Kathryn Lindley, MD, FACC, Associate Professor of Medicine and Associate Professor of Obstetrics and Gynecology at Washington University in St. Louis discusses cardiovascular contribution to maternal mortality.
Twitter @PennMDForum New Paradigms in the Clinical Care of Patients with Hypertrophic Cardiomyopathy | Penn Medicine Gaining a Deeper Understanding of Inherited Cardiomyopathy - Podcast with Dr. Anjali Owens | Penn Medicine thank you so much just for having me virtually at penn to speak to all about this um topic, which I think is incredibly important and is I'm obviously near and dear to my heart. I'm going to give a little bit of a sort of overview of this today. Um I unfortunately cannot uh teach everyone how to take fully take care of pregnant women in an hour, but I think we can highlight really the key issues that we as a cardiology community really need to drill down in on and um some of the areas that really need expanded research on. Mm So maternal mortality has been steadily rising in the United States over the last several decades. And this is in fact while all other major developing developed countries have seen a decline in pregnancy related mortality and importantly, maternal mortality is just a fraction of severe maternal morbidity. Um, we know that this mortality rate is particularly rising among black women and other socio demographic groups are disproportionately affected as well. We can only expect these numbers to continue to rise as women continue to delay childbearing and deliver at older ages. And it's the number of underlying cardiovascular risk factors continue to increase among women who are pursuing pregnancy. Speaking of which I don't have to really educate any of you about the fact that um cardiovascular risk factors are markedly rising among all patient populations in this country. And that certainly does not include the childbearing population. Um, as you can see pennsylvania is in the red along with my home state of Missouri when it comes to adult obesity rates which have been steadily rising over the last several decades. Um we also see that other cardiovascular co morbidity, risk factors such as hypertension and diabetes are steadily rising among the childbearing population as well. And these are particularly rising among patients who fall into the lower socioeconomic classes, putting them at particularly high risk for cardiovascular complications in pregnancy. We also know that the number of women with adult congenital heart disease who are now surviving to adulthood are significantly increasing, thanks to the fantastic um uh progress that our cardiovascular colleagues in surgery and in pediatric cardiology have made. And so that population is also significantly growing as well, leading to a really burgeoning a number of women who really need cardiovascular cara during pregnancy. Now, in addition to women with underlying cardiovascular disease, we really need to think about the women who are socio economically deprived. We know that those women who are the most socially deprived are those who bear the greatest burden of maternal morbidity and mortality. And it's really those women living in the most urban and the most rural areas of the country that are going to fall into those most deprived segments of the population who have actually the highest rates of maternal morbidity and mortality. Just looking at my state of ST louis, you can see that, can you see my my arrow here out here in the blue. This is the sort of ST louis suburbs. I live somewhere down in here. And um this is nice and blue, indicating high levels of education and stable housing and um and high levels of employment. But up here in north ST louis, here's Ferguson where the Michael Brown um uh situation happened um several years ago. And down here in south east ST louis, you can see that these are very red areas indicating um really high levels of social deprivation. However, if you get out into the more rural areas of the state, down here in the boot hill in Southern Missouri and up here in the northern areas of the state, these areas are also very red, indicating that it's really the most urban and the most rural areas of the state. And we see this across all states in the US that are really at highest risk of cardiovascular complications in pregnancy. And what we have seen over the last several decades is that maternal morbidity and mortality has been steadily rising among both of these populations. Um These groups have continued to rise, and we can only expect based on calculations these numbers to continue to go up. We recently actually performed an analysis of the N. I. S. Database looking at sort of drilling down to specific causes of maternal morbidity in rural and urban areas. And what you can see here is that areas falling into the most rural areas of the country have the highest rates of maternal morbidity across all um sort of subgroups of morbidity, and that certainly does not exclude cardiovascular morbidity. Now, it's important to recognize though, that across all urbanist city or rural Aleke um locations, black women always have worse outcomes than white women did. So really the worst possible situation for a black woman would be to be living in an urban or a rural area. Um where really those disparities just sort of multiply upon one another. Mhm. In fact, we know that there are really substantial racial disparities and maternal mortality, as you can see here, black women have 3 to 4 times the rate of maternal mortality compared to white, non hispanic women and America are in native american or Alaskan. Native women also have really substantial increased risk of maternal mortality as well now, although hispanic women, um oftentimes are not found to have particularly elevated risk of maternal mortality. Um we do think that some of those studies are flawed and there do certainly appear to be some subgroups of hispanic women who do appear to be a particularly increased risk of maternal complications as well. Now importantly, this doesn't appear to be completely related to socio demographic disparities because we do know that black women, even when very well educated continue to have markedly increased risk of maternal morbidity and mortality. In fact, you can see here, a black woman with more than a college education is still at higher risk of maternal mortality than a white woman with less than a high school education now. Um yes, it may be true that there are some genetic contributions to this, but really what this indicates is that there are much greater structural and social contributions um likely related to structural bias and and systemic racism that are really contributing to these disparities that need to be addressed on a much larger level. What you may not be aware of is that cardiovascular disease is actually the leading cause of maternal mortality. So this is why I is a cardiologist um and so involved in this field and why it's so important for other cardiologist to begin to collaborate with our obstetric colleagues. Um, R. O. B. Colleagues have really done an amazing job of addressing some of the obstetric causes of death like hemorrhage and infection. And now, as you can see here, cardiovascular disease and cardiomyopathy, combined account for over a quarter of all maternal deaths. Um when you consider other conditions, which I would really consider to be cardiovascular conditions. So rahmbo embolism. So pulmonary embolism, strokes and hypertensive disorders of pregnancy. Um, these conditions really combined account for about half of all maternal dust. So, I think it's really time for us to begin to collaborate together both in terms of patient care and research in order to really use our combined expertise to figure out how we can take better care of women now, importantly, these