Cardiologists Jennifer Lewey, MD, MPH, and Monika Sanghavi, MD, led a case-based review of various risks, presentations and recommendations to help provide patients the best cardiac care during the “4th trimester” after pregnancy. The Penn specialists discussed the following topics:
Risk factors, presentation and causes of acute cardiac symptoms during the postpartum period
Current management and treatment of postpartum hypertension
Follow up and preventive care recommendations for patients at risk for cardiovascular disease after pregnancy
Good afternoon everyone. Welcome to our case based presentation of cardiac symptoms and risk in the postpartum period. What not to miss. We'll just give them, we know there's a lot of people registered for this CMI. So we'll just give people a minute or two to to join and we'll get started in just a couple of minutes. Okay? It's 12.02. So I'll go ahead and get started. Welcome again. Everyone to our case based presentation, cardiac symptoms and risk in the postpartum period. What not to miss. This is A. C. M. E. That's sponsored by the women's health cardiovascular and primary care service lines. And we're really excited to be hosting this CMI today. So thank you for joining just a couple of housekeeping items before we get started. This is the CMI code. Um You can submit it via one of the following options. Um You can text it um use this website um and or use the app that's here. Um and you have to create a profile in order to receive credit which I think most people are familiar with. Um And the institution code is you pen. Um and also as a reminder probably about 30 minutes ago everyone that's registered to participate in the CMI received a survey. So if you could um it just takes probably a minute or two. If you could fill that out we would love to do a pre assessment prior to the CMI and we thank you in advance. Um And then this is the only other thing I'll mention is we got some great questions in advance. Um If people have questions during the during the presentations please put them in the Q. And A. Um And I'll be monitoring the Q. And A. And we'll get to as many questions as we can at the end of the presentations. And if there are questions that we don't get to um we will try to and follow up to the cmi we'll send out a recording but also we'll try to answer some questions that way. And also will send some summary of some of the highlights of um pearls from this from this presentation afterwards as follow up with the recording. So with that I want to thank you all again for joining us. Um And what I wanted to start out with for just a couple of minutes is some background on on this topic and how we came to picking this um this topic for today's CMi um as people know. Um and I'm sure I've seen in the news over many years that we're in a kind of state of maternal health crisis. Um maternal mortality and morbidity rates have been rising. Um And these are some sort of snapshots from some of the articles that have been in the news over the last 3-5 years or so. Um and there's been significant disparities that we've noted and and continue to see in maternal mortality and morbidity and what this raises is sort of the issue of when I think people hear about maternal mortality who are not O. B. G. Y. N. It's not really clear what the um what the impact is of non O. B. G. Y. N. Um providers are in in the area of maternal mortality sort of. Does it really it impacts us all from a societal perspective but from a provider or a nursing perspective in fields that are not O. B. G. Y. N. Um I don't know that it's always clear kind of some of the epidemiology around maternal morbidity and mortality and how this isn't just a, you know, a pregnancy problem or a problem in pregnancy. It actually very much spans the postpartum time period and the time period when many of us O. B. G. Y. N. Is included. But primary care doctors, emergency medicine, doctors, um nurses in all of these different spaces um have an opportunity to impact the maternal mortality rates and the disparities that we're seeing. And so our hope today is to sort of share the ways in which we all kind of can work together to really reduce maternal mortality rates and disparities in this country. And so the first question is always about the timing. So I think when people hear maternal mortality, they think in pregnancy or at the time of delivery and while a lot of more, some mortality happens in that time frame. And this is a paper that is a summary from 14 maternal mortality review committees in 14 different states that the CDC published. And it just shows you that actually like 60% of mortality actually happens postpartum. Um and about 50% of it is happening after patients are discharged from the hospital. Um and even, you know, further out as you can see through that one year postpartum. And so that's sometimes surprising to people to know that mortality is really a significant proportion still happen is happening actually beyond the traditional time period that we think of in terms of during pregnancy or immediately kind of after delivery. The second thing, I think that's surprising and how we came to this topic is, you know, what are the causes of pregnancy related death and that's particular deaths that are due to pregnancy or were exacerbated by pregnancy. And you can see in red in this bar graph that they're all those are all the cardiac related causes of deaths and there's a number of them. Um and this is also from the CDC pregnancy mortality surveillance system. So you can see that cardiac um, there's a several cardiac related contributions to maternal mortality and hence the sort of choice of really coming together as multiple service lines to really bring this educational session to all of you. And while I know many of us that are on the CMI were from across the system and we're really excited to have everyone joining us from across the health system. Wanted to just highlight some things that have been noticed in philadelphia and how they mirror um what's seen nationally in the data that I just showed you philadelphia um and Penn Medicine, you know, We do 9000 deliveries, which is the majority A high proportion of the deliveries in the city of Philadelphia. Um there's been a city-based mortality review for over a decade. Um and we've noticed that in pregnancy-related deaths in these reviews that 46% of them are related to cardio myopathy or other cardiovascular causes. And those disparities that I noted previously in our in our introduction are very much seen in philadelphia, just like they are seen across the country. Um and those figures at the bottom there show that the causes of death for pregnancy related death. This is from a Philadelphia maternal mortality report that was published in 2020. So, mirroring sort of what you saw in that national bar graph in terms of causes cardiovascular being among the top. Um and the timing also showing you that in philadelphia, it's the same as what we're seeing kind of nationally, which is that a large proportion are happening in the post delivery or postpartum timeframe. So from this report, there was several recommendations and one of which um in