pick up smoking.
These are all thingsthat you can do to help
with your overall cardiovascular risk,which in turn will also help you when you
decide to get pregnant.
But I also want to sort ofsay that there are women
who don't have any of these risksand are actually doing pretty well
and doing all the right thingsand could still develop issues
(39:33):
during pregnancy for whatever reason.
Right? So that's alsoimportant to keep in mind.
But in terms of what can be doneand putting the onus on the patient,
I would say the best would be modif,those risk modification
factors mainly make, you know,hypertension management,
making sure you don'tdevelop diabetes, you know,
managing your cholesterol.
So optimizing all those numbers priorto pregnancy is always a good idea.
(39:54):
All of your advice is so important.
And with the fetal morbiditynumbers being what they are,
I really have such respectfor what you're doing
and what your focus ison cardio obstetrics.
How did you find yourself intothis niche? Yeah. Medicine.
Was there a certain case?
Did you know that you wanted to do thisor did you, were you in
cardiology medical schooland what happened?
(40:18):
Yeah, no, that's an interesting question.
No, I actually did not knowfrom the very beginning.
I knew I wanted to becomea cardiologist when I
was doing residency.
And I will say I was a firstyear cardiology fellow at Johns
Hopkins when I first did mycardio obstetrics rotation.
And I was really amazed byhow complex the patients were
(40:40):
and how collaborative care workedand how it impacted
positively the outcomesof these patients who are young
and high risk for pregnancy.
And I was so fascinated by that.
I was also shocked to knowthat maternal mortality
and morbidity were highand it was driven by
cardiovascular disease.
(41:00):
And it sort of informed me abit more about the gap we have,
not just in patient education,but also within medicine that
how many of us within medicineas physicians really know, knew that.
Right. And that was shocking to me thatthat statistic or knowing that.
And then I was also on apersonal front going through
(41:21):
my own journey into motherhoodand I was pregnant during my first year of
Cardiology Fellowship.
And it just sort of mademe more sensitive to
how vulnerable women are during pregnancyand how important this time in life is.
Not just because you are makinglife inside of you, but also
because of what that couldmean for you in the future.
(41:42):
And to me that was really humbling.
So it was really a combinationof looking at the science,
the collaboration, theadvocacy, the prevention
and really that human connection.
And so many, so many casesduring my one training
in at Hopkins of patientsthat I've seen and sort of seen
how up this particular specialtyhas transformed their lives
(42:05):
and given the abilityfor them to have children
and have children safelyand navigate that safely was,
was really, really special.
And that was when I knewthis is what I wanted to do.
What is the one message youhope every woman hears about
pregnancy and heart health?
I guess my biggest message isthat women should feel
empowered to speak up.
(42:26):
If you're having the severesymptoms like shortness
of breath, chest pain, fainting,persistent palpitations,
or symptoms that justfeel out of proportion,
please never brush them aside.
Right? So that's the mostimportant thing I will say.
Empower yourself to seek care.
The second thing is know your history,know your pregnancy history,
(42:47):
and know your healthhistory really well so
that when you do decide to get pregnant,you seek prenatal counseling
and you make sure you're reallyoptimized prior to pregnancy.
And for clinicians, we needto ask more about
pregnancy history as partof our cardiovascular risk,
because pregnancy can give us someof the earliest warning
signs we will ever get.
So when we protect a woman'sheart during pregnancy,
(43:08):
we actually protect her health for life.
Perfect ending message.
Because pregnancy can reveal more thanhow a baby is developing.
It can offer a powerful glimpse into awoman's future heart health.
And by identifying risksearly and supporting women
before, during, andafter pregnancy, cardio
obstetrics is helping save lives.
Thank you, Dr. Chu. We'vebeen talking with Dr.
(43:31):
Minhal Makshood, a cardiologistand cardio obstetrics
specialist at MedStar MontgomeryMedical Center in only Maryland.
Thank you for sharing yourexpertise with us on Doc Talk.
If you'd like to makean appointment with Dr.
Makshood and be seen at the Women's Healthand Cardio Obstetrics
Clinic at MedStar Health,call 3 0 1 5 7 0 7 4 0 4.
Comprehensive, relevantand insightful conversations about health
and medicine happen here.
When MedStar Health Doc talk,these are real conversations
with physician experts fromaround the largest
healthcare system in theMaryland DC region.
Pregnancy is really oneof the most transformative
times in a woman's life,but it can place extraordinary
(00:23):
demands on the body,especially the heart.
During a healthy pregnancy,blood volume increases
dramatically, heart rate rises,and the cardiovascular
system works over timeto support both mother and baby.
In many ways, pregnancy actsas a natural stress test for the heart.
For some women that stresstest can reveal previously
(00:44):
undiagnosed heart conditionsor trigger new complications
such as high blood pressure,pre-eclampsia,
or even heart failure, that'swhere cardio obstetrics comes in.
Cardio obstetrics is a rapidlygrowing new field of medicine
that brings together cardiologyand maternal-fetal medicine.
It focuses on protecting thecardiovascular health of women
(01:06):
before, during, andafter pregnancy
through a highly coordinatedteam-based approach.
This specialized careis designed for women
with preexisting heart conditions, suchas congenital heart disease,
valve disorders, arrhythmias,and cardiomyopathies, as well as women
who develop pregnancyrelated complications
that can affect long-term heart health.
(01:28):
Today we're joined by Dr.
Minhal Makshood, a cardiologistand cardio obstetrics
specialist at MedStar Health,to discuss how this emerging
field is improving outcomesfor mothers and babies
and why pregnancy canoffer critical insights
into a woman's future.
Cardiovascular health. I'm yourhost, Debra Schindler. Dr. Makshood,
(01:49):
Thank you so much for having me.
Yeah. I didn't tell you this before,but this topic is a
little close to my heart.