um cardiovascular deaths don't only occur in pregnant women. Um, I think something that I oftentimes see when cardiologists are taking care of pregnant women is there's a lot of anxiety during pregnancy and sort of leading up to delivery and then there's sort of this sigh of relief once the baby is born. That woo we made it, we're through the pregnancy, everything is good now. But if anything, that is the time when you need to be on highest alert because About 25% of cardiovascular deaths will occur during pregnancy, primarily related to cardiovascular and coronary conditions. And only a small percentage percentage of those are related to cardio myopathy. However, within the 1st 42 days or six weeks after delivery, there are another substantial uh number of cardiovascular deaths. Um, about another 20% of those deaths will be related to cardiovascular conditions. And then finally, um There are another substantial amount of cardiovascular deaths that occur between 43 days and one year after delivery. And the majority of those deaths are related to cardio myopathy. So it's really during that postpartum period where we really need to accelerate our uh surveillance of these patients are screening of these patients are education of these patients in our care of the patients as well. The american college of obstetrics and gynecology recently came out with a practice bolton a few years ago, which is really an excellent summary. And it was primarily written by O. B. G. Y. N. S. But there were some of our our expert cardiology colleagues who were involved in the manuscript as well. And among several other things in the manuscript, they identified four key factors related to maternal cardiovascular mortality and I think they really hit the nail on the head with this. What the four main factors that they recognize as putting women at high risk for cardiovascular mortality, Jerez and ethnicity. So we know that black women have a 3.4 times the risk of dying compared to white women Age. So we know that women who are over age 40 are at 30 times the risk of dying compared to women under age 20 hypertension. So whether that's chronic hypertension or hypertensive disorders of pregnancy. Those women have a 13-fold risk of developing a myocardial infarction and an eight-fold risk of suffering from heart failure And then obesity. So 60% of all maternal deaths occur and overweight or obese women. So these are likely the groups of women that we really need to focus in our efforts in order to reduce cardiovascular deaths. Now, as I mentioned before, there are really a substantial increase in the number of women with underlying cardiovascular risk factors as well as the number of women with underlying congenital heart disease. I have to admit, I really love taking care of women with congenital heart disease through pregnancy. But the great news is these women generally do really well during pregnancy. As you can see here. They really account for the minority of women who are hospitalized postpartum for their underlying cardiovascular disease. Now, this may be because we're already aware of their underlying heart condition. We may be experts are already taking care of them. Um, you know, maybe we're already treating them more aggressively. So this certainly may be related to some underlying bias and how we're caring for them. But these patients tend to do well and the likelihood of death and a congenital heart disease patient with pregnancy is very low. However, it's those patients with acquired disease, so heart failure, arrhythmias and valvular disease in particular, that are the most likely women who are going to be admitted postpartum. I think these are women who oftentimes either have unrecognized underlying cardiovascular disease, who have new, newly diagnosed or newly developed cardiovascular disease during pregnancy or women who we tend to underestimate their likelihood of cardiovascular complications. Perhaps are not receiving care by someone who's an expert in taking care of pregnant women with cardiovascular disease. So let's talk just a little bit about women with, with pre existing cardiovascular disease. I'm actually performing like the classic faux pas on a power point slide here, where I'm going to say, I don't expect you to read this whole slide. Um, but there are several different ways in which we can we can risk stratify women who are considering pregnancy or who are recently pregnant to think about how likely are they to have pregnancy related complications. Um The three main strategies we use are either um there are two risk calculation scores, The car bread to score which was developed at a Toronto by Candace Silversides in her group. Um There's one called this a terrorist score which is really um primarily indicated for patients with underlying congenital heart disease which was developed out of europe. And then there's the World Health Organization classification score which isn't really a risk score per se but it kind of classifies women based on their underlying structural or functional heart disease into classes of kind of low intermediate or high risk. And um really The most important group to remember is who falls into that who class four. So class one is no higher risk in the general population. So those are patients with simple repair or mild conditions like a repaired P. D. A. Or mild pulmonary valve stenosis. Those women really don't have a higher risk of complications with pregnancy than the general population, Who class two is a slightly higher risk than the general population that includes women like an un operated asd bicuspid valve without significant stenosis, um repair technology. Follow those women are a little bit increased risk of complications but you would expect them to do well. Women who fall into, who class three are at substantially increased risk of pregnancy related complications but we don't expect them to be life threatening and we don't expect them to die, but they should receive coordinated expert care by cardiologists and maternal fetal medicine specialists who have expertise in taking care of women with complex cardiovascular disease during pregnancy. Now that includes women with complex congenital heart disease. So systemic right ventricles, single ventricles, mechanical heart valves or top A these. And so just to back up a little bit, mechanical heart valves are not contraindicated in pregnancy. Single ventricles are not contraindicated in pregnancy. Um, but it does require really expert care and really meticulous care and buy in from both the patient and the supervising physicians. But those women who fall into who Class four carry substantial risk of death or severe morbidity um which we consider that basically to be a risk of death of more than 10%. And for these women, we recommend that they do not become pregnant or if they do become pregnant, we should consider we should recommend that they consider a termination of pregnancy. Now, this is a hard conversation to have and something that I didn't realize I was signing up for when I decided I wanted to be a cardiologist, but I think that it's something that is really important for us to be able to talk to our patients about um and really prioritizing the care of our patients. So what are these conditions and why might these women be at particularly high risk of death with pregnancy. Well, the first one that is really important to know about is pulmonary hypertension if the pulmonary arterial hypertension of any cause. And the reason that this can be such a life threatening condition is because we know that as women go throughout the course of pregnancy, the pulmonary arterial pressures are going to substantially increase. Women with substantial pulmonary vascular vascular apathy are going to have a high PVR and they're not going to