Jyoti Sharma, MD, FACC, FASE, Medical Director at Piedmont Heart Institute in Atlanta, presents a case-based discussion on how to care and manage cardiovascular health in pregnant and post-partem patients.
And I'll be happy to present our next speaker, Doctor Joy Sharma. She's the medical director of the Women's Health Program at Piedmont Heart Institute. I had the pleasure to work with Doctor Sharma Pima for 14 years. She's an outstanding speaker. She's a phenomenal clinician and most of all a great friend, Jo. Thank you. Thank you. Thank you. Thank you, Jamie does all my pr work. Thank you. So nice to be here with all of you this morning. I am going to be talking about cardio obstetrics. The point of this talk is that it's really supposed to be a practical talk. I realize not all of us are cardio ob experts, but my hope is that after we go through some of these cases, you're gonna feel like this was a good refresher and just a good reminder of places uh to start. So, let's see. I have no disclosures. So a little bit of what we are going to talk about, just a little bit of background on cardio obstetrics and this is going to be a case based discussion. Um And so we're gonna go over some uh hopefully some common things including a hypertension uh in pregnant women, taking care of that and then additionally appropriate cardiovascular imaging in your pregnant patient. And this is gonna be uh based on a case of a clinic patient of mine with a aortic valve and aortopathy. So why do we care about cardio obstetrics? Well, maternal morbidity mortality here in the US has been rising for the last very many decades and even worse for those of us in this room. The numbers here in Georgia are terrible cardiovascular disease is the leading cause of pregnancy related death here um in the United States. And so why is this happening? Women are older when we're getting pregnant, we have more risk factors and just more complex cardiovascular disease when we show up with our pregnancies. And so out of this was born, this sort of emerging cardio obstetric model of care. And so why again, why do we care? So this is a picture of the US uh gold uh gold medal winning Olympic team. They were, this was in the four by 100 in Rio. Um And this woman on the right, her name is Tori Bowie. She's 32 years old. She's a three time Olympic medallist and she died when she was eight months pregnant uh due to complications for preeclampsia and she lost her baby. This woman on the left Alison Felix, her teammate had an emergency C section. Her story was had a much happier ending. She and the baby are OK. But why again, why do I share this with you? It is to make this point that cardiovascular disease and maternal morbidity mortality are intertwined in, in such a way that even our country's finest and most elite athletes cannot escape this, that there is a deep impact and that we have a lot of work to do within our own cardiovascular communities. And this needs to be top of mind for us when we're taking care of our patients. And so having said this, let's get started. So first case I was on service a couple weeks ago, I got called for a consult. She's the 38 year old lady. She has a history, she tells me of high blood pressure at the time of her last delivery, uh, which was two years ago and she's admitted to the hospital for vaginal bleeding and also a headache. She's about 22 weeks pregnant. She's not on any cardiovascular meds. She didn't really follow up after her last pregnancy. Um, so when she originally presented to the, er, her blood pressure was like 200/100. So they gave her some IV hydrALAZINE. And then by the time I saw her, her blood pressure was a little bit better. 1 73/1 09, I'll point out a couple of pertinent negatives on physical exams. She didn't have any JVD. She's clear lungs, her chest x-ray EKG were all unremarkable. A couple other things to note on her lab work. Creatine looked OK, she's a little bit anemic platelet count is OK. And by the time I saw her, her analysis was pending. So when we think about hypertensive disorders of pregnancy, I like, I like this uh this model sort of this framework. This is a, a cog uh bulletin that was published in 2019. So not anything you have to memorize but easily Google. I'm sure that's a verb. Uh And so really, when you think about pregnancy or hypertension in pregnancy, is it severe or not? And is your patient before or after 20 weeks pregnant? And so, in this case, my patient is after 20 weeks of gestation and she had um severe, severely elevated high blood pressure features um that were also consistent with preeclampsia. So, um and with her, in particular, her um sort of her headache was the other thing that was particularly important. Her analysis later came back and she did not have any proteinuria. Just a reminder also that hypertensive disorders of pregnancy are the most common adverse pregnancy outcome that you will see in your patients. About 5 to 10% of women does disproportionately impact African American women. So you've got to treat this patient. What are your options? Really? When you think about treating pregnancy in women and hypertension in pregnant women, you really want to think about three drugs. Just remember these three you wanna think about and you can also think about alpha methyldopa. But I think I've used that like maybe one time in my life. Um really, we can get very good blood pressure control just with labetalol and Nephetapine. And if you do need to use something um IV drugs in the acute setting loni and also hydrALAZINE as was used. In this case, I do want to make a point about ace inhibitors and arms. I think all of us know that we shouldn't be using that in pregnant women. The data that was originally published was all in 2nd and 3rd trimester. But more recent data has come out about even using this in first trimester. And there is bad outcomes uh when the fetus is exposed to this even in first trimester. So in my clinic and in my clinical practice, if there is any woman of childbearing age, I will not put her on ace inhibitor or s for treatment of her hypertension just this week. And when I was in clinic, one of my patients is like, did you hear Courtney Kardashian got pregnant and she's 44. And so just again, sort of a good reminder that we want to be conscientious about that. No, I didn't know that Courtney Kardashian was pregnant. Um And so again, why do we care about this nice study that was published in 2019 and Jack about the long term cardiovascular um uh outcomes that are associated with hypertension. This was done in the UK, looked at over 200,000 women. And so, what did it show? Well, hypertension is associated with accelerated uh cardiovascular aging and really probably even in more diverse conditions than we had previously appreciated. So, yes, we think about heart failure. Yes, we think about coronary disease. But these women are going to be showing up in our clinic decades after their pregnancy with aortic stenosis and mitral regurgitation. And in fact, when I talk to