My father's mother, now we'regoing back to the forties,
she had something calledrheumatic heart, which we now know
to be a valve disorderfrom having rheumatic
fever as a child.
And after she carriedmy dad in her pregnancy
and the untreated valveproblem took its toll
(02:11):
and at 25 years old, she died.
And I was surprised to readas I researched this topic
for this discussion today,that they only started really
looking at rheumatic heartand cardio obstetrics in the nineties.
So why now is it surfacing?
Great question. So I'm sorry aboutthat personal experience,
(02:31):
but this is actually, you know,still the reality for a lot of women.
So the truth is that maternal mortalityand morbidity has been
rising in the United States.
And if you look at the reasonwhy the primary driver of
that is actually iscardiovascular disease.
So then the questionremains, why is that so?
Well, a couple different reasons.
We are seeing more and morewomen become pregnant with
(02:53):
other comorbidities such asadvanced maternal age, obesity,
diabetes, high cholesterol.
So PA patients are havingpreexisting conditions
and choosing to havechildren at an older age.
We are also seeing women whohave preexisting heart disease,
such as prior congenitalheart disease, get pregnant
'cause they're living longenough to go through pregnancy
(03:14):
because of the advancementof medical care, which is fantastic.
And then we are also learning that womenwho have adverse pregnancy
outcomes such as preeclampsia,gestational diabetes, preterm
labor, these are thingsthat can happen during pregnancy
as complications of pregnancy.
And we are learningthat these complications
of pregnancy actually havelong-term effects on your
(03:36):
cardiovascular system.
Well, you know, many listenersare probably hearing cardio
obstetrics for the first time.
And I heard you reference it as cardio B,which I thought is very clever.
How do you explain that to patients?
What exactly is cardio obstetrics?
So cardio obstetrics is afield that was born as a result
of that data that I just toldyou, that maternal mortality
and morbidity is primarily drivenby cardiovascular complications.
(03:59):
It is the care of womenwith heart conditions
before, during, and after pregnancy.
So this could include womenwho already have preexisting
heart disease, such as womenwith congenital heart disease,
valvular heart disease,like the example you gave
of your own family member,abnormal heart rhythms or
existing heart failure.
And these women, prettystraightforward, right?
They have preexisting heart disease.
(04:21):
So they're high risk during pregnancy,but it also includes taking care of women
who de develop heartrelated problems, such as,
like I mentioned before, hypertension,preeclampsia heart failure
or abnormal heart rhythms.
We need to understandthat pregnancy places an
extraordinary demand on thecardiovascular system.
As you mentioned, your blood volume rises,the heart rate increases,
(04:44):
and the heart now has to work much harderto support both mother and baby.
So pregnancy like is a naturalstress test to the body.
So cardio obstetrics is reallyabout anticipating that risk,
recognizing problems earlyand creating a coordinated
care plan so women can movethrough pregnancy and postpartum
as safely as possible.
(05:07):
And this is how we decreasethat maternal mortality
and morbidity that is drivenby cardiovascular disease.
So cardio obstetrics iswhere maternal health
and heart health meet.
So you mentioned these,these conditions pre-eclampsia,
explain what that one is.
So when we think ofcomplications of, you know,
pregnancy related complications, we thinkof hypertensive disorders of pregnancy.
(05:32):
High blood pressure,High blood pressure, correct.
So you can either develophigh blood pressure,
there are very diff strictdefinitions for each of these.
You can develop gestational hypertension,which simply means you have
elevated blood pressureduring pregnancy, or an extreme form of
that is preeclampsia or eclampsia.
Preeclampsia essentiallyis not just elevated blood
pressure, but now you'reseeing consequences of
(05:54):
that elevated bloodpressure to the vasculature
that results in end organ damage.
So patients can starthaving kidney dysfunction,
heart dysfunction, retentionof fluid in their lungs, in their legs.
So what you're seeing is thatelevated blood pressure is now
causing an inflammatory responseand causing destruction to the
vascular endothelial systemthat then results in through
(06:15):
this cascade of complicationsthat cause end organ dysfunction.
So patients will startdeveloping protein in the urine
as a complication of kidney dysfunctionand then they can start having,
like I said, fluid retention.
So it's an extreme form of hypertension,belated complications.
And that's always an emergency,Typically.
(06:35):
Yes. So been patients at preeclampsia,usually the treatment primarily
for preeclampsia other thandecreasing blood pressure
and treating them withother ME medications,
including magnesium, isdelivery to save mom.
Of course. I know some womenwho have been through that
and they've had emergencycesarean sections.
But what if the preeclampsiastarts earlier in the pregnancy?
Does that happen? Is it treatable?
(06:56):
Would that be when thepatient would come to you?
So that's a very good question.
So oftentimes preeclampsiawe see closer later on in
pregnancy, but it patientscan have hypertension related
complications, particularlypreeclampsia earlier on,
particularly in the secondtrimester and so on and so forth.
So that is why it's very importantto identify patients at risk
and make sure that they'reon the best management in
(07:18):
terms of their blood pressure.
But if they do developpreeclampsia, to your point,
the treatment unfortunately is delivery.
Okay. So it's treating theblood pressure and delivering
because mom needs tobe healthy for baby to Survive.
Absolutely. So when these changes happento the cardiovascular
system during pregnancy,do they usually revert
back to, to normalcyafter the pregnancy?
(07:40):
And does it reveal anythingabout the woman's future health?
This is a really, really good questionand a very important one.
You know, oftentimes all theseconditions that I mentioned,
and I'm gonna repeat them again'cause they're important
to know, preeclampsia,gestational hypertension,
gestational diabetes,and preterm labor, they're
often all just treatedas pregnancy complications, right?
(08:01):
So oftentimes you'll talkto women, they'll say,
I had preeclampsia during my pregnancy,I delivered baby, and everything's done.
But they're actuallycardiovascular warning signs.