be able to have that pulmonary arterial vaso dilation, which is a normal response during pregnancy in response to relaxing and progesterone levels. So as there are going to increase their cardiac output by 50% but not reduce their pulmonary vascular resistance. The only potential outcome of that is for the pulmonary artery pressures to increase. So, whatever their pulmonary artery pressure was at the beginning of pregnancy is not going to be the same as what it is, third trimester of pregnancy. And so as you can see here on these graphs of both echocardiography and invasive human dynamic measurement. The pressures are going to rise substantially, which leads to right sided heart failure, cardiovascular collapse. And um, particularly these women aren't being taken care of by cardiovascular anesthesiologist and uh pulmonary hypertension specialists and cardiologists who have expertise in caring for them, this can lead to cardiovascular collapse um, later on in pregnancy at the time of delivery and postpartum, which leads to most often early post part of deaths now um, severe LV dysfunction or previous perry pardon cardiomyopathy with residual LV dysfunction are also considered contraindications to pregnancy. And the reason for that is that we know that women who have had prior perry pardon cardiomyopathy. But recovery of their LV function tend to do pretty well with pregnancy. Now we know what we consider recovery is an L. V. E. F. Greater than 50%. Now I personally would not consider an L. B. E. F. 51% normal, but that's sort of what's been considered normal in the studies. And there have been um four or five different studies that are pretty consistently shown that if women have a recovered E. F. Um although they do carry some substantial risk of having a reduction in their E. F. They're here in the red um with subsequent pregnancy so about 20% of them will have decline in their E. F. About 20% of them will develop heart failure symptoms and you cannot guarantee that they're going to have recovery of their E. F. With G. D. M. T. Postpartum, their immortality has not been shown to be significantly higher than the general population. On the other hand, women with persistent LV dysfunction going into pregnancy have been shown to have about a 50% chance of developing heart failure symptoms. About a third of them will have ongoing LV dysfunction after delivery. And there's about a 20-25% risk of mortality with the subsequent pregnancy. And so for that reason we don't recommend subsequent pregnancy and women who have residual LV dysfunction. And then finally, um women with significant left sided heart obstruction are not recommended to pursue pregnancy. So those are women with severe mitral or aortic stenosis. Um and the reason for that is similar to what we see in pulmonary arterial hypertension. The cardiac output is going to increase by about 50%. But obviously you have a fixed opening in your mitral or aortic valve. And so what we can expect with that is about 50% increase in the gradients across those valves as we go through pregnancy. So of course the actual valve area is not changing. But the pressure gradient across that valve is going to go up, which can precipitate left sided heart failure and pulmonary oedema. Um Oftentimes we, you know with expert care, we are able to get these patients through pregnancy and delivery and postpartum, but they are at substantial risk for heart failure and pretty significant complications. And then finally, I don't have a slide on this. But women with a significant aortic dilatation are also at substantial risk of aortic dissection. And so those women we also typically don't recommend pregnancy for now. The other important thing to recognize though is that even women going into pregnancy without a known cardiovascular condition are remain at risk for heavy pregnancy related cardiovascular complications because really pregnancy itself is a cardiovascular risk factor. We know that pregnancy is a program about IQ state their increased levels of estrogen progesterone and relaxing throughout pregnancy and that increases women's risk of aortic and coronary dissection, plaque rupture if women have underlying atherosclerosis, stroke, anabolic phenomena. And these um Changes do not return to normal until about 12 weeks postpartum. So once again, these risks do not resolve once the baby is delivered but really continue to persist until about three months after delivery. Um, we know that, you know, for example, women who have been perfectly healthy going into pregnancy remain at risk for conditions such as spontaneous coronary artery dissection, which of course is a rare cause of coronary uh cardiac ischemia, but it is actually the leading cause of myocardial infarction in premenopausal and pregnant women and counts for about half of all myocardial infarction is occurring in pregnancy. Another really important contributor to cardiovascular morbidity and mortality and pregnancy is that we, as a community of medical community oftentimes fail to recognize the disease when it occurs. You know, these are oftentimes otherwise pretty healthy young women presenting to the hospital with cardiovascular symptoms. And number one, we oftentimes don't recognize that women are pregnant or particularly recently pregnant and even if we do, we oftentimes don't recognize that that changes their risk for having a cardiovascular event. There are a myriad of studies that show that we as a community not just cardiologist but also obstetricians, emergency room physicians. Primary care physicians tend to underestimate the risk of cardiovascular complications in these women and miss these diagnoses. There was a really nice study done in Alberta recently that showed that in women coming to the emergency room with postpartum preeclampsia, which is really a life threatening disorder in these women, only about 40% of those women um had their disease actually diagnosed and were appropriately treated for this. Um we also have several studies that show us that women with period partum cardiomyopathy often have their diagnosed unrecognized. Um they're oftentimes diagnosed with pulmonary disorders such as asthma or pneumonia. And we know that a delay in diagnosis of more than one week in peri partum cardiomyopathy is associated with substantial increased risk of cardiovascular complications, including the need for death and transplantation. So even though we all know that pregnant women are at risk of period part on cardiomyopathy and pre eclampsia. Sometimes it's still hard to put all those pieces together and to recognize the conditions when they arise just because they're not conditions that we see on a regular basis. Yeah, now the good news is that maternal mortality is preventable. Um, we know that about based on our state maternal mortality review committees, that about two thirds of all maternal deaths, including cardiovascular conditions right here in the middle are deemed to be likely preventable. And when we look at the main uh contributing factors to those deaths that um that could have potentially been changed to prevent those deaths. We see that about 40% of those deaths were the primary contributing factor were patient-related factors, including failure of the patient to recognize symptoms and chronic conditions primarily obesity. About a third of them were related to provider related uh, factors including failure of the provider to recognize the disease, provision of ineffective treatment and failure to refer to the appropriate specialists. And then about 20% of them were related to systems of care problems such as lack of communication and barriers of coordination of care. Now before, um, it appears that I'm patient blaming. I think it's important to recognize that really the majority of these patient related