Maggie McKay (Host): When a woman is pregnant, there's so much to think about, and heart issues usually are not top of mind. But Dr. Nadine Montemarano, Associate Director of Clinical Cardiology, says you got to think about it. She'll discuss cardiac obstetrics. This is Maimo MedTalk from Maimonides Health. I'm your host, Maggie McKay. So wonderful to have you here today, Dr. Montemarano. Would you please introduce yourself?

Nadine Montemarano, MD: Yes, thank you so much for having me. So my name is Dr. Nadine Montemarano. I'm the Associate Director of Clinical Cardiology at Maimonides Health. I practice general non-invasive cardiology, and I also specialize in Cardio Obstetrics and women's heart health.

Host: So let's just start with what is cardiac obstetrics?

Nadine Montemarano, MD: So our goal of Cardio Obstetrics is to provide comprehensive, specialized care for these patients to ensure the health and safety of both mom and baby during pregnancy, childbirth, and in the postpartum period.

Host: And who is at high risk?

Nadine Montemarano, MD: So some of the factors that increase the risk of cardiac complications during pregnancy are women with pre-existing heart conditions. So anyone who has a congenital heart disease, arrhythmias, valvular heart disease, anyone with cardiomyopathy or disease of the heart muscle, patients with hypertension, patients with diabetes, patients with obesity, anyone with advanced maternal age over 35 years old, patients with multi parity, so anyone carrying twins or higher order multiples are at increased risk, and women with a history of preeclampsia in a previous pregnancy are at increased risk of developing preeclampsia with subsequent pregnancies.

So it's really important for these women with known risk factors to receive specialized care and monitoring during pregnancy to minimize the risk of cardiac complications. And ideally, consulting with the healthcare provider before becoming pregnant can help identify and manage these risk factors to avoid complications during pregnancy.

Host: So let's say you don't have any idea that you have this. How do you recognize and manage cardiovascular complications of a pregnancy? How's it diagnosed?

Nadine Montemarano, MD: Women who are pregnant and may or may not know that they have complications, can develop certain types of symptoms. So what are the symptoms? What are the warning signs that we're looking for to say maybe there is a problem here? If you have shortness of breath, so persistent shortness of breath, especially with minimal exertion, that could be a sign of heart failure or other cardiac issues.

Anyone with chest pain or discomfort, that's really important to get checked out. Palpitations, which are irregular heartbeats or a rapid heart rate, that could be a sign of cardiac arrhythmia. If you have a lot of swelling in your legs, your ankles, your feet. These could be signs of heart failure that need to be checked out. Excessive fatigue or weakness that's not relieved by rest. That could be a sign of decreased cardiac function and fainting spells, lightheadedness or dizziness could indicate inadequate blood flow to the brain, which may be related to cardiac issues. Anyone with persistent high blood pressure during pregnancy that's not responsive to treatment or even before pregnancy, they definitely need to be evaluated, and anyone with a history of heart disease.

So when you have these symptoms, it's very important to be seen by a Cardio Obstetrics specialist. And what do we do? How do we evaluate them? So we start with a medical history, and a patient comes to the office, we get a detailed history to assess for any pre-existing conditions, any previous cardiac events, any family history of heart disease, and really any other relevant information that can impact a woman's cardiovascular health during pregnancy.

We do a physical exam, which assesses vital signs and heart sounds, and we look for any symptoms of fluid retention or any clinical findings. We can do blood tests, which check your cardiac function, your electrolytes, we could check cardiac markers, your cholesterol, your blood sugar level, your thyroid level, etc.

We can do an EKG, which is an electrical recording of the activity of your heart to assess for any abnormal heart rhythms or signs of heart damage. And that's very safe to do in pregnancy. And we can also do an echocardiogram, which is an ultrasound of the heart, which gives us detailed images of the heart's structure and function, helping us to assess if there's any abnormalities.

We can get Holter monitors. which are portable devices that record the heart's electrical activity over a period of time to see if there's any abnormal heart rhythm or arrhythmia. We can do a stress test. And in pre-pregnancy counseling, if it's indicated, we could do a cardiac MRI or a CT to give us a lot more detailed information about the heart structure and function. So there's a lot that we can do.

Host: You've mentioned pre-pregnancy counseling. For somebody at high risk who's worried, when they're thinking about getting pregnant, how soon should they see a doctor before they're planning to get pregnant if they're at high risk?

Nadine Montemarano, MD: I would say at least a couple of months because at that point you can address what the risk factors actually are. You can do any appropriate workup that's needed. You can optimize the patient's cardiovascular health to help decrease risks. And if any procedures need to be done that can all be undertaken prior to pregnancy.

Host: So let's say a woman is pregnant. She didn't know she was at high risk. So if a woman does need a cardiac procedure during her pregnancy, does that affect the baby?