They tell us that a woman'sblood vessels may be more
vulnerable to high blood pressureand vascular disease later in life.
And we've actually lookedat this and studied this.
Patients with gestationaldiabetes also tell us about their
future risk of diabetesand cardiovascular disease.
(08:23):
So oftentimes, if you havean adverse pregnancy outcome,
which is one of thoseconditions that I mentioned,
this is a great clue aboutyour long-term cardiovascular
risk, because we know that patientswith adverse pregnancy
outcomes are at increased riskof heart failure, coronary disease,
and overall bad outcomes,cardiovascular one.
So this is why it's importantto identify these patients early
(08:46):
and in the postpartumperiod, intervene early
and help with lifestyle modificationsand risk assessment so
that these things can beprevented in the future
and that patients don't presentin their forties, fifties
with heart attacks or heartfailure or other conditions
because they weren't adequately screenedor thought about in more detail
or intervened upon earlier.
(09:09):
Who are some of the patientsthat you see who's typically a patient
who needs cardio obstetric specialty care?
So it's a whole host of patients.
So if I were to describethe typical patient
with preexisting heart disease, right?
So someone that already has aheart condition, like I said,
that's a straightforward one.
Typically I would see thatpatient for prenatal counseling,
which is before they become pregnant.
(09:31):
So these patients who arepreexisting cardiac conditions
should plan pregnancy, right?
So they should go see their OBand also see a cardio obstetric
specialist or a cardiologistand make sure that they're
on the right medications,make sure that they're
optimized cardiovascular wise,if they need further imaging
or testing to understandtheir disease process further,
(09:51):
that needs to be completed.
If they have conditions thatrequire surgical intervention
or anything like that,that needs to be handled
before pregnancy, thosethings need to be discussed.
So the prenatal counselingentails taking care of women
of preexisting cardiacdisease like heart failure
or you know, valvular dysfunctionor underlying arrhythmias,
and essentially risk stratifying themor even chronic hypertension and diabetes
(10:14):
and making sure that allthese factors are optimized.
So they're going inwith their best foot
forward into pregnancy.
So that's the typical patientwith preexisting cardiac disease.
The second layer of patientsI see is risk factors
or prior pregnancy related complications.
So if you have had preeclampsiain your first pregnancy
or gestational diabetesin your first pregnancy
(10:35):
or any of these other adversepregnancy outcomes, it's good
to have a prenatal counselingwith a cardio obstetric
specialist to make surethat these things are optimized prior
to getting pregnant againand making sure we are on top of it
and controlling blood pressure,controlling other risk factors,
making sure for example,that you're on an aspirin for
preeclampsia pro prophylaxis,and then making sure they're
frequently followed throughoutpregnancy so they can meet the demands
(10:59):
of pregnancy without complication.
So that's the second flavor of patients.
Then the other flavorof patients are patients
who are pregnant and thenstart having problems.
So when you are pregnant, ifyou have severe chest pain,
worsening shortness ofbreath, you're passing out,
you're dizzy, you're feelingsignificant palpitations,
(11:19):
then you should absolutely see a cardioobstetric specialist.
A lot of people will say,well wait a minute, a lot
of pregnant women get shortof breath during pregnancy,
they'll get a little dizzy.
Do we panic every timewe have these symptoms?
Well, yes and no.
So for example, it's veryimportant to pay attention
to trends and listen to your body.
If something feels off,you are more short of
breath than expected.
(11:41):
You're noticing your legsare getting more swollen,
your passing out is never normal,chest pain is never normal, right?
Then you should immediatelyseek evaluation, right?
Early intervention here is key.
So those are patientswho develop heart issues
during pregnancy that thencome and see me at that time,
and then we follow them through pregnancyand then we transform into
the third trimester postpartumphase where patients are more vulnerable,
(12:08):
pregnant patients are morevulnerable at that time
because of all the changesthat occur at that time
and can develop heart conditions then.
And then I'll see a host of patientsthat either develop things
like peripartum cardiomyopathythat typically occurs at the
end of pregnancy or postpartum.
What exactly is that?
So peripartum cardiomyopathyis heart failure
that occurs from pregnancy.
(12:29):
And there's a whole host ofreasons as to why that happens.
You know, during the post thethird trimester going into the
postpartum phase, yourbody is going through a lot
of hormonal changes.
There's a lot of changes inthe inflammatory pathways,
the metabolic pathways and delivering inand of itself is a huge
stressor to the body,specifically vaginal delivery.
So patients goingthrough these changes can
develop heart failure.
(12:51):
And there are some patientsthat are more prone to that.
Like for example, patientswho already have elevated
blood pressure, right?
They already have somethingthat's vulnerable about their vasculature
that increases their riskfor endothelial dysfunction
and dysfunction of their vascular systemthat can then down the
line lead to heart failure.
So for some reason, we see thismost in the third trimester
(13:11):
to the postpartum phase for that reason.
Okay? And we are hypervigilant about thisbecause a lot of times women
can come in, they're shortof breath, they'll have
swelling in their legsand they'll be diagnosed with this, right?
And they can even developpreeclampsia postpartum,
you can be completelyfine during your pregnancy
and then you deliver a baby.
Oh, and then your bloodpressure is elevated
and you're having swollen legsand it could just be from preeclampsia
(13:32):
that develops postpartumAnd, and the risk for that is stroke.
So yeah, it's, yes ifpreeclampsia is untreated,
but the risk for that isalso heart failure, right?
So preeclampsia is also on a spectrumwhere it can end up causing
destruction to the heart too.
And you can end upleading to heart failure,
which is the extreme form of that.
So understanding that these are all thingsthat cardio obstetrics takes care
(13:55):
of in a collaborative fashion.
So it's either preexistingheart disease, heart disease
that you develop during pregnancyor someone that has risk factors
to develop heart disease in pregnancy.
