Talking Tall Rounds®: Team Based Approach to Cardio-Obstetrics

Podcast Transcript

Announcer:
Welcome to the Talking Tall Rounds series, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Deirdre Mattina, MD:
Good morning everyone, welcome to Cleveland Clinic Tall Rounds. I'm Deirdre Mattina. I'm one of the newest members of the Cleveland Clinic staff, and very excited to be here with you today to talk about a team-based approach to cardio-obstetrics. We have a great lineup of professionals, including OB-GYN, maternal-fetal medicine, cardiology, and we'll be discussing how we go about managing high-risk pregnancies and any complications that may appear in the postpartum period.

Deirdre Mattina, MD:
I'm going to bring us back to a public health level. I know we've talked about some very dangerous, but albeit rare, complications with aortopathies and even valvular heart disease in pregnancy. But pregnancy-related mortality is still a very significant contributor to maternal death. This data is from the Ohio database from 2008 to 2016, and while we can see some ebbs and flows in mortality trends, we are still below the national trend line with about 12 deaths per 100,000 live births in Ohio, and there are about 135,000 births in Ohio yearly.

Deirdre Mattina, MD:
Despite these numbers, the United States still remains ranked 64th in the world for maternal mortality, and this is one of the very worst in the developed countries. We're about on par with Sudan and Afghanistan, which seems quite amazing with all the technologies we have available.

Deirdre Mattina, MD:
This is a similar pie chart that many states will put together for their maternal mortality review boards, and I know we can hear different numbers, depending on how we label our diagnoses. Most, if you see here, we have cardiovascular and coronary conditions is lumped separately from cardiomyopathies. I would argue also, as a general cardiologist, that preeclampsia or the hypertensive disorders might also fall within this cardiovascular component, and then in this other slice of the pie, cerebrovascular accidents are also contained within there. If we add up some portion of all this pie, we can have up to 40% of pregnancy-related deaths due to cardiovascular conditions.

Deirdre Mattina, MD:
70% of the deaths occur within one year postpartum, and sadly a third of those occur within the six weeks postpartum. Overall, 57% of these deaths are preventable, and if we just look at preeclampsia and eclampsia itself, 85% of these deaths are preventable, so we need to develop better systems in place for recognition and management of these in the postpartum period.

Deirdre Mattina, MD:
This does create a healthcare disparity, as black women have 2.5 greater risk of death than white women. And for all of the numbers we hear and see related to death, every death there is about a hundred more women that have significant life-threatening injury or illness during pregnancy as well. So outside of the death, there's significant morbidity associated with this.

Deirdre Mattina, MD:
Why I bring this up in the postpartum period, again, I know we're tired of looking at red and blue states at this point post-election. This is not a political slide, but this does give us a review of expansion of Medicaid, because when we look at healthcare in the postpartum period for many pregnant women, traditionally about half of pregnancies are funded by Medicaid in the United States. Before the Affordable Care Act, they had coverage for only 60 days postpartum, so when I give you that information about a third of these deaths occurring in six weeks postpartum and 70% in one year, it is very important that many of these can be unrecognized or lost for the uninsured.

Deirdre Mattina, MD:
These are just showing you states... There are at least 14 states that did not expand Medicaid under the Affordable Care Act, and obviously we're not exactly sure what will happen to the Affordable Care Act, but this is another region where we need to work on for healthcare disparities.

Deirdre Mattina, MD:
One may ask, "Why do we have such poor outcomes in pregnancy-related mortality?" Of course, our landscape is changing in terms of cardiovascular health across America. This review from the AHA earlier this year is looking at all pregnant women, and it's using the guidelines of the simple seven outlined by the AHA, basically a healthy diet of fruit and vegetables, physical activity of 150 minutes weekly, no smoking, adequate BMI, blood pressure, cholesterol and sugar control. When they looked at all of the pregnant women age 20 to 44, only about 5% were in ideal cardiovascular health. 60% were intermediate cardiovascular health, and about 35% are in poor cardiovascular health, so obviously we are dealing with a different substrate of women getting pregnant, getting pregnant later in life, and already with comorbid conditions that may complicate pregnancies going forward.

Deirdre Mattina, MD:
Another risk factor is that many women, as we've discussed, aortopathies and other things, many of these women may have been followed by a cardiologist, or at least in some form of medical care because of their diagnosis. In preeclampsia, and I'll get to gestational diabetes, a lot of times these may happen very late in the pregnancy, just before delivery. It may have been presumed to resolve at the time of delivery and then not mentioned again for a significant amount of time after that, but I want to drive home the point that preeclampsia is not a benign condition.