philadelphia, but sort of more broadly and this is sort of mirroring kind of recommendations and things that are activity that's happening nationally is really to heighten the awareness of high risk pregnancy and postpartum complications in non obstetric care settings and in philadelphia itself. There's a philadelphia cardiac cards obi task force that's directed by one of the pen maternal fetal medicine um attending one of my colleagues after lisa Levine really looking to sort of implement and evaluate a cardiac risk algorithm for when patients present in these non obstetric settings in particular with cardiac complaints. So more to come on that. But philadelphia itself has a significant lens on this issue and this issue is also being kind of looked at through partnerships with our national professional organizations um like the AJ. And like the A. C. C. And and the American College of O. B. G. Y. N. As well. So this is sort of a timely topic and one that we hope will be very informative to all of you participating. So these are our learning objectives for today that you um received when you registered. So we're excited to kind of get to our two presenters today. And here are two speakers. Um Dr Louis is an assistant professor of medicine and the director and co director of the pregnancy and heart disease program. Her research really focuses on identifying optimal strategies to reduce cardiovascular risks during pregnancy and postpartum and reducing racial disparities in maternal cardiovascular health. Um And then dr Monica Sanga V. Is the director of women's cardiovascular health at pennsylvania hospital. Um And she's a non invasive cardiologist who works at um happened pansy and is the director of women's cardiovascular health there, as we said. And her clinical focuses on women's cardiovascular disease and prevention. And she also serves as the vice chair of the National AJ Women and Cardiology Committee. Um So I want to thank both of them for doing this. See me with us today um and I will turn it over to them. Great, thank you Cindy. I'm just gonna go ahead and share my slides. Okay. Thank you for the thank you for the introduction and thank you to everyone who's joining us today. I know that we have a diverse audience. I'm across the health system and excited to talk about this increase awareness and to hear your questions and hopefully answer them. I have no conflicts of interest to disclose. So the objectives for this talk are to review the leading causes of pregnancy. Associated mortality in the US which Sindhu already alluded to understand the diagnosis and early treatment of peri partum cardiomyopathy. Review the causes and evaluation of chest pain and the postpartum period and hopefully to improve confidence and screening for postpartum cardiac complications. Um as Sindhu pointed out, cardiovascular disease is the leading cause of pregnancy related deaths in the U. S. Which are deaths during pregnancy for the first year postpartum. But when we look at just the postpartum period cardiomyopathy is the leading cause of death and the majority of these cases are due to peri partum cardiomyopathy. Um a few additional facts about maternal mortality that is relevant to all of us is that half of maternal deaths occur after delivery and after hospital discharge. So these patients are presenting to the emergency room to primary care to urgent care. They may or may not be in contact with their OBI providers. 60% of cardiovascular deaths are considered preventable and most individuals who die from cardiovascular disease, postpartum do not have a prior diagnosis of cardiovascular disease. And I think it's also important to point out that although the data on maternal mortality is critically important and compelling, it does not capture the high burden of maternal morbidity as well. In terms of racial disparities, we know that they are present um, and severe and that black women are three times more likely to die than white women from pregnancy related causes. And specifically when we look at different causes of maternal deaths. Um, the greatest disparities for black women exist for deaths due to cardiomyopathy, pre eclampsia and eclampsia and venus from the symbolic disease. So I'm just going to jump in and start with a case. Uh, case one is a 30 year old woman who is presenting with destiny on exertion for one week. Um, she also has dry cough Ortho apnea and some mild like swelling. Asymmetric legs swelling. She has a history notable for hypertension, sleep apnea, not using cpap obesity. Her B. M. I. Is 60 and she has an active tobacco smoker on presentation to the emergency department. She's hypertensive, she's tachycardic. Her 02 sat is 90% on two leaders. She has increased work of breathing at rest. She has wheezing on exam and find faint bi basilar crackles. Her GDP was not well visualized as she did not have obvious murmurs and her extremities were warm and she did have a left greater than right, lower extremity edema. And so what's missing in this history and what's missing is her over history. Um And I bring this up because the CDC um in their campaign to increase awareness of of disease of I should say complications during pregnancy and postpartum highlights that many clinicians do not know that their patients maybe postpartum. Um And the importance of asking um you can imagine that a patient who delivered a few days ago a few weeks ago would bring this up as relevant. But what about someone who delivered one month, three months six months ago, it may not spontaneously come up um in conversation. And so I just emphasized the importance of all of us getting a pregnancy history for a variety of reasons. And so for this woman, she's been pregnant four times and has delivered twice. Her last delivery was six weeks prior. She had a full term deliveries Assyrian section and she did not have pregnancy complications separate from her medical conditions. And she is not currently breastfeeding top of the differential diagnosis for this patient in the emergency room. And I think appropriately was pulmonary embolism and she did have a C. T. A. Of her chest which showed no pe but she did have extensive patchy um and modular capacities concerning for pneumonia. And I think this case is very uh uh salient to me because I think in some settings this is probably the extent of her work up. She would have been treated with antibiotics and potentially discharged from the emergency room but it was not the end of her work up. She had labs drawn and notably her NT PRO BNP level was greater than 4000, which led to a bedside echo and then a formal echo which showed that her LV was severely dilated. Her EF was about 20% and she also had hypothesis of her right ventricle consistent with a diagnosis of peri partum cardiomyopathy. Many of you may be familiar with the criteria for defining a pre partum cardiomyopathy but it includes new onset heart failure with an E. F. Less than 45%. It's diagnosed towards the end of pregnancy or in the months following delivery. Um and it occurs without preexisting heart disease. The reference I put up here are the 2018 European Society of Cardiology Guidelines for the Management of