So that's the entire hostof patients we care for.
And once you are a patient,you should be our patient forever.
And now, if a woman hasany of these conditions,
pre-eclampsia, gestational hypertension,gestational diabetes, is the baby at risk,
(14:19):
is there any impact to the baby's health?
Yeah, so that's a great question.
So for, for example,gestational diabetes can lead
to large babies because ofuncontrolled sugars, you know,
because blood sugar is a toxin, right?
So that can lead to LAlarge for gestational age.
Preeclampsia itself, like I said,it's an issue with the vasculature.
So it can result in the babynot getting enough perfusion.
(14:40):
So when mother is not doing well,baby naturally won't be doing well.
'cause the baby depends on mom to do well.
Is is a large baby a risky baby?
I mean, is that a danger to the baby?
Yeah. So a large babytypically, so I'm not an OB GYNI
Understand. So,But I would say that, you know,
gestational diabetes can thenlead to large gestational age
(15:02):
that can then lead to laborand delivery related complications, right?
Larger babies are harderto deliver, sometimes need
to do C-sections, whichIm important to know.
And knowing that, youknow, babies that are born
with macrosomian who arelarger, also an increased score
of obesity and diabetes in thefuture and things like that.
So there are obviously fetalimplications for this as well.
But it's important to understandthat in, when you think
(15:24):
of pregnancy, mom needs to be healthybecause whatever mom is
experiencing baby's invariablyexperiencing the consequences of that too.
I have seen babies bornwhen their moms were
with gestational diabetes andthey're fat and they're cute.
They're just so cute. Yeah,they look pretty healthy,
but they, they look just little chubby.
(15:44):
Yes. Yeah, yeah, yeah, yeah.
I think it's more important tosort of think of these things
as a lens into the future, right?
And I think that's kind ofwhere the narrative sort
of shifts a little bit,where we need to understand
that pregnancy is not just anexperience a woman has once in
her lifetime, whatevercomplications she develops,
she develops and then we forget about it.
These are not just memories,these have long-term
(16:06):
cardiovascular consequences.
So the pregnancy historyshould be a huge part
of a woman's history interms of her health history.
I tell women, know yourhealth history really well.
Know your pregnancy history.
Oftentimes I will speak to patientsand I'll ask them about
their pregnancies, you know,even when they're in their fifties
and they'll say, I thinkI had high blood pressure.
(16:28):
I remember my legs were quite swollen.
I think my sugars weren't great.
It's just almost likeit becomes this memory
and it's, it's only Ithink a human response
to sometimes shieldthings that are negative.
And most people remember,you know, holding their baby
for the first time andhow that made them feel.
And that's all beautiful.
But it's important to remember the stuffthat didn't go well too,
because that stuff is reallya clue into the future, right?
(16:50):
It's telling you, you know,this is a window into your future.
It's telling you howyou may have issues 10,
20 years down the line.
And I think that's really keybecause it's so valuable, that information
and it really gives us that opportunityto intervene earlier on.
So we can save women from a lotof cardiovascular complications later on.
So cardiologists should be askingtheir female patients about
(17:11):
their pregnancy history.
They should be asking them,did you develop preeclampsia?
Did you develop gestational diabetes?
Did you have preterm labor?
These things are important.
Did you ever have uncontrolled bloodpressure during pregnancy?
Right? And if, and if theanswer to that is yes,
that changes how theyrisk stratify that patient
and how they think about that patient.
(17:32):
I mentioned my grandmotherhaving had rheumatic heart
and she delivered my dad, butsubsequently was weakening
and she knew that she was going to die.
Sad story. But it was,you know, 1940. Yeah, one.
Nowadays, if a woman camein with the same problem,
we know now to be a valvularproblem, what would they do
(17:52):
with a situation like that?
Could the woman undergo surgery forthat? Yeah, while she's pregnant.
Great question. In fact, Iactually had an experience
during fellowship where of a womanwith mitral stenosis in the setting
of rheumatic heart disease.
And she got operated on, had it fixed,and then she went through pregnancy
and we were able to carryher through that pregnancy.
(18:13):
So this is where thatprenatal counseling is really
key, right?
So then the question is, whoneeds prenatal counseling?
If you know that youhave a cardiac condition,
then it's pretty easy to justgo see a cardiologist, right?
Because you have a cardiac condition,but you also need to be on top of it
and make sure you talk to thembefore you decide pregnancy
to make sure it is safefor you to get pregnant.
'cause not all cardiacconditions are created equal
in her situation.
(18:34):
We were able to fix her mitral valvebefore she could go into surgery.
But there are some cardiac conditionswhere pregnancy is truly contraindicated,
where you shouldn't consider pregnancybecause it is too high risk.
But then there are conditionswhere you know, you have mild
to moderate disease,you're pretty optimized
and we can safely carry you through them.
And and we do. So it's importantthat prenatal counseling
piece is important for womenwith pre-existing heart disease.
(18:57):
And if you are someone whois deciding to have a baby
and your advanced maternal age,and even if you're not
advanced maternal agent,know you have diabetes, obesity,
high blood pressure, go see someoneWhile a woman is pregnant,
can she be on blood pressure medications?
Absolutely. Or cholesterol me.
Yeah. It doesn't affect you. Well, bloodPressure you do cholesterol
is a little challenging.
So let's talk a little bit about that.
(19:17):
So blood pressure medications,there are safe medications
studied in pregnancy.
So that's another reasonwhy if you have chronic
hypertension, you needto make sure you see your
cardiologist before you consider pregnancybecause we need to ensure that
whatever medicines you're on,it is pregnancy safe
both for you and baby.
So if you're on somethingthat isn't pregnancy safe,
we will switch you prior to pregnancy.
So that's, that's one thing.
Cholesterol is a little tricky.
