Scott Webb (Host): Pregnancy is a happy time for many women, but it's also a time when the body is undergoing unprecedented stress, especially related to the heart health of mothers. Most women with a heart condition can safely become pregnant and deliver a healthy baby. But cardiovascular disease does complicate about four out of 100 pregnancies. It also is a leading cause of pregnancy related deaths. Today, Dr. Ankur Cora will talk about heart conditions that can be discovered during pregnancy and steps patients and physicians can take to make sure mother and baby are safe and healthy.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, thanks so much for your time today. We're going to talk about pregnancy and heart health. So let's start here. What normal changes, putting those in quotes. What normal changes on a woman's heart health does pregnancy have?

Kalra Ankur MD, FACP, FACC, FSCAI (Guest): The one important change which pregnant women and people taking care of pregnant women should be aware of is that the volume, the intravascular volume, so the volume of fluid in the body; actually goes up significantly. It happens more so in the third trimester than it does in the earlier trimesters, but that is a very common physiological change that happens in the body, which has an effect on the heart because the heart is now dealing with a lot more volume across its chambers than it is normally used to.

So the result of which, is that it tries to compensate and it compensates by, increasing its pumping function, which we call stroke volume or going up on the heart rate to increase the output overall because, the body, the mother's body is not only trying to get nutrition through circulation for herself, but also for the baby. So the cardiac output, which is the pump power of the heart, has to go up and it can only go up by two mechanisms. You either increase the stroke volume, I know it's a technical term or you increase the heart rate. So the heart rate tends to go up to compensate for this physiological change because now you have an increased fluid, sort of quote unquote status or capacity in the body.

Host: Yeah, I see what you mean. And so there are, obviously, there's some normal changes that happen, quote unquote, normal changes and some women may have some preexisting conditions, some preexisting heart conditions that might put them at risk. So maybe you can talk about that a little bit, those risk factors, if you will, during pregnancy.

Guest: Yes. So I think it is important for women to consult a cardiologist, a heart doctor if they are aware of any preexisting conditions that they may have from a heart standpoint. The most common a preexisting condition in pregnant women in the United States is actually high blood pressure, or, something which we call as hypertension.

And hypertensive heart disease, is the most common cardiovascular condition in pregnancy, which may have severe ramifications if it is not optimized in a pregnant woman. So I think working in close concert, not only with their obstetrician, but also with their cardiologist is important.

Because if uncontrolled, it can have severe downstream ramifications, both during pregnancy and after pregnancy, both to the mother and to the fetus. In, in a paper which we published, in the European Heart Journal last year in November, it was actually presented at the American Heart Association Annual Scientific Sessions in Chicago in November of 2022. That's where we showed that hypertensive heart disease is the most common pre-existing condition and its incidence has gone up. I mean, the incidence of diagnosing

Host: Right.

Guest: Like you said, preexisting heart conditions have gone up between 2010 and 2019 have gone up significantly. And among those conditions, hypertensive heart disease happens to be or tends to be the most common one. That is the most common one that I do want to stress on. Certainly the other big one which patients get concerned about are heart attacks during pregnancy and heart attacks during pregnancy, fortunately are rare but can occur.

And, again, there has been an increase in the incidence. Now whether that increase is because we've gotten more aware of underlying heart conditions in pregnant women in general, or because there has been an increase in the incidence of heart disease in the population overall. Or is it because women are getting pregnant at a later age compared with what they used to?

I think it's multifactorial. I think it's a bit of all three of them, but, you know, heart attacks in pregnancy could be from many different causes. It's not the typical usual heart attack that happens in a middle-aged man with traditional risk factors for heart disease, which I'm sure all of us are aware of. Like high blood pressure, high cholesterol, diabetes, smoking, sedentary lifestyle. These are heart attacks which are different. They get classified and labeled as heart attacks, but what's happening physiologically inside the mother's body and in the heart arteries is something which is entirely different.

So I think it, it is important to keep that in mind. And then the third most common condition which we tend to see in clinics is valve disease. And valve disease is also something which is a preexisting condition. I think of the women who have valve disease, more often than not, this valve disease happens to be a congenital valve abnormality, which again, because now you're dealing with more volume and more fluid and more circulation, it is very important. It's crucial to optimize the valve loading and unloading conditions, which can be done with the help of medications but have to be prescribed in close concert with a cardiologist or a heart doctor.

Host: Yeah, so you can certainly appreciate, women have either diagnosed or undiagnosed heart problems that could put them at risk during pregnancy; obviously speaking with a cardiologist, having a sort of team, if you will, in their corner before they get pregnant would be a, a really good plan.