Cardiovascular Diseases during pregnancy. Very helpful resource, very easy to read for all of you in the audience. Major risk factors for peri partum cardiomyopathy include older maternal age. Black race. So it's more common in black women than in white women and the reason for that is not entirely clear twin gestation and pre eclampsia. So interestingly overall the prevalence of pre eclampsia is 3 to 5% in the US, whereas 20/20 percent of women with pre partum cardiomyopathy have preeclampsia. The schematic at the bottom highlights the fact that preeclampsia can lead to subclinical cardiac dysfunction, which Doctor Song B. Will be talking about next. Um These patients have a normal E. F. And R. Increased risk for long term cardiovascular disease. A much much smaller subset of women with preeclampsia will develop peri partum cardiomyopathy. Um The good news is that most women 65 to 70% will fully recover. However, predictors of poor recovery are having a severely decreased E. F. At the time of diagnosis, having a severely dilated LV. Being of black race and having a delayed diagnosis or greater than one month postpartum. You can see here the recovery by race and baseline E. F. And it's important to note that 15% will have serious adverse outcomes including death, need for Salvador heart transplant or severe persistent cardiomyopathy. Um I also wanted to highlight using the data that we have here at penn the timing of diagnosis. So diagnosis most often occurs within a month after delivery but can occur six months or more postpartum again getting at the importance of asking about the oBI history and what we showed in our data which is consistent with other studies is that black women are diagnosed later in the postpartum period. As you can see in this. Um This figure uh non black women are diagnosed, half of them are diagnosed within a week of delivery, whereas black women are diagnosed throughout the post pardon period. An early diagnosis is associated with a twofold higher odds of recovery. Um delayed diagnosis largely occurs when symptoms are not recognized or promptly um evaluated. It is possible that some women do not develop symptoms until much later in the postpartum period, and I certainly have patients who very clearly say they felt well. They were exercising until you know, two months or three months postpartum and then their symptoms started suddenly. But I have seen more patients who have been diagnosed with new onset asthma um in the postpartum period have received several courses of antibiotics without a cardiac evaluation. For example, this past year I met a woman who was 26 years old and her first pregnancy, she developed gestational hypertension, had some worsening shortness of breath and adama. During her third trimester she developed severe preeclampsia was induced at 36 weeks discharged on nifedipine for blood pressure and then postpartum. She initially had some mild dystonia but it progressed so she could um she had difficulty walking upstairs, She was sleeping in a recliner, She saw her postpartum provider several times. She was referred to a pulmonologist and for P. F. T. S. At five months postpartum she had a chest ct for a completely separate reason. Um And that incidentally found cardio medically and pleural effusions. And so after this she was referred to cardiology and her echo showed an E. F. Of 15 to 20%. She felt immediately better with diary sis. But her eF is still low and her odds of recovery are lower given her delayed diagnosis. Dilated LV. And low E. F. The medical treatment for peri partum cardiomyopathy is goal early goal directed medical therapy with this table here showing that even for postpartum breastfeeding women um they can be started on many of the medications that we use for Gold directed medical therapy. And I just wanted to highlight that there may be a role for medication called broom a crypt in which is a dopamine agonist which inhibits prolactin release. Um There's equipoise about whether this is effective or not. And there is a national nationwide R. C. T. And we will be enrolling women at penn probably starting within the next few months. Um who are interested in being in this decade. I do want to highlight that BNP levels can help evaluate for heart failure both during pregnancy and postpartum. This is really important. So BNP levels are higher in pregnancy but still within the normal range they are higher and pre eclampsia and may be associated with subclinical cardiac dysfunction and there may be a spike and BNP in the very early postpartum postpartum period in the first few days after delivery. Um That being said in a study of women with cardiac disease who had cereal BNP levels drawn throughout pregnancy. A normal BNP level had 100% negative predictive value for a cardiac event. Um And I would say that an elevated, I said very elevated here but really any elevated BnP level should raise suspicion for heart failure during pregnancy or postpartum. In some cases those patients you know may have preeclampsia but if they have preeclampsia and shortness of breath, perhaps a cardiac evaluation is warranted. Okay moving on to case two is a 35 year old woman who is two weeks a status post full term vaginal delivery. She has no past medical history, no cardiovascular family history. She's a nonsmoker. Um She's had four pregnancies and four deliveries and no pregnancy complications. She is coming in because she had chest pressure lasting 20 minutes while sitting on the couch associated with some dia freezes and nausea. Um and then it recurred overnight and woke her from sleep and lasted a little bit longer. Um The differential for chest pain after delivery is similar to our differential for chest pain in a non pregnant or postpartum individual with the sort of increased knowledge that the risk for P. E. Acute coronary syndrome and aortic dissection is increased in the early postpartum period. Her E. K. G. Is shown here and as you can see she has deep T. Wave inversions. T wave inversions in the an trilateral leads and poor r. Wave progression um concerning for an trilateral ischemia. On arrival her proponent was negative and it's steadily increased overnight. And in the setting of this she was sent for cardiac catheterization which showed a spontaneous coronary artery dissection involving her entire led. The white arrows here show that there is severe narrowing of the proximal L. A. D. And a diagonal branch. And the red arrows show where there should be the mid to distal led. But there is in fact no flow, spontaneous coronary artery dissection occurs when there is a hematoma that forms within the wall of the coronary artery. Um and it compresses the true lumen and decreases myocardial blood flow. Um And in some cases the intramural hematoma can lead to increased pressure and actually cause an internal tear with the progression of the intramural hematoma and internal tear shown on the right um scan is an important cause of acute coronary syndrome in younger women and is diagnosed on cardiac catheterization. I bring this up because the questions sometimes come up about whether we can diagnose scattered by C. T. A. Of the coronaries. Um And the question