(19:40):
It's tricky because there's now newer datawith a statin called Pravastatin,
and we could use pravastatinin certain select high risk
cases, but statinsfor the longest time were
contraindicated in pregnancy.
So women who have had, youknow, issues with cholesterol,
typically if they've nothad a heart attack or stroke
and they're going intopregnancy, we're okay
(20:00):
with them staying off their statin.
But then there are afew subset of patients
who are high risk, who have hadpregnancies, have had stents
before, and in the past wewould never put them on a statin
because of high risk.
But then this patient shouldalso have a discussion
with their cardiologist andwhether pregnancy is truly safe,
if they have stents and other heartdisease, coronary disease.
However, in in this population,now we can consider pravastatin
(20:22):
if we need to use it.
We do have that tool.
What's important tounderstand is in pregnancy
and not all cardiac medications are safe.
So a cardio obstetrician is someonewho specialized in understanding
what medications can beused in pregnancy as well
to treat specific cardiac conditions.
So that's why it's importantto make sure you're on
all the right medicinesbefore pregnancy and
if you develop anythingduring pregnancy that you are treated
(20:46):
with medicines thatare safe. You and baby,
We know that black womenin the United States face
significantly higher ratesof pregnancy related death.
How can cardio obstetricshelp close the gap?
Yeah, so this is actually a very,very important topic when
it comes to maternal health.
And the disparities are actually quiteprofound and heartbreaking.
(21:08):
Black women have a higherrate of maternal mortality
and morbidity compared to other women.
This disparity is actuallytrue across income
and education as well, whichis what makes it shocking.
And it also sort ofhighlights the importance
of system level inequities.
A huge part of it is delayed diagnosisor that they present early
(21:28):
and their symptoms arenot taken seriously.
So there is a so sort ofsystemic inequity component here
as well that plays a role.
Cardio obstetrics can actually helpby creating earlier access
to specialized care,early recognition that is key.
Understanding the demographic,understanding the dis
disparity exists taking theirsymptoms seriously.
They have higher rates ofpreeclampsia knowing that,
(21:50):
and importantly, it's thiscare coordination piece with OB
and cardiology to make surethat these high risk women
are taken care of during pregnancyand are not lost after delivery.
So it's, it's aboutlistening, trust, access
and advocacy, which cardio B allows for.
So closing the gaps actuallystart with listening to women
(22:10):
and acting earlybecause we know that we
don't do a good job at that.
And that's another reason whywe're seeing this disparity.
Which makes me think of the casethat we were discussing
prior to our recordingwhere you have a mom who's
in her fifth pregnancy, neverbefore knew that she
had a hole in her heart.
Yeah. How is that possiblethat she has had four healthy
pregnancies, never knewthat she had this anomaly in her heart?
(22:36):
Yeah. So you know, that's,that's an interesting case
because she actually did notpresent with any symptoms
during her first few pregnancies.
And you know, when people say lotsof people are having
babies for years and yearsand years, not everyone
has a terrible outcome.
Pregnancy is a huge stressor to the body.
But you would be surprised byhow well your heart adapts to it.
(22:57):
And some people adapt sobeautiful in her situation.
Yes, she had a hole in her heartand she likely was born with this.
Right? And this is somethingthat progressed over time.
So interestingly, for whateverreason that I cannot explain,
for the first four pregnancies,she didn't have any symptoms.
She didn't have the shortness of breath,the swelling in her legs.
But her last pregnancy,she's a little older,
(23:18):
she's had the condition a little longer.
She likely had more stretch of her heart,increased shunting from the left to right
because of that hole inthe middle of her heart.
And eventually when shewent through pregnancy,
which was the ultimate stressor, it kindof tipped her over the edge.
And she's a great example of someonewho also presented in
the postpartum phase.
She didn't actuallypresent during pregnancy.
(23:40):
She presented towards the endwhen her heart couldn't take
the stressor anymore,particularly delivery.
And that's actually another great areawhere you could learn more
about a woman's heart.
Because when women gothrough vaginal delivery
and go through labor, there'sa lot of hemodynamic shifts
that occur there to your blood pressure,to the fluid shifts, right?
(24:00):
That your heart has to adaptto and work well. Right?
And some women, when they showyou that they're not doing
that as well, that's another clueof something probably isn't.
Right. Right. So this is whereit's important to understand
that pregnancy unmasksor can unmask underlying
cardiovascular disease,which her case was a
phenomenal example of that.
(24:22):
Someone that has diseasedidn't know about it,
she gets pregnant, goesthrough that stress test
of increased blood volume,heart rate around delivery goes
through those hemodynamic shiftsand our heart says,
Hey, I can't take this.
And it starts retainingfluid and causes symptoms.
And then there she's diagnosed.
So sometimes pregnancyactually isn't the cause,
it's just showing youwhat your underlying
(24:43):
vulnerabilities already arethat were already there to begin with.
Well she attributes that pregnancyand that baby with saving her life.
Yes.
Just to finish off that story,she delivered the baby just fine
and she Yeah. And then what happened?
So I actually saw herin the postpartum phase.
That's when I was first introduced to her.
And you know, she was havingheart failure symptoms
(25:05):
and we ultimately diagnosedher with a hole in the heart.
And we had a phenomenalstructural heart team here.
And it was something thatwe were easily able to fix
through non-invasive surgeryor minimally invasive surgery.
She didn't need an open heart surgery.
So we were able to fix it witha minimally invasive surgery.
And I actually just saw her yesterdayand she's doing fantastic,
(25:25):
Wonderful, wonderful news. I mean, allHer symptoms have resolved
and she's already on thetrajectory of full recovery.
I think it does make sense that she can gofor pregnancies now that we
we're talking about it and,and not, not reveal
any issues in her heartbecause of the strain
that is constantly being puton her heart through all these,
(25:46):
the, the many pregnancies.
