Heart Care for Two: Cardio OB Clinic

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On today's episode, we're talking about heart health in pregnancy, an important part of maternal care. I'm joined by Dr. Adina Kern-Goldberger, a maternal fetal medicine specialist, and Dr. Karlee Hoffman, a heart failure specialist. Both are part of Cleveland Clinic's Cardio-Obstetrics Clinic, a multidisciplinary program dedicated to caring for women with heart conditions before, during, and after pregnancy. Dr. Hoffman, Dr. Kern-Goldberger, thanks so much for joining us. Before we start, can you tell our listeners a little bit about your role in Cleveland Clinic and your background? Dr. Hoffman, you can start.

Karlee Hoffman, DO:

Sure. I'm an advanced heart failure specialist, cardiologist, and my real interest and passion is cardio-obstetrics. So we've developed this clinic where we see high risk patients who are pregnant who also have a cardiac disease and we support them to build their families and align with their goals along with taking in the medical risk.

Erica Newlin, MD:

Great. Dr. Kern-Goldberger, what about you?

Adina Kern-Goldberger, MD:

I'm a maternal fetal medicine specialist, which means I'm an OB/GYN physician who has done dedicated training in pregnancy complications. And one of my focuses is on pregnant patients who have complicated chronic diseases like cardiac disease. And so I'm very lucky to get to see patients alongside Dr. Hoffman in our joint heart failure clinic.

Erica Newlin, MD:

To start, why is heart health such a critical part of pregnancy care?

Adina Kern-Goldberger, MD:

So I would think about that in two ways. I would consider sort of a general heart health important for all pregnant patients because pregnancy is really like a stress test. There are a lot of changes that happen in the body during pregnancy that can affect how somebody's heart works both in the short term and in the long term. And there are pregnancy complications, one of the most notable of which is something called preeclampsia, which is a high blood pressure complication in pregnancy that can happen to anybody. And so I think about pregnancy as sort of a time when there can be issues that arise that might affect somebody's heart health in the long run. Separately from that, there are people who enter pregnancy with heart conditions and given sort of the changes and the stress that pregnancy can put on the body, there are unique risks that affect that patient population and special things that we do before, during, and after pregnancy to help monitor those patients and to help reduce risks.

Erica Newlin, MD:

What sorts of heart conditions can affect pregnancy?

Adina Kern-Goldberger, MD:

So there's really a whole range. What Dr. Hoffman and I focus on specifically in our joint clinic is on people who have what's called heart failure or cardiomyopathy, people whose heart muscle doesn't work the way that it's supposed to. And that can sort of present with a whole range of severity. There are people who just have sort of very mild changes in their heart function all the way to people who have really significant changes in their heart function. There are all kinds of other heart conditions that can affect pregnancy too. Another big group is people who are born with a heart structure, a heart shape that is different than typical. And those are usually conditions that people are born with and have been followed for many years leading up to pregnancy.

Erica Newlin, MD:

What symptoms should women pay attention to that might signal a heart-related concern?

Karlee Hoffman, DO:

Yeah, so I always tell patients, this is why we have a job, because it's really difficult to differentiate what's a normal pregnancy and what's an abnormal pregnancy. And I think what we tell our patients is you have to trust your gut. So things that would be concerning would be blood pressure. And this is something objective that we can monitor with blood pressure cuff readings. So I always tell them, take your blood pressure regularly and trend it because if something trends up or down, that could be an objective marker that something is going awry. Other things we often see in pregnancy is swelling or swelling of the legs, edema, shortness of breath. These things, again, are common during pregnancy, but sometimes they can, if out of proportion to pregnancy, which is hard to differentiate, can definitely be a red flag that something else is going on like heart failure and specifically what we treat as postpartum cardiomyopathy in our clinic.

Karlee Hoffman, DO:

So again, just being aware every pregnancy is different. Every patient's going to respond differently to pregnancy, but I always tell them, you have to trust your gut. You have to advocate for yourself because if you feel something is wrong, it's better to be checked out and everything be normal than on the flip side of just letting things go and being dismissive and saying, "Oh, this is just pregnancy. This is my third, fourth pregnancy, this is just what happens." It might not always be the case.