Nadine Montemarano, MD: So, cardiac procedures can be performed during pregnancy if absolutely necessary to address serious cardiac conditions that pose a risk to the mother's health. The decision to undergo a cardiac procedure during pregnancy is definitely carefully considered by a multidisciplinary team to weigh the risks and benefits for both the mother and the baby.

And cardiac procedures during pregnancy do carry some risk to the baby, but they may be necessary to address life threatening cardiac conditions that pose a significant risk to the mother's health. So the decision to proceed with the cardiac procedure is made based on the individual circumstances and the expertise of the healthcare team to ensure the best possible outcome for mom and baby.

Host: I imagine it's different for every patient, but is there a certain point in the pregnancy that problems crop up that usually occur?

Nadine Montemarano, MD: So cardiac problems can potentially occur at any point during pregnancy, but they are more likely to present or worsen in the second and third trimesters when the cardiovascular system is under increased stress. And this is due to the physiological changes that occur during pregnancy, such as increased blood volume, heart rate, and cardiac output, which can put additional strain on the mother's heart.

Host: Do genetics play a part? Like if your parents both had heart attacks, are you more likely to have an issue while you're pregnant or?

Nadine Montemarano, MD: I would say yes, genetics can play a significant role in the development of cardiac disease during pregnancy. Some cardiac conditions, such as congenital heart defects, cardiomyopathies, arrhythmias, and genetic syndromes are associated with cardiac problems. So yes, there can be a genetic component.

In some cases, these genetic factors can predispose patients to developing cardiac issues that may be exacerbated during pregnancy because of the physiological changes and increased stress on the cardiovascular system. So it is essential for women with a family history of cardiac disease or some genetic predisposition to undergo genetic counseling and testing before becoming pregnant, to assess their risk of developing cardiac issues during pregnancy. Because understanding the genetic factors that may contribute to cardiac disease can help us develop personalized care plans to monitor and manage the patient's cardiac health during pregnancy effectively.

Host: Are there any statistics? How common is it for pregnant women to have cardiac issues?

Nadine Montemarano, MD: So the overall prevalence of cardiac disease in pregnancy is estimated to be around 1 to 4%. So up to 4 out of every 100 pregnancies in the United States. So it's not very common, which is a good thing. But if we look at the statistics, about 1 in 3 pregnancy related deaths in the United States are due to cardiovascular problems. So it can definitely have serious implications for both mom and baby.

Host: Right. So if not treated, it's

Nadine Montemarano, MD: It's problem.

Host: It's not going to be a good outcome.

Nadine Montemarano, MD: No, not good.

Host: How do you manage any cardiovascular complications during pregnancy?

Nadine Montemarano, MD: So managing cardiovascular complications during pregnancy requires a multidisciplinary approach involving obstetricians, cardiologists, and any other relevant health care providers, and the management may vary depending on the specific condition and the severity of the condition. So some general strategies for managing these patients include close monitoring.

So these women should receive regular prenatal care, keeping an eye on their heart condition, on their blood pressure, getting serial EKGs or echoes if indicated. Some women may require medications to manage their cardiovascular complications, and so we closely monitor that and modify those.

Lifestyle modifications are important for some patients, such as maintaining a healthy diet, regular exercise, avoiding smoking and alcohol, and on the counter, other patients may need bed rest or just rest in general to avoid overexertion and manage symptoms. We create a delivery plan for our patients, so the mode and timing of delivery should be carefully discussed and planned in collaboration with the entire team, with anesthesia, with nursing, with OB, with cardiology, with neonatal ICU, to minimize risk to both mom and baby.

And then close monitoring and follow up are essential in the postpartum period to ensure that any cardiovascular issues are promptly addressed. In some cases, women with severe cardiovascular disease may require specialized care in a high risk pregnancy center such as Maimonides, and these specialized centers can provide comprehensive care and expertise in managing all sorts of cardiac complications ranging from very mild to very severe.

So overall, I would say the management of these complications during pregnancy should be individualized based upon the specific condition, the woman's medical history, and the recommendations of a multidisciplinary team. And the take home message here is early identification, close monitoring and timely intervention are key to optimizing outcomes for both mother and baby.

Host: Thank you so much for sharing your expertise and making the time to join us today on Maimo Med Talk.

Nadine Montemarano, MD: Thank you so much for having me.

Host: That was very informative and helpful, and we really appreciate it. Again, that's Dr. Nadine Montemarano. If you'd like to make an appointment, you can call 718-283-2600, or to learn more, visit maimo.org. If you found this Maimo MedTalk podcast helpful, please share it on your social media channels. To listen to additional episodes of Maimo MedTalk, please visit maimo.org. This is Maimo MedTalk, a podcast from Maimonides Health.