my patients who are in their fifties and their sixties and I'm taking my history and I say, tell me what happened to you during your pregnancies. Do you have any Children? You are gonna be very surprised at the amount of women that tell you yes, I had hypertension, pre eclampsia, eclampsia. And sure enough, this is what you're gonna be seeing them for um in clinic. And so in the interest of time, we'll move on to the next case. So this was a lovely 36 year old lady who um showed up in my clinic, she had as a bicuspid aortic valve. She was diagnosed with that as a teenager. Um She had an echocardiogram previously that showed moderate aortic regurgitation and an ascending aortic aneurysm that measured 4.3 centimeters. She came to see me when she was 14 weeks pregnant. She has no symptoms, feels great. She just moved to town and needs a cardiologist. She has a normal blood pressure on exam when I saw her. So I knew that I was going to want to do some kind of imaging to take a look at this valve, take a look at this AORTA and sort of figure out next steps. I think these are some things I could think about. But really, for me, what was top of mind was really probably starting with a transthoracic echocardiogram. If you look at the ACOG uh recommendations for doing transthoracic echocardiogram and pregnant, pregnant women, pretty much, everybody gets a transthoracic echocardiogram, hypertension, pulmonary hypertension a or atop at the uh cardiomyopathy, anything that you can pretty much think of hypertension palpitations, everyone should get an echo again. No, um no radiation exposure widely available. So let's look at um management in particular of women with opathy. And let's focus here on bicuspid aortic valve. The thing that you really want to remember again, the number that you want to keep in your head is 50 millimeters. If a woman has a bicuspid aortic valve, and if she comes to see you and you see her aorta is more than 50 millimeters and she tells you she wants to get pregnant, you probably want to think about intervening on that aorta prior to her pregnancy if she comes to you and now she's pregnant and the aorta is more than 50 millimeters, you want to think about Cesarean delivery. The other thing is that if it's somewhere between 40 50 millimeters you are gonna want to do very frequent imaging on her. And additionally, you also want to get a fetal echocardiogram. Let's also think for a minute about this patient because she also had a reported history of aortic regurgitation. And so regurgitant lesion tends to be far better tolerated in pregnancy um than stenotic lesions. But again, in aortic regurgitation, if it's anything, then more than moderate, you're going to want to continue to do serial imaging. Um You can think about vaginal delivery. And additionally, you do though want to sort of anticipate the need for diuretics in the para part uh period. So you're gonna order this echocardiogram and you want to be very conscientious about how you are going to interpret this echocardiogram in pregnant women. I love this diagram just because it's such a nice sort of reminder of how we should be um thinking about interpreting this. So a couple of things as a reminder of things that should not change in pregnancy. The LVEF the RVEFP A systolic pressure really should not be changing in pregnant women. I want to make a comment here about the aortic root. There's some limited data that probably says again, in sort of your run of the mill patient, your aortic dimensions again, really should not be changing in pregnant women. Although we do know that pregnancy can result in a weakening of the aortic media. So in some women who are more vulnerable, for example, we do see increased rates of dissection, things like that. Um Things that will increase in pregnancy is your left ventricular and diastolic dimension and that is normal. So, particularly in the setting of aortic regurgitation, we know that we're gonna be using LV and diastolic dimensions to help us grade our aortic regurgitation. So you want to be conscientious of things like that, you're gonna want to use other parameters that you look at when you interpret your echo uh to uh just keep that in mind. So here is my patient's echocardiogram on the left parasternal long axis view. Uh Sorry, I can't get that to loop, but overall LV size looks normal. LVEF looks normal. And then here you can see that she does have some aortic regurgitation to my eyeball. I don't know, somewhere between mild to moderate. And then here was her aorta on her um echocardiogram measured around 4.4 centimeters or so. So I wanted more information. This wasn't good enough for me. I do know that CT and MRI are really sort of gold standards for looking and uh looking at the aorta. So I chose to do a non contrast cardiac MRI to take a look at her aorta. Again, picture on the left, you can see indeed her aorta is big. She's got regurgitation that middle picture. Again, you get a sense and sort of this long axis that the aorta is big. And then truly when we take these dimensions and short axis, her aorta measured about 4.2 by 4.1 centimeters. So overall, she has normal LV, size and function, moderate aortic regurgitation and an ascending thoracic aorta that measured 4.2 by 4.1 centimeters on Mr and it was 4.4 by E. We ended up doing serial echocardiograms every trimester on her, uh everything essentially remained unchanged. Her blood pressures were well controlled and we did get a fetal echocardiogram in the second trimester. She had a scheduled C section that was due to obstetric indications, not cardiac. Um She had a really super cute healthy baby um and there was no per partum diuretic use that was required. Um And now I've seen her in clinic and she's done great. She's done great with Echo and I'll plan for a cardiac MRI here coming up in the future. Uh Just some closing thoughts for um the group here. Don't be nervous when the pregnant lady walks into your office, you can do it. Um And I'll share some of my favorite references here at the end. Um When she has hypertension, I really want you to think about Ol and Nifedipine and use lots of caution when you want to use ace inhibitor and a a in women that are of childbearing age. Remember that echocardiograms are gonna be one of your first line tools to help image your pregnant ladies and talk a lot with your partners mfmob to kind of help sort out what you're doing. And I will share some of my most recent favorite references because I have so many, but I'll just share my top, my most recent favorite ones Jack published at the end of 2021. They did a uh focus seminar on cardio obstetrics. It was a series of five articles. Um and uh it really covered everything from acquired disease to inherited disease, sort of how to manage airy valve disease per part. And cardiomyopathy arrhythmia as you name it. Um, it's all in there. So, uh just want to be conscientious of time. Thank you so much for your attention this morning.
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