Erica Newlin, MD:

Understanding the risk is important, but equally important is knowing where to go for care. Let's talk about what makes the cardio-obstetrics clinic unique. What is the cardio-obstetric clinic and how does it differ from traditional pregnancy care?

Karlee Hoffman, DO:

The way I describe our cardio-obstetric clinic to my colleagues and patients is it's a clinic that fills a gap. We have cardiologists here at Cleveland Clinic that are amazing at what they do and they're really great cardiologists. However, most of them don't want to take care of pregnant patients because it's out of their comfort area. Same thing with our OB and MFM team. They're amazing OBs, amazing high risk docs, but again, not as comfortable with cardiac disease. So what we do is in our cardio-obstetric clinic, it's a combined clinic that fills this gap. And we provide care to these patients that are the highest risk. They're pregnant or they want to get pregnant or they want to build their family. So they have an underlying cardiac condition or at risk for a cardiac condition. And we bring them into this physically combined, truly multidisciplinary clinic that includes a cardiologist.

Karlee Hoffman, DO:

We have a whole team of cardiologists who do this that are very comfortable with pregnant patients and understand the physiology. And then we have a whole group of high risk MFM doctors who treat from the OB side. So physically together we combine these two doctors with their expertise into the same room to see the patient together. And I think that's really unique. And each patient who goes through our Cardio-OB clinic also has a nurse navigator that helps them make sure all the scheduling and testing is done on the same day so that we have all the available data from a cardiac and OB side. A lot of people describe Cardio-OB clinic. Ours is a truly multidisciplinary, real-time clinic with the appropriate resources to really funnel these patients through so they can make sure they get the best care possible. And I'll just backtrack on one of your first questions.

Karlee Hoffman, DO:

Why is this even important? It's because we know cardiac disease in pregnancy accounts for about 30% of mortality when related to pregnancy. So that's our goal. And what's even scarier about those statistics is about 60% of those when we looked at Northeast Ohio of pregnancy-related mortality could actually be prevented if you bring the right care teams together. If you can educate providers, patients, and get them the appropriate follow-up and resources they need to prevent pregnancy-related mortality. And in my mind, that's our goal. That's the end goal is to prevent mortality related to pregnancy. So we support these very high risk women who want to build their families. We get them through pregnancy and we follow them after pregnancy in an effort to reduce the cardiac pregnancy-related mortality.

Erica Newlin, MD:

Who should consider being seen in the cardio-obstetrics clinic?

Adina Kern-Goldberger, MD:

So we really target our joint multidisciplinary clinic to people who already have a known cardiac disease or have an underlying significant risk factor. And so the majority of people come to us already with a significant cardiac disease. Again, in the context of our clinic with Dr. Hoffman, specifically heart failure, cardiomyopathy, a heart muscle that just doesn't function the way that it's supposed to. We do also see some people who have normal heart function but have either a significant family history or have a known underlying genetic risk that puts them in a higher risk group to develop heart failure during or after pregnancy. So we do take care of those people too. And that's really important. As Dr. Hoffman said, we're learning more and more about our ability to prevent bad complications from pregnancy related to heart disease. And some of that has to do with getting people into this type of multidisciplinary care so that we can do the right evaluations.

Adina Kern-Goldberger, MD:

We can detect any problems early and intervene appropriately.

Erica Newlin, MD:

So once someone is referred to the cardio-obstetrics clinic, what does that care actually look like? Let's walk through the patient experience. What can a patient expect during their first visit to a cardio-obstetrics clinic?

Karlee Hoffman, DO:

So again, a very unique resource that we are very thankful to have are cardio-obstetric nurse navigators. So when a referral is placed to our clinic, the patient will actually be contacted by our own navigator who can advocate for them and get them into the appointment. So what that nurse navigator does is it schedules them with the appropriate cardiologist, the appropriate MFM doctor on the same day, and they make sure all the testing is done the same day. Because as you can imagine, patients come from all over the country, all over the region to our clinic. So we want to make this as seamless as possible and really focus on the patient experience. So prior to our combined clinic with our cardiologist and MFM team, they will have all the appropriate testing done. So if, for instance, my patients with heart failure or risk of heart failure, they have an echo before, they have lab work before, they have an EKG before.