I mean, I can't imagine thesewomen who are 12, 13 babies,
what's going on withthem cardiovascular wise.
Yeah. And then also we needto understand that, you know,
the whole agent, advanced maternal agealso does play a role.
I mean, there are women whowill present in their early
twenties also with heart failure,but you're less likely
to have more complicationsif you don't have chronic
(26:09):
hypertension, diabetes, you'renot obese, you're young girl
with none, no other comorbidities.
Not that you can't, and it does happen,but typically most of those women do well.
But there's a reason why weworry more when women sort
of progress in ageand then start developing
other chronic conditionsbecause then you're sort
of piling on risk factorsand more stressors to the heart.
(26:29):
So when you put someone through pregnancy,they may not be able to
deal with that stress.
And a lot of women, you know,the really nice thing about this is a lot
of women do recover.
They do well, they go home to babyand they just live their lives.
And the truth is, Ican't tell you the number
of times women are shocked inmy office when I tell them,
oh, you had preeclampsiathat increases your risk of,
(26:51):
you know, cardiovasculardisease in the future, whether
that be heart failure or coronary disease.
They look at me just shockedlike, but I feel fine.
I went home, I feel fine, you know,but does that really increase my risk?
And then I try to explainto them like, yes,
because this is a clue aboutwhat things would be 10 years down the
line, 20 years down the line.
So if someone had an adversepre pregnancy outcome at the
(27:13):
age of 30 during a pregnancy,10, 20 years down the line,
they can come in with long-termcardiovascular issues if
they were not seeing a doctorand not caring for
themselves during that time.
And I think that time is so crucialbecause you can really intervene
and make sure their bloodpressure is well controlled
to make sure their blood sugars are not,or they don't develop diabetes
because all these thingsin the long run are
(27:33):
gonna affect their heart.
'cause women also thengo through menopause,
which is another hugeshift in their bodies
that also increases theirrisk of heart disease.
So it's important to kindof think about pregnancy
and pregnancy relatedcomplications as not just a clue,
but also just something thatyou have to think about deeply
for a patient in terms of howyou're going to manage them
(27:55):
and how you're going toprevent really, you know,
stroke heart attacksand things like that
early on in their lives.
Is it your suggestion thenthat anyone who's listening now
who had experienced preeclampsiaduring their pregnancy
have a cardiologist?
Yeah. Should they follow upwith a cardiologist even
if it's 10 years later?
I think they should see a doctor,whether it's a primary care doctor
(28:17):
or a cardiologist,depending on the situation.
So at at the least, see your PCP,make sure you're getting your blood
work, knowing all your numbers.
Make sure your bloodpressure's under control.
Know what a good bloodpressure is supposed to be.
Understand the cutoff of blood pressuresand make sure that you're below the cutoff
and you don't develop hypertension.
Pay attention to your cholesterol numbers.
So look at them, lookat the good cholesterol,
(28:37):
look at the bad cholesterol.
Make sure you're optimized.
Ask your doctor questions about that.
Look at your A1C, make sureyour diabetes is under control.
A primary care physicianis very much capable
of doing all of those things.
And yes, you can certainlyfollow with a cardiologist
as well, particularly if youhad more adverse complications.
But even for primary prevention, you know,either a cardiologist or a PCP,
(28:58):
but it has to be a physicianthat you need to see
for your routine careand that you're working on
lifestyle things, whetherthat be diet and exercise as well.
You mentioned those heart health numbersand I wanted to make sure that we,
we emphasize knowing thoseheart health numbers.
Are there any other ones thatpeople should be aware of?
I would say weight trends as well.
So blood pressure, cholesterol.
(29:19):
So know your lipid panel,what's your LDL, your A1C,
and then know how yourweights are trending.
I would say those are somebig ones that you should know
When you have a patient come inand you know that this
patient is high risk.
How does your care team and,and who makes up the care
team, how do you preparefor a case like that?
Yeah, so this is reallyvery, very important
(29:40):
because cardio obstetricsis primarily a collaborative
multidisciplinary team.
And that's what makes it amazing.
So it's a team that is acombination of cardiologists
for high risk pregnancies,maternal fetal medicine,
OB obstetrics, maternalfetal medicine, anesthesia
for delivery planning, nursing,and sometimes genetics if
patients have genetic conditions.
(30:03):
Advanced heart failurespecialists if patients already
coming in with heart failureor developing heart failure
or cardiothoracic surgery.
Even sometimes if patientsneed surgery before pre,
before pregnancy if they have valvularissues, so on and so forth.
So it is really a pretty large team.
But I would say the coremembers are cardiology, MFM,
which is maternal fetal medicine,obstetrics anesthesia, and nursing.
(30:24):
I think these are the core folksand we all work together to
take care of the patient.
Does that mean when the woman comes infor her monthly checkup
during her pregnancy,everybody is there
or is everyone talking abouther case at some point?
That's an excellent question.
So I would say it's acombination of both depending
on where you practice.
So where I trained, we hada cardio obstetrics clinic
(30:47):
where it was combined carewhere a patient would come
and see the cardiologist andthe OB person at the same time.
But that would only occur once a month.
And then sporadically,if they need to see each
of them individually, they will as well.
And then patients will also be discussedas part of meetings.
They'll go through differentpatients and delivery planning
and what's going on and updates.
(31:08):
In some places it's exclusivelymessaging, you know, you,
you make sure that all thepeople involved in the care
of the patient are talking to each other.
Right? And we constantlytalk to each other.
I can tell you when I'm takingcare of pregnant patients,
I'm talking to ob, you know,and if, if they're high risk
and we are worried about the deliveryand what their delivery plan is.
So most of the talking happensalso closer around delivery,
(31:28):
then we talk to anesthesia,we ask them about their concerns.
So this is something we constantly discussand mostly happens behind the
scenes in a lot of programswhere patients may not be
privy to those conversations,but they will know when
they come to visitsand we will tell them
about what we discussed.