factors are really dependent on provider and systems of care related factors. So providing better patient education would likely improve the ability of the patient to recognize their symptoms and having better systems of care and community support systems would likely improve some of these chronic conditions such as obesity. So, um I think it really suggests that we are in significant need of um improved community support and education of both patient and provider as well as improved access to care. We know that problem that patients suffer pregnant women suffer from inconsistent access to care, primarily related to inconsistent access to insurance, and this seems to be a key contributor to adverse maternal outcomes. This is just a small slice of some of the states and in the US pennsylvania, I apologize, is not on this state. Um, but unfortunately, I'm embarrassed to say that Missouri is and we are not showing well here. Um So in the in the orange here is the the percent of the national, the federal poverty line of income that a patient needs to make when they are not pregnant. In order to qualify for Medicaid insurance, This is the 138% of the federal poverty line. And in the blue here is what the state's eligibility level is during pregnancy. So all states are required to have expanded coverage of pregnant women up to at least 138% of the federal poverty level. Um For all pregnant women, most states have gone beyond that level, however, for women who have not yet conceived or for new mothers um In non expanded states, women uh women may not be eligible unless they make very low levels of income. So as you can see here in texas, Women have to make only 17% of the federal poverty level here in Missouri, only 21% of the federal poverty level. In order to actually qualify for Medicaid insurance. Um once they become pregnant, they can qualify for what we call pregnancy insurance, but then this is only valid for 60 days after delivery. And then they have to re qualify based on their income postpartum and if they don't make sort of in Missouri less than 21% of the federal poverty level, then they become uninsured. Again, we know that lack of insurance um in between pregnancies substantially contributes to uh lack of inter pregnancy care preconception counseling um and and lost to follow up after delivery. As you can see here are following the Medicaid expansion related to the Affordable Care Act. Um We did have a substantial improvement in uh insurance among pre pregnant pre pregnancy women um in those expansion states. So and and also it becomes very apparent that Medicaid really finances the a pretty substantial number of pregnancies in the U. S. So as you can see here for preconception coverage here among Medicaid, non expansion states. Um Medicaid expansion covers about 35% of all women, whereas it covers over half of women in non expansion states. Now, still though About 34% of women in non expanded states. And almost a quarter of women in expanded states continue to have no health care insurance prior to conception. So there continues to be a pretty significant insurance churn between pre pregnancy pregnancy and post pregnancy. What has been apparent though is expansion of Medicaid has substantially reduced maternal mortality. As you can see in the dark line here, those states who did expand mortality had a significant slowing of their rate of maternal mortality in comparison to those that did not expand Medicaid. So it really does appear that improving pre pregnancy postpartum and her pregnancy care seems to be pretty substantially associated with improvement in maternal outcomes. I'd also just I don't know why that didn't show up. I'd also just like to uh for a moment uh mentioned the lack of physical access to care, which can be a major contributor to adverse maternal outcomes as well. And particularly as this relates to contraception and abortion care. Um This is really true for all low income women, but particularly for women living in rural America. Um We know that those women have a pretty difficult time accessing um really effective forms of contraception. Um And this really contributes to a high rate of teenage birth and unplanned pregnancies. As you can see on the left here, this is a study done in rural Minnesota. And you can see that about 10% of ninth grade females and 55% of 12th grade females were sexually active, but only about a third of ninth grade females. And two thirds of 12th grade females were using any form of contraception. Um As you get into more and more rural areas of the country, the percentage of teenage births significantly goes up. And as you can see here in the more pink and yellow areas, there are what we call contraception. Desert areas of the country that are really lacking access to adequate methods of contraception. And um what what these areas mean. Our counties of the U. S. Where there is no uh medical center that provides the full range of contraception and by that I don't mean abortion care. I mean just offering things like long acting reversible contraception, emergency contraception. So um really just standard contraceptive care. Um This is a study that um that we actually did back when I was a fellow and um we know that about half of all pregnancies in the U. S. Or unplanned and that actually does not, that's no different for cardiovascular patients. Um importantly, we also know that the majority of our patients do not ever recall talking about pregnancy or contraception with their cardiologist. Only about half of them recall ever discussing it. Um We also know that only about a quarter of women who are taking care of pathogenic medications have any documentation of contraception anywhere in their chart. Um In a study of our adult congenital population who were of childbearing age, um looking at their rates of other the other rates of having had an unplanned pregnancy, you can see that about a third of all our patients have had at least one unplanned pregnancy. And of the women who had absolute contra indications to pregnancy. A full half of them had had at least one unplanned pregnancy. When we asked them about what kind of method of contraception they were using at the time of the survey. Um a full third of them were using no method of contraception. And actually only about 10% of them were using a highly effective method of contraception. So you know this is really consistent with with those findings that, you know, we're not talking to our patients about contraception or pregnancy. They're not on highly effective methods of contraception and consistent with the rest of the US population. Um They're having a lot of unplanned pregnancies. So we've kind of talked about the problem. So what can we do to start to improve this? Well, there's a lot that needs to be done. Um but I think that, you know, we need all hands on deck and we can kind of start to break it down and piece by piece. Start to improve outcomes for these women. So number one, we need to improve education for both our patients and the cardiology community and honestly not just the cardiology community, but also the obstetrics community, the primary care community and the emergency medicine community, really all of the health care team that's going to be taking care of these patients needs to be engaged in collaborating together to figure out how we can better take care of these patients. About two years ago we formed a cardio obstetrics workgroup and the American College of Cardiology um which is house under the the Cardiovascular Disease in Women Committee which I chair and really the goals of this work group. It's a small group of people, multidisciplinary group and the goals are to kind of determine the state the current state of maternal cardiovascular care. Um develop some cross specialty training