Karlee Hoffman, DO:

We make sure all their OB testing is up to date with a growth ultrasound or whatever testing they need from an OB perspective. So when we see the patient in person, they have all of that testing done the same day before our appointment so that we can make real time decisions and they leave there with a plan. And I think that's what's reassuring to patients and that patient experience they come from all over and they may have heard so many different things, whether online or from other providers that they can or can't do or they can or can't proceed with pregnancy. And when that patient leaves our combined clinic, I'm confident we have a plan and the plan is followed through on. So I think the patient experience is our utmost responsibility and just talking to our patients and building expectations and talking to them.

Karlee Hoffman, DO:

I feel they leave there feeling very reassured and knowing that we support them. That's the key. Whether they decide to proceed with pregnancy or whatever decision, if it's too high risk or not high enough risk or how to build their family and what their goals are, I would hope that every patient leaves our clinic feeling truly supported in what they're doing and educated on the medical facts to make that decision.

Adina Kern-Goldberger, MD:

For sure. And I think that's actually what's so unique about this is they're really, both as a clinician and as a consumer of healthcare, there are so few contexts where you would ever see multiple healthcare providers, multiple physicians in the same room. Even most multidisciplinary clinic models, they might have sort of co-located specialties, seeing patients in the same space, maybe discussing patients, but actually physically to all be in the same room together I think is something that's so unique here because so often as a high risk pregnancy specialist, if I see a patient, I can talk to them about the pregnancy implications of their disease. I can talk to them about how pregnancy might affect their disease, how their disease might affect pregnancy. And then I often say, and I would also like to speak to your fill in the blank specialist. I'd like to speak to your gastroenterologist.

Adina Kern-Goldberger, MD:

I'd like to speak to your rheumatologist and make sure we're all on the same page and circle back. And what's so unique here is we're in the same room. So there isn't any, “oh, let me talk to the cardiologist and make sure they'll agree” or “let me talk to the OB/GYN and make sure that this plan sits well with them” because there is so much coordinated planning that really does require both specialists to make the plan together, particularly surrounding delivery timing. We know that delivery is actually the highest risk time delivery in the immediate postpartum period for patients who have heart disease. So really coming up with a coordinated plan. How do patients need to be monitored where in the hospital? What kind of delivery do they need to have? Where is the safest location for them to deliver? What kind of medications might they need?

Adina Kern-Goldberger, MD:

What kind of surveillance of monitoring do they need after delivery? Those are really decisions that we have to make together. The cardiologist in isolation can't make a decision about the OB monitoring and the delivery plan and it really benefits the OB doctor to have the perspective of the cardiologist on ways to modify risk and sort of the timing of potential interventions and when to follow up, when to give different medications, et cetera.

Karlee Hoffman, DO:

And I'm confident the patient's in the center of all of this. So you could walk through our clinic. There might be some cases where as a cardiologist, I'm like, "This is crazy. Why are we doing this? " But it's to support the patient and their goals, wishes, knowing that they're well educated in what they're doing if they're proceeding with pregnancy in a high risk cardiac condition state. And personally and selfishly, I like to have my high-risk colleagues beside me because I know I've walked out of the room with Dr. Kern-Goldberger multiple times and I said, "Are we really doing this? " And she's like, "Yeah, we're doing this.” Because again, we don't have an option. Our goal is to serve our patients and support their goals and what they want and we're here to do it. So it's truly multidisciplinary and I think we lean on each other's expertise and really make those decisions as they're walking out the door.

Karlee Hoffman, DO:

And the patient is absolutely in the center of all that.

Erica Newlin, MD:

Now that we've talked about the care journey, let's focus on awareness and what women can do to advocate for themselves. What can women do before or during pregnancy to support their heart health?