And, when we think about things that, that women can develop during pregnancy, I'm sure we've all heard of gestational diabetes, you know, and some other things like that. But what heart issues do they develop during pregnancy?

Guest: I'm not familiar or sure how many people would've known of terms preeclampsia and eclampsia. These are related to underlying hypertension and are more exacerbated in patients with underlying hypertension or high blood pressure in pregnancy. And, these are obstetric diagnoses. Both pre-eclampsia and eclampsia are. And our obstetric colleagues are very well adept and know how to manage these. I think this is just more for patients to be aware that these are common conditions, which do have an intersection with underlying preexisting heart conditions or cardiac conditions. And hypertension happens to be one of them.

Specifically from a heart standpoint, the two big ones in pregnancy to, to be concerned about, or at least to be aware of. I think one is something called postpartum cardiomyopathy. And this can happen starting from the third trimester all the way up to 60 days after someone is delivered, you know, or you in some cases even longer. And what I mean by postpartum cardiomyopathy, so this is a new diagnosis. It's a diagnosis of decreased pump function of the heart. What we typically call is heart failure. So cardiomyopathy is any condition which is affecting the heart muscle.

And, postpartum means that it's happening after pregnancy and it has an association of race to it. So it, it tends to occur more commonly in Black women than women of other races and ethnicities. And some of the telltale signs will be that the fluid retention hasn't gone away after pregnancy or, the person is now retaining more fluid in the body compared with their pre-pregnancy body weight.

Or they are now feeling short of breath or cannot exert themselves as much as they were used to pre-pregnancy. And then you get yourself checked out by an an obstetrician and if there is concern that there is fluid retention, or if there is a new murmur or they can't lie flat for some reason, that raises suspicion, maybe this could be something related to the heart. And once a referral to a cardiologist is made, or once cardiology care is established in these patients, we typically get a heart ultrasound, which is referred to as an echocardiogram, which usually gives away the diagnosis, once you put everything together.

It's important to then, be in the care of a cardiologist. Postpartum cardiomyopathy is a serious diagnosis. It has implications for future pregnancies. We typically tell patients not to get pregnant again once diagnosed with postpartum cardiomyopathy, cause that could be life threatening.

So it's a very serious diagnosis and a close relationship with both a cardiologist and a cardiologist working in close concert with their obstetrician is crucial in managing these cases, if someone is contemplating a future pregnancy. So that's one, which is an important one that needs to be kept in mind.

The other one is during pregnancy there is a predilection toward a particular condition which can present as heart attack, and that is spontaneous dissection of the heart arteries. So the heart has arteries that run on its surface, and these are the arteries that are supplying blood to the heart muscle.

And for reasons we do not entirely necessarily know, there ar obviously hormonal changes that occur in pregnancy and there is a theory or a postulation out there that these changes may be causative factors for why this condition occurs in pregnant women. But, women can have spontaneous dissection of the heart arteries. So the heart arteries, they typically have three layers. The innermost layer, the middle layer, and the outermost layer. And these layers just tend to separate from one another leading to obstruction of flow. So when the layers separate from one another in medicine or in medical terminology, that is referred to as dissection.

And if these vessels dissect, they tend to impede flow. And once the flow is impeded, whether it's because of cholesterol plugs and plaque blocking the arteries, which is what the typical cause of a heart attack is, in this case it's not the plaque, it's not the cholesterol plugs, it's not the clots. It's the dissection, which is impeding flow. So anything that leads to impediment of flow will cause a heart attack. Earlier during our discussion I mentioned heart attacks occur and they present in a similar fashion. They just don't have the same causes or etiologies as we call it in medicine.

Host: Yeah.

Guest: And, in pregnant women, spontaneous dissection of the heart arteries is the condition that one should suspect right off the bat immediately if someone is presenting with symptoms, if a pregnant woman is presenting with symptoms and signs of a heart attack. Cause the management, how you manage these cases is completely. different from how you would manage a typical heart attack case, and that's why it's important to keep that in mind.

Host: Sure. I'm wondering, Doctor, these sort of emergent heart conditions that a woman might experience during pregnancy, will they suffer from those effects long-term? I know mentioned, recommending, highly recommending not getting pregnant again with one of the conditions, but what's the long-term prognosis if there are some of these sort of emergent conditions during pregnancy?