courses, identify the major short term needs of the field, develop educational goals for cardiologist at large. So to figure out how do we need to incorporate this into co cats training, What sort of education do all cardiologists need to have so that we can sort of improve the baseline knowledge of all cardiologists who may encounter pregnant or potentially pregnant women. And also to propose legislative priorities to begin to advocate for changes that are going to improve outcomes for women. Um and then uh secondly it's going to be very important for us as a cardiology to community and obstetric community, begin to expand the availability of experienced multidisciplinary cardio obstetrics practices. Um We really need to increase the number of expert centers across the country so that we are able to send these really high risk complex patients two centers where they can receive coordinated multidisciplinary care um that can be performed by providers who really have a lot of training and expertise in in high volume experience in taking care of these women. Um We do improve the accessibility of referral centers of these patients in need. So what I really um kind of envision this is a sort of a spoke and wheel model similar to what we have for stroke care or stem e care. I don't think that it is reasonable or feasible to have a, you know highly um expert cardio obstetrics center in every hospital in the country. I don't think there's the volume for that or the need for that, but we do need to have these at every major academic center and we probably need to have smaller centres at smaller outreach hospitals so that rural centers can place referrals to local hospitals. And those local hospitals can then refer to the high volume centers so that we can sort of develop a referral network to make sure that the patients who need to be seen in. Um really the expert centers can get the care that they need within those um expert centres. It's important that we really develop a multidisciplinary team. Um You know, the key model to this is to kind of innovate the way that we take care of patients similar to what we've done and taking care of valve patients, or similar to what we've done in cardio oncology where we sort of get out of this idea of providing siloed care but really move into a team based model where we can all provide the expertise that we have in order to determine the best plan for the patient. That's most certainly going to involve experts in cardio obstetrics as well as maternal fetal medicine and obstetrics and gynecology, but that's also going to involve other experts within cardiovascular medicine. So within our team here at Washington University um you know, I lead the team but I have key members that I call on in electrophysiology and interventional cardiology an interventional cardiology in cardiac surgery who you know consistently take care of these patients and have become familiar with the physiology of pregnancy. Have been comfortable in performing procedures and pregnancy so that um we really have a a sort of consistent message and um really a consistent team working to take care of the patients. Um anesthesia is really a critical component of taking care of these patients. Really thinking thoughtfully about how to provide anesthetic care and monitoring at the time of delivery and postpartum is really essential for these highest risk patients. Um I think both to avoid um over monitoring and um over intervention as well as to avoid um you know under treating patients as well. And then of course our colleagues in nursing and pharmacy and social work and honestly our mental health providers are all really critical components to providing care to these patients now. Not only do we provide care during pregnancy and delivery and the hospitalization, but really this care begins before women even become pregnant. Um we recommend that patients who are of childbearing age really that begins at age 15 be counseled on their risk of of pregnancy and their need for contraception early on. Um It's important to start developing a reproductive care plan with these patients early on so they can start thinking about what their reproductive goals are so that they can understand what their personal risk is. So they understand the safety of their medications because I've run into both situations of a woman not calling us until she's seven months pregnant and continuing on warfarin the whole time as well as women becoming pregnant with a fresh stent and stopping her Plavix because she's afraid it's not safe. So really educating patients on which medicines are safe, which ones aren't? What are we going to do to plan or prevent pregnancy is really important for getting really optimal outcomes for both mom and baby. This also includes talking to women about contraception and importantly um I think it's really important that we talk to women about highly effective contraception. We know that highly effective contraception including the I. U. D. And the next plan on which is um it's the only brand which is why I use the name. It's a little plastic rod that goes under the skin in the arm. Um Those are as effective as getting a tubal ligation but they're completely reversible. Those methods of contraception reduce the risk of unplanned pregnancy and they reduce the need for abortion. Importantly they are also completely safe for all of our cardiovascular patients even if they have valvular heart disease history of endocarditis if they have a history of um of pulmonary hypertension. Um So they fall down here in this green group um in terms of being safe for our patients and and also highly effective. It's really primarily the combined hormonal methods. So the pill the patch in the ring that we need to be concerned about because those can increase the risk of thrombosis embolism. Now, as I mentioned before, postpartum time is really a time when we need to be on high alert. We are not out of the weeds in the postpartum period, but in fact that is when we are in the weeds, we know that postpartum the systemic vascular resistance begins to rise, cardiac output begins to fall and that's a time when um heart failure in particular. Um Also strokes can really become uh can really show themselves. Um It's not surprising then that this is the most common time when perry pardon, cardiomyopathy presents. And this is really some nice work performed here at Penn, showing that it's very common for the blood pressure to begin to rise in the postpartum period and actually peak up 3-8 days after delivery. Um so really close postpartum blood pressure monitoring after delivery can be really critical in order to prevent some of these complications such as stroke. We also know that about two thirds of coronary dissections occur. Postpartum and about a quarter of aortic dissections occur postpartum. So this is a time when blood pressure and heart rate control monitoring for heart failure is really essential. The postpartum time is also really important time for screening for cardiovascular complications and providing that inter pregnancy care when women have had complications of pregnancy or at risk of pregnancy related complications. We really need to take that time when they're engaged with the medical community to screen for the long term cardiovascular risk factors counsel them on their long term risk. Get them engaged in weight loss, nutrition counseling, treatment of their Disl epidemiology or diabetes treatment of their hypertension and by optimizing their cardiovascular risk factors theoretically that should reduce the risk during a subsequent pregnancy and overall reduce their risk of long term cardiovascular disease. In response to this, um we have recently started a postpartum multidisciplinary hypertension clinic here at Washington University. Um