And those things are repeated multipletimes at each of the visits.
So they know that everyoneis on the same page.
(31:49):
And I think patients deservecare where their doctors talk
to each other and we know thebest care comes from that.
Nothing is worse than when a patient comesto see multiple doctors
and they're all tellingthem different things
and they're just nottalking to each other.
Right, right.
And that's not gonna be effective.
Cardio OB is only effectivein doing its job of reducing,
(32:10):
you know, bad cardiovascular outcomes.
Only if you work as a team. Right?
I can see a patient in clinicand tell them to do something,
but if I'm not communicatingthat with the OB team,
the maternal fetal medicineteam, when they see the patient,
if not, probably more frequently than I dobecause especially towards
the end of pregnancywhere they're seeing them weekly and so on
and so forth, then they're not gonnabe looped into the care.
(32:31):
So none of that stuff is reallygoing to come to fruition.
So in order for all thisto work, well we all need
to come in 'cause weall bring very expertise
and we're all thinkingabout a different aspect.
OB thinks about a different aspect,cardiology thinks about the
cardiovascular consequences,anesthesia will, will think
about labor, delivery, sedation,that aspect of it, right?
(32:52):
So all of us come in withour own sort of, not agenda,
but our, our own concernsand our own plans.
And then we come together, put it togetherand come up with the best
plan for that patient.
And that's when we see this workingAnd then the baby is
born, everything goes welland we're in the, what
some people have called thefourth trimester.
(33:13):
And I love that you had mentioned beforeor I appreciate that you had mentioned
before that sometimeswomen get preeclampsia
after the delivery, which isa surprise to me actually.
Yeah. Tell me what thatfourth trimester is
and why is it such a criticaltime for heart health?
Yeah, so a lot of timeswhen women give birth,
you think the hardest part isover, no, I'm gonna go home
(33:35):
with my baby and everything's fine.
But unfortunately that'snot how it works in terms
of your just cardiovascular riskand overall just how your body works.
So towards the endof the third trimester
transitioning into delivery,your body is going through
a lot of changes, right?
We're seeing a hormonal shift,we're seeing changes in metabolic
(33:55):
and inflammatory pathways, right?
Which is huge. And then yougo through the whole process
of delivering labor, right?
Labor primarily.
And that itself is causing, you know,variations in blood pressure,
variations in fluid shiftsthat are going in the blood
vessel, outside the blood vesselthat can cause issues if they
have underlying preeclampsiaor underlying propensity
to develop heart failure.
(34:17):
So during this time it's reallycritical to pay attention
to the patient andunderstand that even well
after delivery daysand even up to weeks,
patients can still have faceconsequences of the pregnancy.
In fact, peripartumcardiomyopathy can be diagnosed up
to five months and even longer postpartum.
(34:38):
Wow. And some patients alsodevelop, it's very rare,
but can develop thiscondition called spontaneous
coronary artery dissection.
Which for some reason wesee happen closer to the end
of pregnancy in that postpartumperiod for all those changes
because of all those changes I justMentioned.
What, what is that? What happens?
So it's basically spontaneouscoronary dissection is the
(34:58):
blood vessel supplyingyour heart, the wall
of those blood vessels can dissectand it can lead to a heart attack
to patients will presentwith heart attacks.
And you know this, this is somethingthat is treated very
different differently from atraditional heart attack in some ways,
but it's nevertheless a heart attackand patients can present
with that and it's,and there's an entity
that's pregnancy associatedand that's something we also
(35:20):
think of if patients present,which crushing chest pain or
concerning symptoms, it's rarebut it can happen.
So it's important to understandthat preeclampsia can happen,
postpartum heart failurecan happen postpartum.
So many changes can happenbecause your body is still recovering.
And so, so important for womento pay attention to those symptoms.
(35:40):
What symptoms should a new mother neverignore after giving birth?
Yeah, definitely don't ignorechest pain that is severe.
You are having significantshortness of breath
with swelling in your legs andyou're not able to lay flat.
You have to sit up and sleepbecause you're having fluid
going into your lungs.
That's very concerning. You're dizzyand you're passing out alright,
these are all terrible symptoms.
(36:02):
And if, if you are noticingthat the swelling in your
legs are getting worse,that's never good because the
swelling in your legs shouldimprove right after delivery.
You will see more swellingimmediately after delivery
'cause of all the volume you get.
'cause you get a lot of fluidsand things like that during labor.
'cause women lose blood naturally whenthey, when they give birth.
So a lot of times, youknow, women will get fluids
(36:23):
and things like that so youcan feel a little more puffy
right after delivering.
But that should get better.
You should start noticingyour lengths kind
of shrinking back and you know,you're feeling like you're
holding onto less fluid than youdid towards the end of your pregnancy.
But if you're noticingthat that's getting worse,
your legs are puffier, I'm lying downand I just find it hard to breathe.
I can't breathe when I lay down.
(36:43):
I need like two or threepillows to prop myself up.
I wake up in the middle of the nightsometimes short of breath.
Those are all terrible signsI'm having crushing chest pain.
This is so strange. It's odd. Get checked.
I can't walk up a flight of stairsor two flights of stairs without
really getting short of breath.
That's, that's odd. I feellike I'm gonna pass out.
That's odd, right?
(37:04):
Is is this the purposeof a six week checkup
after the baby is born?
Yeah, so you know, the sixweek checkup happens with OB
and they're screening for many things,including postpartum depression
and other things thatthat women experience.
But it, this is also part of it, you know,checking the blood pressure, making sure
that you know the exam looks okay,that they're not having
any concerning symptoms.
Women with preexisting cardiac diseasewho have used cardio obstetrics
(37:27):
during their pregnancyshould also see their cardio
obstetrics specialistor their cardiologist
right after delivery.
