Common Questions about Pregnancy and Heart Disease

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Karlee Hoffman, DO:

I'm Karlee Hoffman. I'm one of the heart failure and transplant cardiologists here at Cleveland Clinic main campus. I also specialize in cardio-obstetrics, which means I see patients who have underlying cardiac diseases and are pregnant. So I am so honored to be here today to talk to you about cardiac disease in pregnancy, and I'm going to start with the five questions I most commonly get from my patients who have an underlying cardiac disease and are considering pregnancy or are currently pregnant. I see heart failure patients specifically, but again, this can be generalized to any kind of cardiac condition that you have.

Some of my patients say, "I am not on any birth control, or I'm not on any contraception because I can't get pregnant because I have an underlying cardiac disease." I always tease this out a little bit with them, and I just want to ensure that they know that yes, they can absolutely get pregnant. Biologically, they can get pregnant. Just because you have a cardiac disease does not mean that you can't get pregnant. I always recommend contraception or preconception counseling for these patients before they start this journey of building their family because I want to be clear, just because you have a cardiac condition doesn't mean that you can't get pregnant. You actually physiologically can get pregnant, it's just a discussion whether you should or not.

With that, I think the great news is there are very few conditions where pregnancy is absolutely contraindicated. Some of these conditions or conditions that I take care of, like heart failure, when your heart pump function is low, or if you have pulmonary hypertension, or if you have an underlying genetic disorder that causes your aorta to be enlarged, these are some, not all inclusive, but some of the reasons it's so high risk that you shouldn't get pregnant. But most other conditions, it's definitely worth a discussion with your provider to weigh the risk-benefit of pregnancy and whether this is a journey that you can fulfill if these are your life goals to build your family.

Again, number one, if you have a heart condition, you absolutely can get pregnant physiologically. The next question is should you or should you not based on the risk-benefit profile for your individual personal goals?

 The next question is that if you have a heart problem, you have to deliver via C-section. This is a great question and a really important topic when it comes to women with cardiovascular diseases. Again, if I take the heart failure patient, for instance, the heart failure patient doesn't have to deliver via C-section. Or if you have uncontrolled high blood pressure, you don't have to deliver via a C-section from a cardiac indication. Most of the time, the mode of delivery is dependent on the obstetric need, not actually the cardiac need.

So for instance, in all of my cardiac patients, I really advocate for them to have a vaginal delivery. That's preferred. It's preferred for many reasons because one, there's not as much physiological or fluid shifts that occur in a vaginal delivery, so it's actually safer for the patient long-term. There's a decreased risk of bleeding and therefore, needing blood transfusions and IV fluids. There's a decreased risk of infection, a decreased risk of having a thromboembolic event if you have a vaginal delivery, so absolutely from a cardiac perspective. Again, there's always very few exceptions, but most of the time it's safe for a patient to deliver vaginally and they do not need a C-section. Again, this is most of the time a very multidisciplinary discussion, and we're fortunate to have a cardio obstetric program here at Cleveland Clinic where we have a combined clinic with the MFM and the cardiologists to make the best decision the patient. But most of the time, cardiac patients can deliver a vaginal birth and they do not need a C-section.

Moving on to the third question that I get most of the time. A lot of our cardiac patients are on a lot of medications, and this is always such a big topic. The moms always want to know, is it safe for my pregnancy? Is it safe for the baby for me to be on these medications? There are definitely medications that are not safe during pregnancy. However, most medications are safe for the mom and the baby during pregnancy. For example, some of the common medications that I prescribe to a cardiac patient who is pregnant are beta blockers like metoprolol and aspirin, and these are safe for the mom and the baby. In all medications in a pregnant patient, there's very limited data. However, again, very few absolute contraindications. I always tell the patients, "If we're treating you with medications to keep the mom safe and the blood pressure down, this equals healthy mom, healthy baby." So again, everything in life is about risk benefit, but most of the time, most cardiac medications are safe during pregnancy.

Moving on, another question I often get asked is if I'm pregnant, do I need to follow with anybody except an OB? Because that's what I'm focused on. That's the goal, is to deliver this baby. Do I need to see my PCP or do I need to see a cardiologist? My blanket statement to that is if you have an underlying cardiac condition, you should absolutely consult with your cardiologist, preferably in a pre-conception counseling type of conversation, but you should absolutely engage your cardiologist and also your PCP. Again, fortunate enough here at Cleveland Clinic, we have this multidisciplinary team of MFMs, which are high-risk OB doctors, and we work closely with our OB doctors, along with our cardiologists to have the safest approach to pregnancy for the mother and the baby. I always tell the patient, "Our goal is to get you and baby here safely, and we have to truly work as a whole multidisciplinary team to ensure that happens." So the answer is yes, you need to see your ob, your cardiologist and most likely your primary care doctor.

That leads to our fifth and final question that I often get. Do I need to follow up with a cardiologist after I deliver? Oftentimes, patients are diagnosed with high blood pressure or something called preeclampsia during delivery and a lot of the times the thought is, okay, if I deliver this baby, blood pressure issues resolve, preeclampsia resolves because the baby's delivered, do I need to see a cardiologist afterwards? The answer to this is yes. So if you have a cardiac condition that comes up during pregnancy, it's really important to have long-term follow-up because I describe pregnancy as the ultimate stress test. It's a nine-month stress test followed by delivery.

So in my mind, I think of it, okay, this is a nine-month marathon, a nine-month stress test followed by the ultimate stress test, which is delivery, and that ends with the sprint. So it's a marathon that ends with a sprint, and you need to follow up with a cardiologist because this is the ultimate stress test. If you have an underlying cardiac condition, it often will come up during pregnancy. We know patients who have high blood pressure or pre-diabetes during pregnancy oftentimes have long-term cardiovascular risk factors like high blood pressure, and they're predisposed to having diabetes long-term. So you need to see a cardiologist after you deliver to ensure everything is safe and stable after delivery, and also that you have a long-term prevention plan to try to prevent these cardiovascular diseases from coming up in the future.

So those are the five most commonly asked [questions] about cardiac disease in pregnancies and I hope this is helpful for you. We're more than happy to see you here at Cleveland Clinic. We have a great team, a truly multidisciplinary team of cardiologists and obstetric doctors who can get you and baby safely through your pregnancy. Again, I'll just promote it's most beneficial to see us even with the preconception counseling so we can go over the risks and benefits and align with your needs of you and your family as you try to fulfill your goals of building your family. So thank you for your time, and I appreciate this opportunity to speak on behalf of cardiac disease and pregnancy.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts, or listen at clevelandclinic.org/loveyourheartpodcast.