We have a pretty high rate of preeclampsia here, a little over 10%. So we now have a combined postpartum clinic which is provides intensive care for 12 weeks after delivery, where we provide routine postpartum care. In addition to expert blood pressure management, cardiovascular screening and cardio metabolic screening. We provide contraception counseling counseling on diet and exercise. We refer to nutritionists and then we refer these patients to long term uh follow up either with a primary care physician or cardiologist depending on their long term risk. I am running out of time as I suspected I might um We do need to improve access and delivery of care during pregnancy and postpartum. We do unfortunately know that those women who are at highest risk of postpartum complications are the least likely to follow up and the most deprived. Um There are many reasons why women may not follow up with this. Many of those are social related reasons. Um, and many of those are financial. And so I think this tells us that we need to improve the patient centeredness of our care. We need to become more innovative, innovative and how we deliver our care and we didn't need to improve both physical and financial access to care. Um, as I mentioned before, there's very inconsistent access to Medicaid, which finances the majority of these women. Um, as you can see here on the left and the green are Medicaid expanded states and the red or Medicaid non expanded states and on the yellow are pending. Um although I won't go into Missouri politics, but we are in a sort of weird hang up right now. Um, what has been proposed is the option to extend Medicaid and actually included in the american rescue plan earlier this year was a provision allowing states the option to extend Medicaid for up to one year postpartum. This provision would allow states to opt in to receive the rhetoric, the regular federal matching rate for an additional 10 months if they provide that coverage, it does include a sunset clause that would limit the loss of five years, but Congress could elect to make it permanent in the future. And um, as Medicaid expansion has been shown to convincingly reduce maternal morbidity. Um, it is believed that extension of Medicaid to one year is likely to reduce the late desk, particularly related to conditions such as cardiomyopathy, pulmonary embolism and hypertension related desk as well to improve the uptake of contraception and improve screening and treatment of cardiovascular risk factors and conditions. So improving inter pregnancy care and likely improving outcomes and subsequent pregnancies, I think um in order to reduce disparities, this is going to require a lot of health policy change. And so we should all be uh involved in advocacy to enact some of these health policy change. I think diversifying our team of both physicians as well as our our nurses and other team members is going to be important for um just sort of diversifying the way we think about patient care and deliver care and connecting with patients. Um, we could do a whole talk on the value of this, but as we're running out of time we won't. And um, and then finally, um really including women in clinical trials, is going to be in synched essential to improving care for these women. As you're very well aware women in general are under enrolled in cardiovascular trials and pregnant and lactating women are almost never included in cardiovascular trials. Um, pregnant women have sort of traditionally been considered a vulnerable population, but in fact they're not truly vulnerable. They're really just a scientifically complex population of patients and by excluding them from clinical trials while we're protecting a small number of women from the potential risk of that trial were actually posing harm to a very large number of women, women and fetuses by then sort of leaving as hampered with a lack of data. So, um really my recommendation is to think very hard when you're building your team's about including a diverse team, leadership, team members and um really prioritizing enrolling women on your team and um trying to think about how you can include pregnant and lactating women in your studies. Of course it's important to first identify safety with early animal studies and once that has been proven, it's really important to offer women and their babies the opportunity to participate in clinical research. And finally, I don't have time to talk much about my research but we really do need to continue to perform research specifically on women with cardiovascular disease. Most of my research is really focused on how preeclampsia affects short and long term outcomes in women. We know that it's clearly associated with increased short and long term risk for cardiovascular complications. Um we have identified through some recent work that we've done here that really heart failure can present in women in the early postpartum period in really a variety of ways with either preserved ejection fraction, mid range ejection fraction or sort of the traditional period pardon cardiomyopathy. And really there is an overrepresentation of preeclampsia and all three groups anywhere between 45 and 80% of these groups of women in our study uh were shown to have associated pre eclampsia. We did also interestingly recently identify that aspirin appeared Women who develop preeclampsia who were taking aspirin appeared to be substantially protected from having persistent postpartum hypertension. And that aspirin use also was significantly associated with lower anti angiogenic biomarker levels, which suggests sort of a biological plausibility for that. Um and then finally, um you know, evidence continues to build that preeclampsia is associated with long term cardiovascular risk in women in this study here, we identified that preeclampsia latency basically the longer that women were exposed to pre eclampsia during their pregnancy was associated with the higher risk of long term cardiovascular hospitalizations, suggesting that there may be a dose dose response effect there. Thank you so much for your attention today. I'm sorry. We're a little short on time for questions, but I'm happy to take whatever questions you may have. This is why I do this job. My patients are amazing. They're babies are adorable and um you know, we're taking care of sick patients and making them well and the losses are hard. But the winds are huge. Mm I'm happy to take any questions. Alright, Katherine. That was a fantastic talk. I'm gonna um try to change the view here for a moment. Um you know, uh fantastic talk. Thank you for coming to speak to us virtually. And thank you for all the work that you've been doing and I congratulate you on this. This is a topic that uh we realize it is quite complex and providing optimal women's health has to do with a variety of issues from socioeconomic to access to care to frankly medical knowledge. And I think you're you're really pushing and raising awareness is going to have a huge impact on on women in the future. So thank you and congratulations on that. I'm going to start with a question and I'm going to kind of run through some of the ones that are coming through the chat. I know this may be a loaded question and hard to answer in a short time. But can you talk a little bit about preeclampsia in terms of even though it's associated with pregnancy, what's the long term path of physiology that we may see affects years down the road? And and the second thing being how do you incorporate clamp CIA into a women's long term cardiovascular risk profile? In addition to traditional risk factors. So, those are good questions. Um, I think no one truly knows the answer to that. I can tell you what I think about it though. Um, I think for a long time, you know, many people assumed that the pre