Transcription:
Heart Disease and Pregnancy

Melanie Cole (Host): Thanks for tuning to Back to Health, the podcast that brings you up-to-the-minute information on the latest trends and breakthroughs in health, wellness, and medical care. Today's special episode is part of our Women's Health Wednesday series, which features in-depth conversations with Weill Cornell Medicine's top physicians on issues surrounding women's health throughout the life course. Listen here for the information and insights that will help you make the most informed and best healthcare choices for you.

I'm Melanie Cole. And today, on this Women's Health Wednesday, we're discussing heart disease during pregnancy with Dr. Inna Landres. She's an Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College Cornell University. Dr. Landres, it's a pleasure to have you join us today. I'd like you to start by telling us some of the changes to our heart and blood vessels that typically happen with pregnancy. We know everything changes with pregnancy, but what happens specifically to our cardiovascular system?

Dr Inna Landres: Absolutely, Melanie. First of all, thank you for inviting me to talk today. So, a lot of changes are happening, most of which women don't actually realize or feel. The most important thing that happens to your heart is that the cardiac output, that is the amount of blood the heart pumps in a minute, increases dramatically and as much as 50% at full term. We tend to see an increase in your resting heart rate as the pregnancy progresses, as well as dilation of blood vessels to keep up with the increase in the cardiac output. At the same time, blood pressure often increases by the second trimester, but then decreases and again starts to rise in the third trimester. These changes will, of course, vary in individual patients and in different pregnancies. So, one pregnancy could be different from another. Also, these changes may be more dramatic in twin pregnancies. While most women do not feel these changes as they happen over time, some can develop symptoms such as racing heart rate or dizziness as the pregnancy progresses.

Melanie Cole (Host): Well, we certainly know our bodies do some incredible things when we're pregnant. Now, what is cardiac disease in pregnancy? What kind of heart problems could develop during pregnancy? And how common is something like this?

Dr Inna Landres: Sure. Cardiac disease refers to any complications related to your heart in pregnancy. New heart problems that can develop in pregnancy can include arrhythmias. Some of these may be benign and can just present with having racing heart rate or palpitations, and that could be managed with lifestyle changes such as cutting out caffeine, but others can be more dangerous and need immediate treatments. So, there are common conditions like arrhythmia, as I mentioned. There are also some rare conditions, but potentially deadly heart condition. One of them is called peripartum cardiomyopathy. This can develop at the end of pregnancy or in the postpartum period. This is essentially a type of severe heart failure. It's pretty rare with a frequency of one in a thousand births worldwide, actually rarer in the United States with one in 2000 births. But there are also pregnancy-related conditions that can affect your heart. The most common condition is preeclampsia.

Melanie Cole (Host): So then, tell us a little bit about preexisting heart diseases that could affect pregnancy. So, you mentioned all of these, but then there are also diabetes and blood pressure issues, and you mentioned pre-eclampsia that can contribute to more pregnancy problems that are heart disease-related. So, tell us whether it's congenital, whether it's new-onset or something related to high blood pressure. Tell us a little bit about how these all go together to contribute to this.

Dr Inna Landres: And actually preexisting heart conditions are more common than heart disease that develops as a new diagnosis in pregnancy. And really, any type of heart disease in reproductive age women can have negative effects on pregnancy. These heart conditions, as you mentioned, may be congenital, that is your born with them, or acquired, i.e., you develop heart conditions due to other risk factors such as preexisting hypertension or diabetes. Examples of some common heart conditions that we see in pregnancy include different types of arrhythmias, which are irregular, abnormal heart rates. Certain types of valvular abnormalities of the heart, so that specifically means abnormalities of heart valves. That can include conditions such as bicuspid aortic valve or perhaps sequelae of old rheumatic heart disease, abnormalities of the aorta, and a medical condition we call cardiomyopathy, which is essentially chronic heart failure. Also, you can have heart disease that can be related to preexisting hypertension or diabetes manifest with negative effects in pregnancy. There are also some rare heart conditions that affect certain patients, such as those with connective tissue disorders, for example, Marfan syndrome.

Melanie Cole (Host): With all of these various forms of heart disease, I'd like to touch on something before we get to treatment. Because we know, and we've learned more and more, Dr. Landres, about disparities in cardiovascular disease and diabetes and all of these things for general outcomes, with higher rates of morbidity and mortality among non-white and lower income women, and that those contributing factors of barriers to pre-pregnancy cardiovascular disease assessment, and pre-pregnancy and neonatal care and care during pregnancy, all of these things, these gaps can contribute to cardiovascular disease in pregnancy. Can you speak a little bit about that?

Dr Inna Landres: Yes. Unfortunately, in the US, there are significant disparities in outcomes of pregnancies with cardiovascular disease, with higher rates of morbidity and even mortality among non-white and lower income women. For example, non-Hispanic black women have more than three-fold higher risk of cardiovascular mortality. And pregnancy outcomes are worse when these risks are not recognized, and disease is not appropriately managed by experts.

Contributing factors include barriers to preconception evaluation, missed opportunities to identify major cardiovascular disease risk factors such as hypertension, diabetes, gaps in appropriate intrapartum and postpartum care, and also major disparities in healthcare access. This leads to misdiagnosis or inappropriate treatment.

So, there is a lot more we need to do to improve healthcare access among high-risk populations, such as having a dedicated pregnancy heart team, improved coordination of care between obstetric service and cardiology services, and also assuring necessary followup postpartum as many patients get into trouble once they leave the hospital and are home with their babies.