Deirdre Mattina, MD:
In this review by the BMJ, there is a relative risk of 1.5 for all-cause mortality for any woman that has had preeclampsia before. When we look at gestational diabetes, the trend in 10 to 15 years postpartum for any woman that has had gestational diabetes is an increase of myocardial infarction, ischemic stroke, coronary bypass surgery and angioplasty. This particular study did not control for smoking and ethnicity, but other cohorts studies have looked at a relative risk of about three for increased risks of ischemic heart disease after a diagnosis of gestational diabetes.

Deirdre Mattina, MD:
So again, it's about what the systems in place that we have, and I'm focusing a lot on preeclampsia and gestational diabetes because I think these are modifiable risk, and the way we can capture a lot of these maternal deaths that are preventable. California has really served as a gold standard for reducing maternal mortality through their states. Several years ago, they were above the national average, and found that their leading causes of death were hypertensive pregnancy disorders and postpartum hemorrhage. They developed a series of toolkits to really address all of these issues, and I think this is a sample of their postpartum toolkit.

Deirdre Mattina, MD:
As I mentioned, many of these women may go home, their blood pressure may have normalized, and can just present to the ER several weeks later, several days later, and so a lot of this triage is happening within the emergency room, and these might not necessarily be physicians that are trained to recognize some of these risks, so I like the idea of simplifying this toolkit so that there can be a checklist for all of our providers across the healthcare spectrum.

Deirdre Mattina, MD:
Basically you're going to look at symptoms of heart failure, any abnormal vital signs, other risk factors for cardiovascular disease, and exam findings obviously. If we add up any of these signs or symptoms greater than four, that prompts us to either consult cardiology, maternal-fetal medicine, OB, and obtain other markers. It could include an EKG, chest x-ray, BMP, which Dr. Bacak talked about before, that would help us ferret out, are these normal physiologic changes from autotransfusion, a lot of volume overload post-op or in the postpartum period, or is there something more significant going on?

Deirdre Mattina, MD:
Again, as many of my colleagues have discussed, the time for managing pregnancy does not begin at delivery. We really need to start with the preconception counseling, having multidisciplinary meetings to discuss what the best timing and plans for labor and delivery are, and what the follow-up plans are post-op and post-delivery, and that should include... Most guidelines are recommending now that a woman be seen within three weeks postpartum, either in the OB clinic or depending on what their specific disease state is, so that we can develop plans for them, long-term management, and to mitigate risk of future cardiovascular disease.

Deirdre Mattina, MD:
And of course, educating women about these, because as I mentioned, many of these can be young women. They hear about gestational diabetes, think "Okay, I maybe took some insulin or metformin during pregnancy and now I'm done, never thought about it again," and we really want to educate them on the future risk going forward, and as well as our providers. Thank you very much.

Leslie Cho, MD:
Like the three-day contractions, were also behind, so I apologize. I want to just spend some time talking about what we offer at the Cleveland Clinic, and just to say the Preventive Cardiology, we have Resistant Hypertension Clinic, Cardio-metabolic Clinic focusing on diabetes, Complex Lipid Clinic, our Cardiovascular Behavioral Health Clinic, a Weight Management Clinic, nutrition and exercise physiologists. It was really no surprise that Dr. Chapa who is part of our OB group, who heads our Maternal-Fetal High-Risk Clinic, reached out to us to develop a specific program for patients who have preeclampsia, gestational diabetes and some other high-risk features pre and post-pregnancy to manage their cardiovascular risk, and this is actually in conjunction with the primary prevention guideline that was published by the ACC group that I was lucky enough to head.

Leslie Cho, MD:
These are the conditions that warrant a clinic visit to Preventive Cardiology, whether you had chronic hypertension, gestational hypertension, preeclampsia, eclampsia, HELLP syndrome, gestational diabetes, pre-term birth. If you have high-risk features, then you get referred to Prevention Clinic. You get seen within three months postpartum. We have a medical history, smoking history, physical exam, whatnot, and then we get some basic lab values, but most of the interventions that we do is really nutrition and exercise. As the group knows, if you have preeclampsia, the next time you get pregnant you're more likely to become preeclamptic again, and gestational diabetes and so on.

Leslie Cho, MD:
That has made it into the summary of updated recommendation for primary prevention cardiovascular disease in women. This was the ACC group. Of course, we now think about traditional risk factors, which is hypertension, diabetes, hyperlipidemia, smoking, family history, but for women, we really want to focus on these pregnancy-related adverse outcome, because that does become a risk enhancer, and then obviously there are other risk factors.

Leslie Cho, MD:
In conclusion, the postpartum clinic visits, from prepartum, all the way to pregnancy and delivery and postpartum, it's a comprehensive care plan here at the clinic. Thank you so much.

Announcer:
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