Guest: Yeah, that's a great question. And I think it's important. So both actually. Both for spontaneous coronary dissection or spontaneous dissection of the heart arteries, and for the cardiomyopathy, the recommendation is to not get pregnant again, which is a big statement to make and not, does not come casually for any of us. And I think any future pregnancies need to be planned in very close concert with an obstetrician and a cardiologist knowing future pregnancy can actually be life-threatening. So we actually are very serious about this recommendation. So for these two conditions, that is a big long-term sequela. For postpartum cardiomyopathy, many times even on medication, which now we have a great backbone of medical therapy from various drug classes; the hope is that for many of our patients, the pumping function recovers. But there is a subset of patients where the pumping function does not recover at all.

And when that happens and they're young and they're still in refractory quote unquote heart failure, then you know, they may be considered for heart transplant and that has been offered to a subset of patients who end up developing end stage postpartum cardiomyopathy, that is the final common pathway there. Certainly if they've had spontaneous dissection, dissections tend to heal on their own. Could they have an episode of dissection later on in life? They certainly are at a higher risk.

So we tend to put these patients on medications called beta blockers. These are the ones which optimize their heart rate and also your blood pressure. And that is considered one of the medications or drug classes of choice in patients who have dissection of the heart arteries. So those are some of the long-term sequelae of these two conditions in particular. Now, obviously long-term uncontrolled high blood pressure has other sequelae not only hypertensive heart disease. So uncontrolled hypertension can long-term also lead to thickening of the heart muscle, and then weakening of the heart muscle causing heart failure.

That's one. We know that stroke is a very important sequela of uncontrolled high blood pressure. Actually, the number one factor, risk factor for strokes is uncontrolled high blood pressure. It's important to keep your blood pressure in check even after you've had a successful pregnancy and an uneventful pregnancy, I think it's important to keep that in check and in mind.

And the third most important long-term sequela of uncontrolled high blood pressure is also kidney disease. Patients can have kidney failure, can also impact their vision because it has long-term effects on the retinal arteries. And it can cause sequential changes in the arteries of the retina, which can then impede blood flow to the retina. And when that happens, then obviously it impacts their vision. So these are more so sequelae of uncontrolled high blood pressure, not particularly in relation to pregnant women, but, I do think it's important to keep that in mind as we're talking about heart health and pregnant women.

Host: Yeah, a lot to consider beyond just wanting to have a family, wanting to become pregnant, especially if you know your risk factors, if you have been diagnosed with heart or other related problems like high blood pressure, things like that. Doctor, really appreciate your expertise today. As we wrap up here, what can women do, right?

So what your final thoughts and takeaways, but what would you recommend, you know, before they get pregnant in terms of their maybe their overall health, but really their heart health and things that can contribute to heart problems during pregnancy? Maybe just wrap it up for us.

Guest: So I think it's important to be aware of your preexisting conditions, whether it's high blood pressure, whether it's known valve disease. I think if you are aware of any underlying heart condition, it's important to let the obstetrician know so that the obstetricians can get their cardiology colleagues involved early in your care.

Cardio-obstetrics is now a recognized subspecialty within the field of cardiology. And these are cardiologists who have now dedicated their careers to taking care of pregnant women with underlying heart conditions. So I think that is a really important to keep in mind.

And then obviously, I think being aware of some of the medications that you may be are taking for underlying heart conditions is essential cause the fetus and some of these medications can have on fetal development is not known. So I think once it's confirmed that you're pregnant and you do have an underlying condition for which you are taking a chronic medication, it is important to get in touch with a cardiologist to make sure that none of these medications are interfering with you know fetal development in the first trimester. That's crucial. And your cardiologist is very knowledgeable and aware of what medications to prescribe and what medications to avoid during this crucial phase of development. And I think the third sort of message, an important message here would be to just be in tune with your body and to keep a close watch on your symptoms and to share any changes you feel which are out of the ordinary.

I do know that women tend to get very short or breath, particularly closing when they're close to term or when they're in their third trimester because of the extra volume of fluid that is circulating in the body. So that may be out of the norm for a lot of women, but if it's something which you think is outside the ordinary and is something which is bothering you, you know your body the best than anyone else.

So don't let any new symptom be considered benign unless you've actually mentioned it to your doctor and they've done a checkup. And if any downstream testing is required, they've done that testing, so that all of us are on the same page that there isn't any new diagnosis of underlying new heart failure developing or new cardiomyopathy developing cause that will have downstream ramifications for the health of the mother.

Host: All great advice from an expert today and you know, obviously we want women to have happy and healthy pregnancies but there are some things to consider and folks you can have in your corner, not just your OBGYN but you know, heart doctors, cardiologists, and so on.

So thank you so much for your time today. You stay well.

Guest: My pleasure. Bye-bye.

Host: And for more information, visit Franciscan health.org/heartcare.

And if you found this podcast helpful, please share it on your social channels. And be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.