the point is that we we may be able to see dissection on a coronary cT A. But we may not be able to see dissection and that's because sometimes the dissection is in the distal vessel or in a smaller vessel and so it just may be difficult to visualize. So cardiac cath is the gold standard. Um A few points about scat in general, since I realized that all of you may see this on a regular basis is that nine out of 10 patients with scat or women, The mean age is 48 years. Traditional cardiovascular risk factors are not usually present and pregnancy is a heightened risk state. So as you can see here, if all pregnant and postpartum women presenting with acute coronary syndrome, Up to 43% of them will be from scat um pregnancy associated M. I. Is luckily uncommon, but it may be underdiagnosed. Um And I do want to make the point that scattered in the pregnant and postpartum period tends to be more severe than scan that does not occur um related to pregnancy. And so these pregnant postpartum women are more likely to present with stem e multi vessel involvement, proximal vessel involvement. Um The majority of cases of scattered car postpartum, especially in the first week or the first few weeks after delivery. Um In general are treatment is scaD is medical management when feasible and that's because a stenting um may maybe high risk, there's a higher risk of pC. I failure. So cabbage may be appropriate for certain high risk cases. The other reason we pursue conservative management is that healing occurs in the majority of cases within weeks to months. And so medical therapy includes aspirin, sometimes Plavix beta blockers, anti intentional medications and then further evaluation includes mental health assessment, referral to cardiac rehab and then screening for other vascular disease. Um also important to point out that postpartum individuals can have M. I. from atherosclerosis or other causes. Um in this case this was a 36 year old woman who had hypertension, high cholesterol and a family history of early coronary disease. She was G one P 13 months postpartum and breastfeeding when she developed exertion all chest pain which was escalating and then started to occur at rest on her labs on presentation. Her troponin was negative notably her LDL was 1 81 and on cardiac cath she had a severe obstruction in her mid L. A. D. Which was treated with a stent. And in this setting this was someone who had previously undiagnosed familial hypercholesterolemia. Underscoring the importance of cardiovascular risk screening in the pre pregnancy pregnancy and postpartum period. Okay so case three is a woman presenting with shortness of breath and chest pain. Postpartum. Um This is a 36 year old woman who is five days status post vaginal delivery. She has a history of asthma on inhalers. She is a G six p. 4 and was actually induced at 34 weeks for severe preeclampsia. Um and discharged on unloaded pie. And she also had a postpartum hemorrhage requiring transfusion. She's presenting with Dystonia, squeezing chest pain, palpitations and lightheadedness. Um And on exam she's tachycardic normal blood pressure. And 02 sat and her labs reveal a normal a negative troponin and an NT pro and BP level that is the upper limit of normal. And her E. K. G. Shown here shows largely sinus tachycardia and non specific T. Wave changes um And so similar to some of our other patients. She also had a C. T. A. Chest to evaluate for PE. And in fact she did have a P. E. Um A few notes about pulmonary embolism in the postpartum period. So the incidents of this is for venus thrombosis bolic disease. So DVT or PE um is listed here but it's important to note that the risk increases throughout pregnancy but the highest risk is actually in the weeks after delivery de timer levels increased through a pregnancy and cannot be reliably used to assess for PE. And the risk factors as listed here is a prior history of thrombosis, history of thrombin ophelia. Older age C section and obesity and symptoms include um symptoms are actually similar to PE that occurs not in pregnancy or postpartum which are Disney apologetic chest pain, cough and hypothesis. And I just wanted to highlight the case of serena Williams who has spoken and written about her experience of having a pe postpartum um Despite having a history of pE um and developing similar symptoms immediately after she gave birth to her daughter. She felt like her concerns were not heard by her medical providers. Um Really underscoring the importance of listening to our patients and realizing how this can contribute to racial disparities in maternal cardiovascular health, um other cardiovascular diseases in the postpartum period. So aortic dissection again rare but an eight fold increased risk compared to nonpregnant individuals. Um Aortic dissection is more common in women who have connective tissue disease such as Marfan syndrome, and to a lesser degree in women with hypertension. Um And the important thing to note is that the almost half of women who have an aortic dissection associated with connective tissue disease do not know that they have connective tissue disease prior to their dissection. So again, the importance of evaluating people prior to pregnancy for medical comorbidities. Um and then other causes of cardiovascular disease in the postpartum period include cardio myopathy. These that are not pre partum cardiomyopathy. So preexisting cardiomyopathy, which may or may not be diagnosed prior to pregnancy. Arrhythmias, and sudden sudden cardiac death valvular heart disease. Congenital heart disease, pulmonary hypertension, as you can imagine for some of these conditions, um exacerbation of symptoms are more likely to occur in the third trimester when women are at peak circulating plasma volume, increased stroke volume, increased heart rate and that higher volume load of pregnancy can often lead to um to new symptoms of heart failure. You know, one of the questions that came up beforehand and often comes up amongst the clinicians who take care of this population is how do we differentiate cardiac symptoms in pregnancy and the postpartum period separate from the normal symptoms of pregnancy? Um And what I would say is it's tough. It can be very difficult. Shortness of breath. Very common in pregnancy, but some of the red flags that I listed here may be able to help so display at rest is unusual. Um I often ask for women who have had have been pregnant before, Does this feel significantly worse than that prior pregnancies For people who are able to easily climb a flight of stairs prior to pregnancy? Do you now need to stop to catch your breath before reaching the top of a flight of stairs and then for postpartum women, um looking at Disney that does not improve or is getting worse after delivery. That would be another red flag associated symptoms such as North apnea, adama or cough. These can be tricky during pregnancy, especially Arthenia. Women maybe sleeping propped up for a variety of reasons unrelated to their breathing, but really trying to get at if it's, you know, are they sleeping in a recliner? Are they sleeping upright because it's hard for them to breathe? Um, Edema can sometimes get