Adina Kern-Goldberger, MD:

So I think it's really important for anybody who has a heart condition, hard stop, whether or not they're considering pregnancy, to make sure they are getting good cardiovascular care longitudinally. Even somebody who was born with a heart problem that then was corrected surgically and then they're fine or somebody who had an episode of heart failure that then recovered. It's really important. The heart is a dynamic organ. The other changes that happen in the body all affect heart health and it's so important for people to have chronic longitudinal cardiovascular care, to have a cardiologist you know and trust because I think that's one of the hardest things that Dr. Hoffman and I see in pregnancy is people who've had a history of a heart condition but haven't been sort of getting regular follow-up and they come into pregnancy with an unknown status that often is a concerning status and they didn't really have the opportunity to optimize things to fine tune things before pregnancy.

Adina Kern-Goldberger, MD:

And that's really a missed opportunity because a lot of heart conditions, including heart failure, can actually be addressed before pregnancy and improved. Once somebody's already pregnant, we have fewer options. And so I think in terms of awareness, that's number one. If you have a heart condition, please see a cardiologist. If you have a heart condition and you're thinking about pregnancy, please, please see a cardiologist before pregnancy. And depending on what the condition is, it might be appropriate even to see us. And that's something that Dr. Hoffman and I do in our cardio-OB clinic is we actually also do preconception visits. So we see people who are contemplating pregnancy who have a heart condition and we can talk through with them the risks of pregnancy, what we would worry about based on their specific health status and also the things that we can do both to improve their health before pregnancy and give them sort of a roadmap of how we would monitor them, how we would take care of them during pregnancy.

Karlee Hoffman, DO:

And I tell patients pregnancy is a marathon. It's a nine-month marathon followed by the sprint of delivery. You would never just show up to a marathon and decide to go run a marathon. That would be crazy, right?

Adina Kern-Goldberger, MD:

True.

Karlee Hoffman, DO:

So when we're expecting your cardiac output to double and all these physiological changes of normal pregnancy, you add on a heart condition, you're not just going to show up to run a marathon. So preconception visits are a favorite to really delineate what are the risks, what modifiable risks? Even just like weight, blood pressure, these are low-hanging fruit that we can optimize and safely get you through pregnancy. So let's not show up for a marathon without the training. Let's show up to pregnancy with a preconception consult if you have a cardiac disease. And again, I'd rather err on the side of reassurance and saying this is okay and low risk than on the other hand to show up pregnant and then we're reacting and not being proactive.

Erica Newlin, MD:

Are there any particular screenings that you'd recommend for women with a heart condition who are considering pregnancy?

Karlee Hoffman, DO:

Yeah. So I mean basic cardiac screenings would be blood pressure screening, making sure you know what your blood pressure is, what your trends are in heart rate also because again, we're expecting the heart to do a tremendous amount of work during pregnancy and we need to know what our baseline is and modify that if we need to. If the patient has any kind of heart failure history or family history, baseline echo would be ideal. Echocardiogram and ultrasound of the heart to really say, what is your heart function? If they have a history of valvular disease, we'd want to look at the heart valves with an echocardiogram again to assess where we are and if there's anything we can modify prior to pregnancy. If a patient has a history of congenital heart disease that was fixed as a baby and maybe they've got lost to follow up and they haven't seen anybody, even if it's for a VSD or ASD, screening echo would be appropriate.

Karlee Hoffman, DO:

So my baseline preconception testing for patients pretty routinely would be an echocardiogram, an ultrasound. We typically get some blood work to make sure there's things we can measure like an NT-proBNP to measure the stress on the heart prior to pregnancy. We like to get a baseline EKG too, especially if they have an electrical condition like long QT syndrome. So baseline non-invasive testing like an echo, EKG, blood pressure screening, making sure their diabetes is controlled, their blood sugars are controlled. All these basic testing would be ideal if indicated based on their personal history or family history.

Erica Newlin, MD:

How can women advocate for themselves if they feel something isn't right during pregnancy?