eclampsia associated risk was simply related to other underlying cardiovascular risk factors. Um, we do know that women with an underlying family history of cardiovascular disease, underlying obesity, hyper lymphedema, mia, hypertension, diabetes. Those women are all at higher risk of developing preeclampsia. So certainly those are already risk factors for developing future cardiovascular disease. So it certainly may be true that preeclampsia is sort of a failed stress test. And just sort of identifies women at higher risk on the flip side. I do not think that that is the full story. There is really a growing body of data to suggest that preeclampsia actually affects the entity liam affects the maya cardi. Um And um I do think we have a lot to learn about it but I do think that it initiates changes in the blood vessels in the maya cardi. Um That um you know may either be persistent or may um sort of trigger changes that cause women to then respond differently in the future when faced with another insult. Um So we know that it causes really substantial endothelial dysfunction. It causes micro vascular ischemia. It causes L. V. H. Which does not appear to be simply related to the hypertension. Um And so I think that you know we know LV. Remodeling and L. V. H. And diastolic dysfunction really are the earliest markers of future diastolic heart failure. Um So I think that it's it's through that endothelial dysfunction, my micro vascular disease that future cardiovascular diseases sort of triggered um how to best manage these women. We don't know because number one nobody has been including pregnancy data in any of their cardiovascular studies. So all of you who are not sitting pregnant women. I would encourage you to start including obstetric histories in your my studies in your heart failure studies because that would be remarkably helpful for us and sort of determining, you know, long term care of these patients. We do know that it is a non traditional risk factor for future cardiovascular disease though. So when I have a woman who's a S. C. B. D. Risk falls in the sort of 5% or above range, I will offer those women statin therapy. Um I do it is recommended that all women with a history of preeclampsia be screened annually for blood pressure. Um they should all be screened within 12 weeks of delivery for diabetes and Disl epidemiology. A and then obviously treated if they fall into traditional guidelines and then um I counsel them aggressively on diet, exercise and weight loss. I think the other really important thing is for patients to know their arrest that they can advocate for themselves and not be sent home from the er if they develop those complications. But what I would love to see in the next 5 to 10 years is some disease specific data regarding um you know, are there specific interventions, pharmacologic or lifestyle interventions that can really modify that risk. All right, great. I'm going to try to run through a couple of questions here with you over the last couple of minutes. This one coming in. Um Thank you so much for bringing up the conversation of childbirth, mortality among race and socioeconomic groups to the cardiology table. Should the recommendation for women 35 and older looking to start a family B to obtain a cardiology consult. Um you know, I don't know that all women have advanced maternal age need to see a cardiologist ahead of time. But I do think those are women, we need to pay closer attention to. Um we know those women are going to be at higher risk for preeclampsia. And you know, I think a lot of those deaths are likely related to hypertension and cardiomyopathy. There's nothing, you know, they would fall into the category of qualifying for baby aspirin for preeclampsia prevention, which most obese would recognize and start them on a baby aspirin. We're not very good at predicting who's going to get get very part of cardiomyopathy. So, you know, even my patients who had it before, I'm not very good at figuring out who's going to get it again. I monitor them closely. But you know, some patients do find some don't and it's hard to know who is going to do. What I think the important thing is for them to be educated on what are sort of the red flags, what our cardiovascular symptoms for them to be on a baby aspirin. And I think we probably really need to really focus our our focus postpartum care on those high risk groups of patients. So black women uh women who are advanced maternal age, women with hypertension and obese women. And then also I think we really need to focus on those women of highest socioeconomic depravity. So women in um in the most urban, in the most rural areas who we know have trouble with access to care and limited resources in terms of spontaneous coronary artery dissection. Um I'm not sure if we're just more aware of it or if we're actually seeing more of it, but as an interventional ist, it seems like now this is routinely seeing this. Um do you have an idea? Is it just that we're more aware of it or is there an actual higher prevalence of it? And then the follow up question is how do you counsel women if they've had an episode of scad on future pregnancies and their future risk. That's a good question. I suspect we're actually just effectively identifying it better. I mean I see a lot of women who come in with one and then it turns out they've presented to hospitals three times in the past with similar presentations and I get their films and I'm like, oh, you had a scout of the, um, that time and it was your diet that other time and just nobody recognized it. Um so I think, I mean the great news is we're, it's better recognize that we're just doing a better job of identifying and treating women, Jen, of course you gave me a really hard question. I don't know the answer to this. You know, I will, I will tell you, I'm flip flopping on a little bit on in my practice. I don't think there's great data because the studies that are out there have like 10 patients in them. Um I have classically been telling people not to get pregnant again. And I will tell you in my personal experience, the only woman I've had get pregnant again have had another scat event. So I'm a little spooked by that. Um that said, I know a lot of experts say, well the data doesn't really isn't robust enough to say we shouldn't tell them. So I do currently have a woman who is pregnant who had a scat event during her last pregnancy. And you know, basically I just discussed with her the lack of data what the potential risks were. Um, and let her make her own decision. She only has one child and strongly wanted to have a second child. So, um, you know, it's not technically a who class for condition, but it makes me very nervous. Um, so we are aggressively data blocking her. She knows all the signs and symptoms. We're going to probably deliver her a little on the early side and watch her a week postpartum in case she does have event, at least she'll be in the hospital, but I don't know the right answer to that. And I think there's a lot of variation in practice out there. Um, Next question that came through is how would abortion restrictions, like the new law in texas that's getting a lot of attention affect medical care when pregnancy termination is medically needed. It's a big problem. I mean, we've got very strict laws in Missouri as well. We only have one abortion center in all of Missouri, which is fortunately here in ST louis and um and the laws around it are extremely strict, um which makes it very challenging to take care of patients. Um you know, you can't take the care of patients that you need to take care of. I think um there's a real lack of understanding about how this really is essential medical care for women like this. Um you know, I've seen women die related to pregnancy and heart