worse in the days or week after delivery. However, it should not be getting worse in the weeks, several weeks following delivery. Um and then objectively observing increased work of breathing, increased respiratory rate or low 02 SATs for chest pain. I wanted to make the point that for a lot of I think in the media there's a lot of discussion about how women presenting with a heart attack often have different symptoms than men. But actually what we know is that the most common symptom for women and men are is chest discomfort. Some people might not call it pain. They might call it discomfort or pressure or squeezing but it is chest discomfort. Um Exertion. All chest pain that improves with rest is highly concerning for angina sudden chest pain at rest lasting more than 5 to 10 minutes. Especially if it's associated with other symptoms such as feeling unwell. Dia freezes or nausea and then escalating symptoms um that eventually occur you know waking someone from sleep would also be concerning. Um Many pregnant women have experienced heartburn you know so asking is this different from your heartburn symptoms can be helpful? Um And I think the other thing that comes up especially in the postpartum period is the role of anxiety and anxiety Can cause chest pain. But also people who have chest pain that causes anxiety as well. And this can be very difficult to differentiate the two. Um And so I think if they're especially if there are any associated symptoms if you feel like something isn't right and especially if the patient feels like something is not right with her body. I think it's important to do a cardiac evaluation. Um I did want to highlight the hear her concerns campaign by the C. D. C. Which underscores the importance of individuals post pregnant and postpartum individuals talking to their care providers about any new symptoms that they develop during pregnancy or the postpartum period. And so my hope is that this reaches a wide audience. Um and that maybe patients will even be bringing in you know this checklist or this guide to help start the conversation when they're feeling unwell. And so this is my summary of what we talked about today. The three CS of postpartum cardiac symptoms clot, cardiomyopathy and coronary syndrome which are the three things we don't want to miss in the postpartum period. Quickly just dropping up resources that pen and our women's cardiovascular health program. We have a number of providers myself and Monica included also married Ambrose and Sharon Rubin who sees patients here at hub. Um And at pennsylvania hospital. We have a combined um cardiology AM FM. Clinic once a month for women with preexisting heart disease or in need of preconception counseling. And you're always welcome to call us with questions or help with triage. Um So in conclusion cardiomyopathy is the leading cause of maternal deaths. Postpartum. Do not diagnose new asthma postpartum until cardiac causes have been excluded BNP or is a helpful tool to diagnose heart failure and peri partum individuals and certainly echoes work well to abnormal E. K. G. And positive troponin is acute coronary syndrome until proven otherwise and then finally scat is a common cause of acute coronary syndrome postpartum and is diagnosed by cardiac catheterization. So thank you so much. Thank you so much. Dr lee for taking us through some of the major causes of cardiac. We're getting mortality in the postpartum period and I'm gonna pivot now. Um And talk about postpartum cardiac risk assessment and risk factor modification and women with adverse pregnancy outcomes I have no disclosures and my goal today is to define adverse pregnancy outcomes, discuss long term cardiovascular risks associated with these adverse pregnancy outcomes as well as explain age appropriate cardiovascular risk assessment and risk factor modification. So when you're looking from the lens of a cardiologist or cardiovascular disease, we think of four main adverse pregnancy outcomes. These include hypertensive disorders of pregnancy, gestational diabetes, preterm birth and small for gestational age, infant within hypertensive disorders of pregnancy. Um If you call it is a spectrum of diseases ranging from gestational hypertension to preeclampsia, preeclampsia and help syndrome and even within preeclampsia. There are several subcategories include pre severe preeclampsia as well as superimposed preeclampsia which happens when preeclampsia is superimposed on chronic hypertension. I want to remind everyone that we use the 20 weeks gestation mark. To differentiate between hypertensive disorders of pregnancy and an underlying chronic condition that is manifesting in pregnancy. So if the hypertension occurs after 20 weeks we think of it more of a hypertensive disorders of pregnancy I'm going to use this um hypertensive disorders of pregnancy as a prototype to discuss cardiovascular future cardiovascular risk in these women. So if you think most of you are probably aware now that pre eclampsia is associated with increased cardiovascular risk. And this includes about a two fold increased risk of atrial fibrillation, stroke, coronary heart disease and cardiovascular death. And almost a fold for 4-fold increased risk in heart failure. Not only does the severity of the disease matter, but also the timing of the disease. Women who have really preterm preeclampsia before 34 weeks have a much higher risk of dying from cardiovascular disease long term than women who have preeclampsia later in their pregnancy. So severity and timing of disease all matter. When we're talking about long term cardiovascular risk. Not only are these women at higher risk for long term cardiovascular disease that we've talked about, but they are also at higher risk for developing um cardiovascular risk factors including hypertension, type two, diabetes hyper lipid, E me A and C. Kg. And when we account for some of these risk factors, we find that there are long term cardiovascular risk is actually attenuated, suggesting that some of the risk is mediated by the accumulation of these risk factors in the postpartum time period. I'm going to use this diagram to try to explain this this cardiovascular risk assessment, postpartum period and why why we think it's so important If you look at this diagram and think about the time on the X. Axis and some kind of vascular dysfunction or susceptibility on the Y axis. The aqua aqua line are healthy individuals and the red line are helpful. Um Women with higher cardiovascular risk. And the green line is a clinical the clinical threshold where their risk becomes apparent and as you can see early and early in the life, you might not be able to differentiate the high risk and low risk woman. However an adverse pregnancy outcomes gives us a window of opportunity to identify these higher risk women that even when their pregnancy risk factors might improve postpartum that there or their blood pressure and blood sugar might improve postpartum. There the risk remains high Long term now that we have been able to identify at an at risk population, it gives us an opportunity for primordial and primary prevention and the thought being that if we can do targeted