Melanie Cole (Host): Certainly a complex problem. I'd like you to tell us about early risk factor identification, modification, obviously you mentioned that earlier, and signs and symptoms. So if a woman does not have preexisting heart conditions, but maybe she develops gestational diabetes or high blood pressure or any number of conditions during pregnancy itself, how does she know?

Dr Inna Landres: Sure. So when we are evaluating risk of pregnancy with anyone with preexisting heart disease, we have a number of risk stratification systems that have been validated to determine pregnancy risks of specific heart conditions. So, the most important recommendations I can make is to make sure you speak with your cardiologist if you have known diagnosis of heart disease, if you're considering future pregnancy and also get a referral to see us maternal fetal medicine specialists for preconception consultation.

What we do is we review your whole medical history and specifically focusing on cardiac history in detail, and counsel you based on risk stratifications about risks of future pregnancy. And of course, it's also important to undergo detailed cardiac evaluation before planning a pregnancy. And you may be advised to undergo additional testing such as cardiac stress test or Holter monitors prior to pregnancy to better quantify your risks in future pregnancy.

Optimizing future pregnancy outcomes also involves making sure you have a healthy lifestyle. This means avoiding tobacco, other recreational drug use, minimizing alcohol consumption even before getting pregnant, regular exercise and having a heart-healthy diet, and ideally a normal pre-pregnancy weight.

Many patients worry about exercise in pregnancy, so I just wanted to mention that, with preexisting heart disease. And although there are a few conditions where we do recommend limiting activity in pregnancy, most patients that will actually benefit from continuing regular exercise throughout pregnancy.

In terms of your question about what if you don't have a diagnosis of heart disease, how do you know, what symptoms do you look for? So, there are actually some challenges in pregnancy. The challenges of diagnosing new heart disease in pregnancy is that many common symptoms of normal pregnancy can mimic those of heart disease. For example, leg swelling in the third trimester is common. A lot of patients can experience benign palpitations and sometimes dizziness. and these are fairly common and often normal, but could also be signs of concerning heart problems. Important thing is to bring up any unusual symptoms to your OB, especially if they're recurring. And additional tests may be needed and often include EKG, blood work, x-rays. And if anything is concerning, definitely a cardiology referral. Anyone with preexisting heart disease, we take these complaints pretty seriously and definitely we'll need to do further testing.

Melanie Cole (Host): I'm glad you made such a good point, Dr. Landres, about telling your doctor about everything because stress can mimic heart issues. Pregnancy, obviously there's so many different things that go on when you're pregnant. Your legs could swell, but they also could swell because there's something wrong. So, we have to be sure to mention every single thing that you think is concerning to your doctor. It's really about that communication and shared decision-making. That's what makes us women our own best health advocates, and that's what these Women's Health Wednesdays are all about, is learning how to take care of ourselves so we can take care of the ones that we love. And certainly when we're pregnant, we're going to have a lot of stuff to do.

So before we wrap up Dr. Landres, I'd like to speak about management of heart disease, whether it's congenital, whether we knew about it before or something new. You mentioned exercise. I'm an exercise physiologist, so I love that exercise component of all of this, but what else do you do? Because pregnant women may be concerned about medications during pregnancy or, you know, some of these other management modalities. So, speak about what you're doing.

Dr Inna Landres: Of course. Management of heart disease involves working with a team of experts to take care of our patients. So here at Cornell, we have the obstetric cardiology program, which coordinates care between obstetrics, cardiology and OB and anesthesia teams. Our goal is to provide multidisciplinary approach to patient care, and we meet monthly amongst ourselves to discuss all of our pregnant and recently delivered patients, review their delivery plans, their medications, and all the followup that they need. We also involve other experts from various fields such as social work, psychiatry, nutrition, genetics, pediatric cardiology when indicated based on individual patient needs. So, I believe that expert and individualized care is really key to success for outcomes of moms and babies with a heart disease in pregnancy.

Melanie Cole (Host): I agree with you. So, wrap it up for us with your best advice for women, so that we can be as healthy during our pregnancy as possible, and really what you would like us to know about heart disease and pregnancy.

Dr Inna Landres: I think as a summary before becoming pregnant, even if you don't have heart problems, make sure you see your primary care doctor for general screening. Know your risks. If you have preexisting heart disease, it's really imperative for you to see your cardiologist and one of us in maternal fetal medicine for full evaluation and risk assessment. And although risks for mothers with preexisting heart disease are higher, both with increased risk for maternal morbidity and mortality, unfortunately, these are scary statistics, it also doesn't mean a healthy, safe pregnancy cannot be achieved. As I have stressed, preconception evaluation and optimization of heart health before pregnancy is key. And there may be some conditions where you shouldn't get pregnant. So, it's really important to know your risks. It's also key to have expert followup throughout pregnancy to vocalize any concerns you have to your OB and your cardiologist. And our goal is always having a safe delivery and postpartum monitoring plan. And as high-risk physicians, we are here to take good care of you and get you through pregnancy safely with close monitoring and followup.

Melanie Cole (Host): Great topic. Thank you so much. That was excellent information. So informative. Thank you again for joining us, Dr. Landres. And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

We're so glad you joined us for Women's Health Wednesday. We hope you'll tune in and become part of a community and fast-growing audience of women looking for knowledge, insight, and real answers to hard questions about their bodies and their health. Please download, subscribe, rate, and review back to Health on Apple Podcasts, Spotify, and Google Podcasts. For more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. I'm Melanie Cole. Thanks so much for joining us today.

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