disease, and it is horrifying. Um and you just can't ever predict exactly when someone's going to die. Um we're really good at taking care of these patients and we can take really sick people through pregnancy and they usually do fine, but you just can't. Exactly. No. And I think that's why when you have someone who falls into that who class for category, it is really our ethical obligation to offer them a determination and the vast majority of these women have other Children at home and you know, they really need to consider not only their own health, but also um what decisions do they want to make on behalf of their family and you know, I always offer to that to them. I tell them that this is the medical recommendation based on their risk. And there are a lot of things that go into their decision making. You know, there's a lot of emotional decisions behind it. There's ethical and in religious reasons why patients might choose one way or the other. And no matter what they choose, then we support them. We don't revisit it. If they choose to terminate, we say great, that was the right decision for you. And if they decide not to, then we say great, that was the right decision for you. But um and you know, the other issue is sometimes in places like texas or Missouri patients kind of get bounced around between places because we don't offer Abortals. The patient doesn't have transportation by the time they get to another place. You know, they are sometimes pushing up on on 24 weeks. Gestation and then they no longer have the option. Um and it really can be a life threatening situation for mom. Um and the other thing that you have to consider is then sometimes mom delivers 24 weeks and has a baby that is in the nicu for eight weeks and then doesn't survive. So it's really an emotionally distressing time for mom and you really don't get a good outcome for mom or baby. So I think we as cardiologist need to be engaged in this conversation. This these are our patients that are being affected by this. And you know, it really comes down to just caring for patients next question. So I'll stay away from some of the politics for now. We're a little we're a little heavy today. Um We're doing race and abortion. Exactly, exactly. I mean all such important topics and issues but really goes to show the complexity of some of these things and the politics behind it. Um what are some of the prime turret hygienic medications that cardiologist should be aware of? So that's a really good question. Um So really the medicines you should absolutely avoid in pregnancy are ace inhibitors and A. R. Bs. Um and spironolactone avoid those at all costs. A lot of the other medicines. Um and really anything that includes that, so that includes things like interest. Oh a lot of the other medicines are really maybes um you know, statins have traditionally been considered absolutely contraindicated Category X. That was actually not based on very good data and hasn't actually really been shown to cause fetal harm. And actually just recently the FDA requested removal of that warning. Um Now I wouldn't put every patient on a statin and pregnancy because really statins are more for long term benefit, but on the flip side, you know, we've had patients who have had a stent in a stent in the left main and aggressive coronary disease and familial hyper lipid e. Mia that patient should be on a statin in pregnancy because her risk of an M. I. Is much higher than the potential risk of that statin to the baby. So um you know we know that the water soluble statins like um like reserve a statin and pravastatin seemed to be the safest option for both pregnancy and breastfeeding. So that's typically what I go with. Um Other medicines like warfarin have traditionally been considered contra indicated. Um That said you know the revised valve guidelines actually recommend for mechanical heart valves. Um that would be continued in the 2nd 3rd trimester. And if the mom is on a low dose less than five mg a day that we actually can continue in the first trimester. The other big. No no we usually think about is amiodarone. Obviously I typically try to avoid amiodarone during pregnancy. But you know we take care of patients with ventricular arrhythmias in pregnancy. To and as one of my M. F. M. Colleagues once said amiodarone is category D. But ventricular fibrillation is category X. So um it's better to have mom on amiodarone and know that there's a risk of fetal thyroid toxicity than to have mom arrest. So I think you always have to weigh the risks and the benefits don't ever fail to treat mom because you're concerned about the risk to baby. We always know that prioritising mom's health is the best way to get a healthy baby because if mom is dying or arresting or having an M. I. You're going to have a really poor fetal outcome. Two. All right. If I can squeeze in one last question here this morning. So what is your experience in pregnant patients with severe try customer regurgitation or polyphonic valvular disease? The two forgotten valves? Well, I am actually in general cardiologist also. So I don't forget about those valves. I actually like those valves a lot. Um So those um valves tend to be very well tolerated in pregnancy. Um In general valve regurgitation of any valve is typically well tolerated pregnancy. It's more your cinematic valves that you need to be more worried about and that's really primarily your left sided valve stenosis. Just because as we talked about earlier as as pressure gradients go up with increasing heart rate and um cardiac output. You're going to have high left sided filling pressures and pulmonary oedema. Even severe pulmonary stenosis is typically very well tolerated in pregnancy. We actually just had a woman with a pulmonary valve gradient of like 90 deliver and do fine. Um I gotta admit I was a little anxious about it. But you know, we had her kind of prepped in case she ended up not doing well and needed a melody valve but she did fine. Um so as long as they're right ventricular function is okay. Um They typically do well. Same with bicuspid regurgitation. We see it. We have a I don't know what your situation is there. But we see a lot of I. V. Drug use here. So we end up getting a lot of patients with trick husband endocarditis and we'll typically just hospitalize them with with I. V. Antibiotics and manage them as long as we can. And we'll usually get them 34-36 weeks and they'll have just wide open tr and as long as the right ventricle is hanging in there. Well just use Lasix two diaries them and keep the volume off and they'll do pretty well. So those conditions need pretty active management typically with some diuretic. Um but they actually typically do fine. I do for the for the synoptic valve lesions. I will sometimes consider an assistant second stage just because that's going to be a pre load dependent lesion. So if they're really bearing down and doing a like strong val salva then they you know that may sort of reduce their their cardiac output. Um But I always say that women can push to some degree because we have to remember they've all been having bowel movements to their whole pregnancy. So it's not that they can't val salva at all. It's just that they may need some you know we let them really labor down and then we'll let them push as we pull a little bit. Um But I never require any right sided valuation to go to a caesarean delivery unless they're just in florida heart failure and we can't optimize them. All right. Fantastic Catherine. Once again, thank you very much for joining us, virtually in the talk. That that was great. You, uh, you taught me a tremendous amount. And uh, once again, thank you. Thank you all for having me. And I hope to see you all in person sometime again. All right. Take care. Have a great day. Thanks you, too.