screening lifestyle intervention and early treatment we can modify these risks. The risk of these women and change and change their trajectory. The cardiology community has um has um accepted that pre eclampsia is associated with increased cardiovascular risk and has um placed it within um the other risk enhancing factors. So preeclampsia is now considered a risk enhancing factor along with other things that you are probably familiar with like chronic inflammatory conditions. CKD um Hyperloop epidemiology to primary family history of premature A. S. C. B. D. However how do you use that information in terms of assessing long term cardiovascular risk And um the goal would be to have these risk factors somehow incorporated into your tenure risk assessment. But that does not exist at this time. Other proposed mechanisms is that you calculate the tenure risk, determine who is borderline and intermediate risk. And then use these sex enhanced um sex specific risk enhancing factors to try to determine whose highest risk. But this doesn't work in the postpartum period because we cannot use the pooled cohort equation to assess 10 year a STD risk In women below the age of 40 you have Be above the age of 40 to calculate 10 year risk. And if you do see a woman who is below the age of above the age of 40, a risk will most likely be low leaving you in a situation where you may not be able to um properly identify her risk. So what what are the recommendations currently provided by our guidelines by our societies? These recommendations are very vague and and and differ significantly anywhere from these women should be seen within 7 to 10 days in the postpartum period all the way to advise um Yeah um advising clinicians to optimize cardiovascular risk factors. So this is very vague unclear and doesn't provide um physicians with guidance. So what I'm going to try to show you in the next few slides and um using a few cases is how to assess these women. Um Using the 2019 A. C. C. A. J. Guidelines and primary prevention as a framework to consider these women. So let's let's meet um Miss Stevie Stevie. She's a 36 year old female G. One P. One who delivered by C. Section at 39 weeks. Because she presented with premature rupture of membranes and then had a rest of dissent and non reassuring fetal heart tones. Blood pressure on mission was normal. Her birth weight the birth the child's birth weight was normal and her medical history is significant for migraines. And she also developed gestational diabetes in the third trimester of this pregnancy. Post delivery, no complications. Um fasting blood sugar was normal and she was discharged home without men's two weeks postpartum. She calls the clinic with the blood pressure of 1 60/1 10. If you ever received this call remember that maternal cardiovascular risk is highest in the postpartum time period and preeclampsia can develop up to several weeks postpartum. I just want to mention that a blood pressure of 1 60/1 05 to 1 to 10 in the period part time period is an emergency that requires immediate attention. I think sometimes when we think about um patients in the E. D. And if their blood pressure is 1 80 we often send them home um As long as they're asymptomatic that's not the case in the period part of the time period. If a woman has a blood pressure of 1 60/1 10 that is an emergency. That requires immediate detention. Also remember to assess for symptoms in any woman with new hypertension in the postpartum time period. This includes assessment of headaches, vision changes, shortness of breath orthodontia. PND and right upper quadrant pain. So our patients she did reports and symptoms of shortness of breath or osteopenia and lower extremity edema as well as a mild headache. And so she was recommended to go to the E. D. For further evaluation. I just want to point out that even if she didn't have symptoms with that kind of blood pressure she should be further evaluated. So MS Stevie's admission. Um She her blood pressure on presentation was 1 69/91. She was standing okay. Heart rate was normal on exams. She was noted to have two plus bilaterally pitting oedema. And her anti pro Bmp was 1300 automatically you should be thinking of peri partum cardiomyopathy which the clinicians were. And so they did get uh echocardiogram which showed normal LV. Function of 58%. She was diagnosed with post partum severe preeclampsia. She was treated with I. V. Medications to lower her blood pressure below 160 millimeters of mercury systolic. She was started on em loaded pine five mg orally. Her blood pressure stabilized on oral meds and she was discharged home with the oral with an oral Lasix protocol and unloaded pine five mg just in case you're not familiar with this oral Lasix protocol. It is based on a randomized controlled trial that was done here at penn by R. F. M. F. M. And cardiology colleagues and what they found was what they thought was that in the postpartum period we sometimes see an elevation in the blood pressure and the thought being that some of this may be due to shifts in fluid. And so they randomized 384 women to five days of Lasix oral A six versus placebo. And what they found is that in non severe preeclampsia They had a 60% reduction in the Um in the prevalence of persistent hypertension at seven days and have faster resolution of hypertension postpartum. So now women who are being discharged in the hospital with this diagnosed with hypertension with hypertensive disorder pregnancy are often discharged with this Lasix protocol. So, and it's only a five day protocol with two days usually completed in the hospital in case you see the sun discharge. So she comes to follow up um she has a follow up visit um with us at eight weeks um post this post discharge. And I want to emphasize that this follow up visit is an opportunity that we should use for cardiovascular risk and risk factor assessment. So what did her eight week follow up looked like she had her symptoms had resolved her blood pressure had normalized. And so she stopped and loaded peeing herself. She's a nonsmoker. She denied family history of cardiovascular disease. Blood pressure is normal. B. M. I. Is 28 weight is close to pre pregnancy weight. So we discussed that preeclampsia increases her future cardiovascular risk and that HHS life's simple seven. We discussed. Ahh ahh Ayes life's simple seven framework for ideal cardiovascular health. We discussed that she can remain off and load up in since her blood pressure has normalized but she should check her blood pressure if new symptoms arise because of the high risk of her developing chronic hypertension. And recommended follow up in one year. So is that that seems like a pretty good visit. However I just want to emphasize that there is a few things that you do not want to miss. One is a lipid panel. So we ended up checking a lipid panel in her and were very surprised to find an l. l. 203. This was a non fasting lipid panel and I want to impress upon you that that is no problem. And that is actually it's more convenient more physiologic and some would argue a better predictor of cardiovascular risk The times to repeat repeat a non fasting Olympic panel would be