Maggie McKay (Host): This is Community Connect presented by TGH. I'm your host, Maggie McKay. Joining me is Dr. Daniela Crousillat, who is the Director of the TGH Women's Heart and Cardio-Obstetrics Program and an Assistant Professor at the USF Health Morsani College of Medicine. Dr. Crousillat, welcome. Thank you for being here.

Daniela Crousillat, MD: Thank you very much for having me.

Host: Can you tell us what is cardio-obstetrics? 

Daniela Crousillat, MD: That's a wonderful question. This is truly an emerging and an exciting field that really has been fueled, unfortunately, by the reality that we are facing in the United States. And that's that most of us know that heart disease is the number one cause of death for women in the U. S., and that's across the entire lifespan.

But we now know and have an increasing appreciation that really the number one cause of death for women at a young age, either during pregnancy or in the year after they deliver, is also cardiovascular disease. Now, unfortunately, this has been attributed to a couple of different risk factors. We know that women are getting pregnant at a later age. We also know that by the time women get pregnant, they have a higher burden of things like cardiac risk factors, things like being overweight, having diabetes, having high blood pressure that's diagnosed either before their pregnancy or during. The field of cardio-obstetrics has really emerged as a way to say, how can we keep our women safe? How can we optimize cardiovascular health, even before women are thinking about getting pregnant? And then for that subset of women who already have diagnosed cardiovascular disease, who we know pregnancy is an additional stress test on the heart; how can we plan effectively to keep both mother and women safe, both during the pregnancy and in the postpartum period?

Host: So why does pregnancy represent a challenge for women with cardiovascular disease?

Daniela Crousillat, MD: Pregnancy is often thought as nature's sort of ultimate stress test for a woman's heart. We know that normal pregnancy has been associated with increases in things like a woman's heart rate, the amount of blood volume she has circulating, and changes in blood pressure. And all of this are really just adaptations of our body to support the growth of the fetus.

However, we know that in some women that have cardiovascular disease going into the pregnancy, these changes really are not well tolerated, and these can lead to complications during that pregnancy. So in some of these women, pregnancy really serves as sort of a stress test that unmasks their underlying disease. 

Host: And you mentioned, complications. What are some of those that women can experience in pregnancy that place them at risk for future cardiovascular disease?

Daniela Crousillat, MD: So for women that have pre-existing cardiovascular disease, these are women that, for example, are born with a congenital heart defect, that have issues with valves inside the heart, that have things such as cardiomyopathy, which is a disease of the heart muscle itself; these are women that are at high risk for complications during pregnancy. And these can be things like having abnormal heart rhythms, commonly called arrhythmias, or sometimes having what's called congestive heart failure, which is when the heart is too weak to pump efficiently enough and causes the woman to have symptoms such as feeling short in breath and accumulation of fluid.

So those are really the complications that women with pre-existing cardiac disease going into their pregnancy can develop. However, we are now becoming more and more aware and recognizing that there are complications that occur during pregnancy in women who don't have cardiovascular disease, meaning this is a subset of women that are doing well, go into pregnancy, and unfortunately, pregnancy is a stress test on the heart. And we see that by them failing the pregnancy tests and developing these complications.

Now you asked a great question. What are these complications? What should women be looking out for? What are these risk factors in their pregnancy that put them at increased risk for future cardiovascular health?

And those are things that we have been on the lookout and screen for many, many years, but just weren't quite sure of the association with future cardiovascular disease. So a couple of great examples for women to know are things like developing diabetes during pregnancy, often called gestational diabetes, or for example, developing new onset high blood pressure during pregnancy, often called gestational hypertension.

Or let's say the most severe form of high blood pressure that women can develop during pregnancy that we often called preeclampsia or eclampsia. Now, all of these complications happen only in the context of pregnancy. What we really want women to know is that even though they tend to go away when the pregnancy is over and after delivery, that the risk that's associated with them unfortunately does not go away. Which is why it's so important for women and for their providers, and particularly us in the field of cardio-obstetrics and increasing awareness about what does it mean for women who have had these complications and how can we keep them safe lifelong?

Host: Dr. Crousillat, what is the importance of the fourth trimester after delivery?

Daniela Crousillat, MD: Yeah, so the fourth trimester is a commonly sort of coined term that we use. There is no fourth trimester, really, of pregnancy. It only consists of three trimesters, as a lot of women realize and would not want to extend any longer. We really call the fourth trimester what happens after the baby's delivered, women go home, and it's sort of that first year of life for the baby and really, for mom adjusting at home.

And the reason why we call it that is because we know it's a very vulnerable period when women are still at risk of having complications after delivery. There's a lot of changes in hormones that go on. There's a lot of changes in things like sleep schedules, and eating habits, and sleep habits. And women are faced with increasing demands from the baby, sometimes having to return back to family responsibilities and work.

And all of these things, I mention them because I think they layer on to the reality of what the fourth trimester really is and the two things that the fourth trimester represents is one, women continue to be at increased risk for heart disease. And two, it's a time where we really see a fallout in terms of access and delivery to healthcare.