I oftentimes will see women within weeksafter delivery just to make
sure that their trajectory is,you know, heading in the right direction.
Maybe there should bea three month checkup
as a routine routine.
And you know, that sometimesdoes happen depending on
what complications that they have.
(37:48):
So if they do, if they are high risk,I will see them a lot more
frequently in the first sixmonths postpartum just to make
sure that everything is goingas planned and making sure
their blood pressure is stable.
If, if there was preeclampsiainvolved, you know, if a lot
of women, you know, who alsohave preeclampsia end up
getting a heart ultrasound at some point,especially if they had
concerning symptoms to make surethat the heart's squeezing
(38:09):
and functioning normally,if there's ever a concern,
you know, we need to lookinto it with further workup.
So a lot of times I will seepatients in the immediate
couple weeks and then after that,a couple months out after that.
And if they're completely finethen I might see them in six
months and then go to a year after that.
And what steps are yourecommending to those women
that they take to reducelong-term cardiovascular risk?
(38:32):
So that's a good question.
I would say in general wouldstart out by saying
outside of even pregnancy,there are things that we all can do
to reduce our cardiovascular risk, right?
So that's weight management,making sure you're
exercising according to the,you know, guide guidelines.
We recommend at least 150 minutesof moderate intensity exercise per week.
That's roughly about 30 minutes a day.
(38:53):
So what is moderate intensity?
You can, you know, you cantalk, but you can't sing.
If you wanna do highintensity, you can, that's up
to 75 minutes per week aswell is what we recommend.
Adhering to a Mediterraneandiet that is, you know,
high in fruits and vegetables,low in saturated fats
and so on and so forth to make surethat you know your cholesterol is good.
(39:13):
Make sure you don't develop diabetes,do not pick up smoking.
These are all thingsthat you can do to help
with your overall cardiovascular risk,which in turn will also help you when you
decide to get pregnant.
But I also want to sort ofsay that there are women
who don't have any of these risksand are actually doing pretty well
and doing all the right thingsand could still develop issues
(39:33):
during pregnancy for whatever reason.
Right? So that's alsoimportant to keep in mind.
But in terms of what can be doneand putting the onus on the patient,
I would say the best would be modif,those risk modification
factors mainly make, you know,hypertension management,
making sure you don'tdevelop diabetes, you know,
managing your cholesterol.
So optimizing all those numbers priorto pregnancy is always a good idea.
(39:54):
All of your advice is so important.
And with the fetal morbiditynumbers being what they are,
I really have such respectfor what you're doing
and what your focus ison cardio obstetrics.
How did you find yourself intothis niche? Yeah. Medicine.
Was there a certain case?
Did you know that you wanted to do thisor did you, were you in
cardiology medical schooland what happened?
(40:18):
Yeah, no, that's an interesting question.
No, I actually did not knowfrom the very beginning.
I knew I wanted to becomea cardiologist when I
was doing residency.
And I will say I was a firstyear cardiology fellow at Johns
Hopkins when I first did mycardio obstetrics rotation.
And I was really amazed byhow complex the patients were
(40:40):
and how collaborative care workedand how it impacted
positively the outcomesof these patients who are young
and high risk for pregnancy.
And I was so fascinated by that.
I was also shocked to knowthat maternal mortality
and morbidity were highand it was driven by
cardiovascular disease.
(41:00):
And it sort of informed me abit more about the gap we have,
not just in patient education,but also within medicine that
how many of us within medicineas physicians really know, knew that.
Right. And that was shocking to me thatthat statistic or knowing that.
And then I was also on apersonal front going through
(41:21):
my own journey into motherhoodand I was pregnant during my first year of
Cardiology Fellowship.
And it just sort of mademe more sensitive to
how vulnerable women are during pregnancyand how important this time in life is.
Not just because you are makinglife inside of you, but also
because of what that couldmean for you in the future.
(41:42):
And to me that was really humbling.
So it was really a combinationof looking at the science,
the collaboration, theadvocacy, the prevention
and really that human connection.
And so many, so many casesduring my one training
in at Hopkins of patientsthat I've seen and sort of seen
how up this particular specialtyhas transformed their lives
(42:05):
and given the abilityfor them to have children
and have children safelyand navigate that safely was,
was really, really special.
And that was when I knewthis is what I wanted to do.
What is the one message youhope every woman hears about
pregnancy and heart health?
I guess my biggest message isthat women should feel
empowered to speak up.
(42:26):
If you're having the severesymptoms like shortness
of breath, chest pain, fainting,persistent palpitations,
or symptoms that justfeel out of proportion,
please never brush them aside.
Right? So that's the mostimportant thing I will say.
Empower yourself to seek care.
The second thing is know your history,know your pregnancy history,
(42:47):
and know your healthhistory really well so
that when you do decide to get pregnant,you seek prenatal counseling
and you make sure you're reallyoptimized prior to pregnancy.
And for clinicians, we needto ask more about
pregnancy history as partof our cardiovascular risk,
because pregnancy can give us someof the earliest warning
signs we will ever get.
So when we protect a woman'sheart during pregnancy,
(43:08):
we actually protect her health for life.
Perfect ending message.
Because pregnancy can reveal more thanhow a baby is developing.
It can offer a powerful glimpse into awoman's future heart health.
And by identifying risksearly and supporting women
before, during, andafter pregnancy, cardio
obstetrics is helping save lives.
Thank you, Dr. Chu. We'vebeen talking with Dr.
(43:31):
Minhal Makshood, a cardiologistand cardio obstetrics
specialist at MedStar MontgomeryMedical Center in only Maryland.
Thank you for sharing yourexpertise with us on Doc Talk.
If you'd like to makean appointment with Dr.
Makshood and be seen at the Women's Healthand Cardio Obstetrics
Clinic at MedStar Health,call 3 0 1 5 7 0 7 4 0 4.
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