if if the triglycerides are greater than 400 If you need confirmation that the LDL is greater than 190 And the threshold for hyper triplets or academia increases from 150 to 1 75. And so I really want to impress upon you that a non fasting lipid panel is better than no lipid panel in this all opportunities that we have to risk stratify these women. So how do you use this information? I just told you that we can't um we these women cannot really be risk stratified according to our A. S. C. B. D. Risk calculator because they're so young. However I want to bring your attention to the first um breakpoint in this algorithm and that is that L. D. L. Should be assessed because in LDL greater than 1 90 doesn't require additional risk assessment. It is a class one indication for a high intensity statin. So if her LDL remains elevated she needs to be on high intensity stand. But she's already identified herself as a high risk individual that we might not have captured if we had not gotten that that lipid panel. Also women between the age of 20 to 39 should consider should be considered for statin therapy. If they have a strong family history of premature C. A. D. And an LDL cholesterol or greater than 1 60 mg of death. The leader and so I think this is an important point that there are LDL levels where we would start status of these women and we should not miss severe primary hypercholesterolemia. Another opportunity is diabetes screening. So about 50% of women with gestational diabetes go on to develop type two diabetes in their lifetime. This is a huge risk and a huge opportunity. Almost all the society guidelines recommend screening for type two diabetes if a woman has a history of gestational diabetes the frequency is not clearly outlined. But I think if they are a significantly higher risk once a year seems like a reasonable time period um to continue to check and even if you don't see these women immediately postcard um long term you should keep this in mind that these women are at high risk for developing long term diabetes. So in this post partum window of opportunity don't forget lipids and don't forget diabetes screening let's meet our next patient. Miss Am. So she's 38 G. one p. One who delivered by c section at 39 weeks for gestational hypertension. The remainder of her postpartum hospital course was unremarkable and her blood pressure quickly improved. She was enrolled in Heart safe motherhood for postpartum blood pressure monitoring and in case you are not aware of this very innovative program. Heart safe motherhood is a text based postpartum blood pressure monitoring program that was created by RMF FM colleagues and what they have found is that if you these women are given a blood pressure log as well as they are enrolled in this texting program. They are reminded to send in their blood pressure readings and they receive feedback based on their blood pressure levels and what they found is that they were able to reduce readmission rate and increased postpartum visit attendance. So a lot of these women are enrolled in this program. Um if you hear the term heart safe motherhood this is what they are talking about. So she comes to follow up about 12 weeks postpartum um in clinic for cardiovascular risk assessment. So her she's feeling well no symptoms. She reports that her father had coronary artery disease. Blood pressure is 1 40/88 improves to 1 35/87 repeat check Her b. m. I. is 37. So um consistent with obesity. And so we discussed that preeclampsia increases her future cardiovascular risk. We discussed life's simple seven um through the H. A. Framework and we order a lipid panel and a one C. Like we discussed and we asked her to follow up in a year. Is this a good visit? Um What I would argue is that there are some things that we should not miss her as well. In addition to the screening we should not miss this opportunity to diagnose chronic hypertension and optimize blood pressure control and to further assess her family history and make sure she doesn't have a family history of premature coronary disease. So what does blood pressure postpartum look like in terms of recovery. So a woman who has developed a hypertensive disorders of pregnancy normalization of blood pressure depends on many things especially B. M. I. And race. And for this woman she was non black and her B. M. I. Was greater than 35. If you take um The women in the study of similar ethnicity and wait. Um only about 45% of them have recovered their blood pressure At about two weeks postpartum. The thought being that about 12 weeks postpartum most of these women should um resolve their blood pressure. Um in in reality about 80% normalize their blood pressure and about 20% um go on to develop chronic hypertension After about 12 weeks to station. You should no longer be thinking that this is a hypertensive disorders of pregnancy. Rather start considering that this is a patient with likely now chronic hypertension and be treating accordingly. There are a safe A small minority of women who will go on to recover their blood pressure. But um at about 12 weeks gestation it should be thinking about long term um blood pressure management. And these women. So 1 30 is the new 1 40. You probably are all aware that hypertension is now diagnosed with a blood pressure above 1 30/80. Stage two hypertension. And that's stage one hypertension. Stage two hypertension is a blood pressure greater than 1 40/90. And um treatment is the same as before for stage one hypertension. Now the recommendation is to divide um uh is to further risk stratify based on the A. S. CVD risk or if you're a CVD risk scores greater than 10% you should consider pharmacologic therapy and less than 10%. Um A CVD risk score is none is treated with non pharmacologic therapy with the gold blood pressure of less than 1 30/80. However we just talked about the fact that a majority of these women are going to be in the low risk category. And so what do you do for them? There's a new h a scientific statement that came out last year which offers new suggestions for management of stage one hypertension in women who have the lowest for all patients with the low S. A. S. CVD risk. So the thought being that if lifestyle modifications don't work, you now can consider pharmacologic therapy in these women. I think really using this opportunity especially in high risk women with strong family history of heart disease or other multiple risk factors to really consider optimizing their blood pressure control um early in life. So what are the medications that you can use safely in a woman who's lactating or postpartum? Um This this diagram shows the first column is pregnant um medication safe in pregnancy and the third column or medication safe and lactation. And I've highlighted with the arrows, the medications that we most commonly used including liberal all my feet up in and load up in and sometimes hydrochlorothiazide aside but really hear our practice pattern is that calcium channel blockers especially di hydro paradigm calcium channel blockers are usually first line therapy during pregnancy and postpartum. So we talked about blood pressure control and also family history. It's really