Meaning it's a time when women are not putting their or prioritizing their health, prioritizing that of the baby, which they should, but they really should be prioritizing the health of the entire family, including their own. So one of the realities that we know is we mentioned that cardiovascular disease is the leading cause of maternal mortality.

But that means both during pregnancy and the year postpartum. And the latest data really suggests that the majority of the maternal morbidity and mortality, that means either deaths or complications due to cardiac disease; the majority of them happen in that fourth trimester period. Meaning not during the pregnancy or during the actual labor and delivery, but in the one year after that.

So this really just highlights the work that we have to do to increase education among the community, to hopefully have programs like the one that we'll talk about that we have started here at TGH to help take care of women during this period. But more importantly, it's really a call to action to say, how can we help women bridge that gap after delivery?

How do we best provide the care during the fourth trimester to make sure that we're keeping women at home and not coming back to the hospital and prioritizing sort of you know, family and all the things that happen in that fourth trimester after delivery. 

Host: That is amazing. I have to say, when we were talking about the fourth trimester, I'd never heard of it. And I thought, what, what is that about? So that's good to know. I don't know if it's that common knowledge. Do pregnant women know about that?

Daniela Crousillat, MD: They don't. And my hope is that a few years from now it will be maybe a term that they either commiserate with or associate with. I think if you ever told a woman there was going to be four trimesters, they would say, no, thank you, 40 weeks is long enough for pregnancy, but it's just a way for us to highlight that it's not over.

And I think if you speak to any of the pioneers and the women in the field of cardio-obstetrics, for us, it's definitely not over. And a lot of our work, even as cardiologists, as primary care physicians and all allied health professionals that care for women after delivery, should really be on emphasizing the importance of care and figuring out where can we meet, right.

How do we expand access to care? How can we be novel and innovative? Like, what do women need? Is it things like telemedicine? And we saw a rise of that after the COVID pandemic. Is it community healthcare centers? Is it like, how can we get to women? Is it providing, you know, care at the same time as the pediatrician visits.

I just think that we need to think a little bit outside the box if we're really going to shift the tide and move the needle in the unfortunate maternal, you know, mortality crisis that's affecting our women and that is being led by these complications and by cardiovascular disease.

Host: So, let's talk about resources provided by TGH Cardio Obstetrics Program. It sounds like you have everything covered, so let's share what some of those are.

Daniela Crousillat, MD: Well, I think we've made some traction, but we definitely have some room for growth. We have now been serving our local Tampa Bay community and really our region and county for about three years now. Our program really provides what we spoke to about in the beginning. It's really multidisciplinary.

We realized that it really takes more than one person to be able to do this work. So our multidisciplinary team really consists of, for example, OBGYNs who are taking care of women who are thinking about or who are pregnant. It accounts for people like maternal fetal medicine doctors. Those are OBGYNs that are highly specialized in the care of women who have complex medical histories including cardiovascular disease.

It also accounts for people like me who are cardiologists and really sort of found a niche in this place of women who were underrepresented, who were under recognized and where we saw an opportunity to really collaborate. And we know that we can't do this alone. A lot of women say, will you deliver my baby or are you an OBGYN and I'm not.

So it's important for them to realize that through a program like this, it's really putting a lot of heads together to think about all the potential iterations and to make sure that we're not thinking more about baby than mom or more about mom than baby, but thinking about everything comprehensively as a whole.

So in our TGH Cardio-Obstetrical program, we see women of all, you know, the whole spectrum of reproductive age. Women do not have to be pregnant to come to our program. They maybe are a survivor of congenital heart disease and had prior cardiac surgery when they were young. And the reality is those women are now reaching reproductive age, which is fantastic.

And they're thinking about having families and they want to discuss what are their potential options and what would be the risk. And those are great. We love talking about things before they actually happen. The reality is that 50 percent of the pregnancies in our country are really kind of unplanned, including among women with cardiovascular disease.

So this is a totally no judgment zone. We're always happy to take women who have cardiovascular disease who are now pregnant and still want to have those discussions about, what will things look like for me and baby? What are the risks associated with pregnancy?

And then last but not least, we spoke a lot about sort of this postpartum and fourth trimester period. So for that, we now have a specialty called postpartum clinic called Healthy Hearts, where we really focus on setting the tone, increasing education surrounding maybe the complications that happen during that pregnancy and making sure that we do risk stratification. What does that mean? It means like, there may be laboratory values or maybe certain parameters that we check to sort of assess what is the cardiovascular health of that woman.

And then importantly, we do our best to connect women to the right resources, including things like primary care physicians so they can continue on that sort of really lifelong trajectory of trying to optimize and improve their future cardiovascular health.  

Host: Thank you so much for sharing your expertise today. I, I learned a lot and I'm sure our listeners will as well. And it's gotta be reassuring to women who are pregnant to know that your program offers all these resources. So again, thank you so much for talking with us on this important topic.

Daniela Crousillat, MD: Thanks so much for having me.  

Host: That has been Dr. Daniela Crousillat. For more information, please visit tgh.org/cardioOB. If you enjoyed this episode, please be sure to like, subscribe, and follow Community Connect, presented by TGH on your favorite podcast platform.

I'm your host, Maggie McKay, and this is Community Connect presented by TGH. Thanks for listening.