Adina Kern-Goldberger, MD:

That's a great question. And going back to what Dr. Hoffman said before, there is a lot of overlap between cardiac symptoms and normal pregnancy symptoms. And so it is difficult to know Dr. Hoffman's mantra of, “if you see something, say something” is really applicable here because you can't always know. What we do as physicians is a lot of risk stratification. If we have somebody who has no risk factors for heart disease and has a symptom that could be reflective of a heart condition, but could also be a normal pregnancy symptom, and we have to decide what level of workup of evaluation is necessary for that person. Our threshold for concern is really different in people who either have a heart condition or are at high risk for a heart condition where pretty much always we're going to want to evaluate any symptom because our level of suspicion is already higher.

Adina Kern-Goldberger, MD:

What's helpful is that all of the evaluations that Dr. Hoffman just mentioned that are relevant for sort of pre-pregnancy testing are all safe things to do during pregnancy. And so we do actually have a lot of tools that we can use during pregnancy to evaluate symptoms and try to determine if they are of a cardiac origin or not. So echocardiogram, which is done with ultrasound is safe. EKGs, lab work, these are all things that we can employ in pregnancy to help to differentiate some of these symptoms between whether they are of a cardiac origin or of a pregnancy origin. On the patient side, I would say if you're nervous, tell your provider, tell your clinician. We have lots of ways that patients who are pregnant can get urgent evaluations if they are worried about something, whether it's through outpatient prenatal care office or through our OB emergency departments and OB triage based on how far along they are in pregnancy.

Adina Kern-Goldberger, MD:

We are always happy to see patients if they are concerned. We would always rather see someone and have everything check out and be fine than as Dr. Hoffman mentioned before than the opposite would have someone say, "Oh, it's probably nothing," and miss the opportunity to make an early diagnosis and intervention. So what I would tell patients always is if you are nervous, please, please tell someone, come in and be evaluated. Pregnancy is a high risk time period for everyone, even for people without heart disease. And it's always better to get checked out and rule out some of these more concerning possibilities.

Karlee Hoffman, DO:

And I always tell patients, if you don't have a provider in front of you that's listening, then you need to go find one that is. You have to trust your gut. And there's no harm in getting a second opinion, seeing somebody else, fresh set of eyes. I encourage this for all my patients. And if you have a good doctor, they're not going to care if you go get a second opinion or have someone else take a look because again, this is your shot. This is your pregnancy. This is your life. You have to advocate for yourself.

Erica Newlin, MD:

This has been such a helpful conversation and I think there's a lot here for our listeners to take away. Before we wrap up, I'd love to ask each of you for one question. What final message do you want women to remember about pregnancy and heart health? Dr. Kern-Goldberger, you can start.

Adina Kern-Goldberger, MD:

Yeah. I think my perspective as a high risk doctor is telling me that what I should say is pregnancy is a wonderful and exciting thing, but there are also risks in pregnancy for everyone. There are heart risks for people who don't have heart disease and there are very real risks for people who do have heart disease. But the good news is we have so many tools at our disposal to evaluate and manage heart conditions in pregnancy. And so I want that to be a positive takeaway. Even if you have heart disease, don't despair. That's why we exist. That's why this clinic exists to help you, to help reduce risks, to help optimize outcomes. So please don't feel like there aren't sort of resources for you if you are somebody who has heart disease and wants to be pregnant. That's why we're here and please come and see us.

Erica Newlin, MD:

What about you, Dr. Hoffman?

Karlee Hoffman, DO:

Yeah. My main takeaway from our Cardi-OB clinic is we are here to support you. It's our job to provide you the medical education, the medical facts, to risk stratify, and then it's up to you and yourself to make the personal acceptable risk to see if you want to proceed with pregnancy or not. So we're here to support you, whatever that personal acceptable risk is if you want to proceed with pregnancy when you have an underlying cardiac disease. So bottom line, we're here to support you. We're happy to see you and find ways to build your family with you.

Erica Newlin, MD:

Thank you both so much for joining me on the podcast today. For more information on the Cardio Obstetrics Clinic, visit clevelandclinic.org/cardioOB. That's clevelandclinic.org/cardioOB. If you found this episode helpful, subscribe and share it with a friend. Remember, understanding your heart health is an important step in supporting a safe and healthy pregnancy for you and your baby.

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.