important to assess for a family history of premature cardiovascular disease and that is a first degree relative with cardiovascular disease before the age of 55 and then and before the age of 65 in women. Because this identifies a higher risk group than someone who has a family history of heart cardiovascular disease later in life. So again, the postpartum visit is a window of opportunity to assess lipids, diabetes, blood pressure and family and further define family history identifying a high risk chord. I'm going to bring this all together now with my last patient, Miss Sw. So she's 31 G two P two who delivered by c section at 33 weeks Gestation for superimposed preeclampsia. Her medical history is significant for type one diabetes diagnosed at age 16 and chronic hypertension diagnosed at 18 weeks Gestation. So we talked about earlier that the 20 week mark helps us um um distinguish between chronic hypertension and maybe a hypertensive disorders of pregnancy. So her blood pressure elevation because began before 20 weeks. So she was diagnosed with a chronic hypertension um delivery was fine but postpartum she actually developed respiratory failure that thought that it was due to h cap. She had a ct chest to rule out pulmonary embolism that was negative. And she had an echocardiogram which showed an LV. EF of 49% but no heart failure symptoms. So um suspicion for peri partum cardiomyopathy was lower respiratory status improved quickly. She presented the clinic for follow up for about four weeks. Postpartum. She felt well blood pressure was normal, oxygen was normal and her B. M. I. Is 32. So we assessed the risk factors that we discussed. I actually got a lipid panel. Her LDL was 221 Um suggesting severe primary hypercholesterolemia or diabetes showed an a one c. of 8.5 on insulin. Her blood pressure was well controlled. However, this was on carvedilol and lose certain that we're starting in patient because she was not breastfeeding. And um she had a mild cardiomyopathy. And we found out that she has a family history of premature cardiovascular disease with a father who died at the age of 41 from an M. I. So this allows me to see the big picture. I really understood that this woman is a very high risk. I actually reviewed her cT scan that she had done for um to rule out pulmonary embolism and found that she had severe coronary artery calcification Given given the family history of LDL greater than 190 severe coronary artery calcification and um the family history. She was started on statin therapy. Um We actually sent her for cardiac catheterization because of the severe calcification in the mild cardiomyopathy. And she was found to have severe three vessel disease. She was sound sent for genetic testing and diagnosed with heterocyclic F. H. And was started on a pc. S. K. Nine inhibitor. So really you can see how this postpartum time period was a window of opportunity that allow us to really um better understand her risk and hopefully we can change her long term trajectory. So don't miss the opportunity to screen postpartum for cardiovascular risk and treat. Don't miss the opportunity to implement blood pressure management, whether that's lifestyle or medications and don't miss the opportunity to educate about normal numbers. A lot of women don't know and to take a pregnancy history because it isn't relevant to to these women's future cardiovascular risk. Thank you so much. Happy to take questions. Thank you doctors louis and sang happy for those great presentations. Um Thank you so much for your great presentations. I know we're two minutes um over I think that you covered the questions that we got in advance. I think you largely um covered some of them. Um One question was about BNP versus PRO BNP and whether there's any difference. Um and those and how to interpret them. That's I think a quick one I think um I think both could be used. We generally have. Nt pro and be Pro BNP available here. So I think that is what we would use in the majority of cases and I want to be mindful of um of time for people I know people will have to start hopping off for maybe an afternoon clinical session. Um I think another one quick question was Um best practices for stopping antihypertensive medications and patients who were started on them for preeclampsia like so they get discharged on an antihypertensive and you're seeing them as you said doctor is going to be like eight or 12 weeks later sort of what's the practice? You think you had a case where somebody stopped it on their own. But how do you sort of generally think about that? So in general if they, a lot of these women do stop their blood pressure medications on their own when their blood pressure normalizes um immediately postpartum um and then so if they have stopped it and their blood pressure is normal I give them you know the green light to stay off of that medication. However if their blood pressure is elevated then we discussed again maybe restarting for a short period of time until um we can reassess in a few months if they remain on the medication and they're seeing us postpartum then and if their blood pressure has normalized then we discuss stopping it to see if there um if they remains normal but I give them strict guidance to really monitor. Now we know they have a blood pressure cuff, they can really monitor their blood pressure um with any medication changes and I always advise them if you get a new headache dizziness really you check their blood pressure because we don't want to miss a new spike in their blood pressure. Great thank you both. I'm gonna just be cognizant of time. There's a lot of comments in the chat, just thanking you both for great presentations. Um I think this highlights uh the sort of collaboration that we all need to have together as pregnancy. As you all both pointed out as a really window into sort of broader health and sometimes as a signal for for things that are you know to come later. And so all of us sort of as a medical community, being aware of that and sort of being kind of engaged in those conversations and discussions about how pregnancy complications might indicate future risk. But also just being cognizant as you brought up dr louis around pregnancy history and how that might make you think differently at you know, the six month mark in the emergency room or in the primary care office I think was hopefully very helpful for people certainly send out the recording of this um of this talk. And maybe a summary of some pearls and we really encourage everyone to we really appreciate everyone that joined us from across the system and encourage people to share um maybe the recording and even the pearls with other people in your practices and your divisions and departments to really continue to engage and educate people outside of the um O. B. G. Y. N. Community, but broadly across the system in primary care, emergency medicine, cardiology etcetera, around um this awareness campaign to try to improve our all of our education and collaboration together. So thank you all so much and thanks again, doctors louis and tangle for great presentations. And you can all look forward to an email from us um and follow up.