Cardio-Obstetrics: Pearls for Every Cardiac Practitioner

Join our special guests, Drs. Lauren Lastinger from The Ohio State University and Sharon Roble from OhioHealth, as we review common issues in cardio-obstetrics for the cardiac practitioner.  We will review pearls for managing common cardiovascular conditions during pregnancy, evaluation of cardiac symptoms during pregnancy, common medication pitfalls, and new concepts in peripartum cardiomyopathy.

For more information, see:
Lastinger et al :Diagnostic and Management Considerations in a High-Risk Pregnant Patient With Ischemic Cardiomyopathy

Cardio-Obstetrics Essentials: Team-Based Management of Cardiovascular Disease and Pregnancy (ACC course)

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Transcript

Kanny: 0:11

So welcome back to the Cardio Ohio podcast. This is Canny Graywall in Columbus, your host, and I'd like to welcome again a co host I think you're familiar with, our current president of the Ohio chapter of the ACC, Dr. Ellen Sabic, who's checking in from Cleveland. Ellen, welcome.

Ellen: 0:30

Thank you so much, Canny.

Kanny: 0:32

So we're really excited today to be able to talk about a field we haven't had the opportunity to address so far in our series, which is the growing field of cardio obstetrics. You know, this is something all of us in general cardiology deal with, as a consultant or on our inpatient wards. But it is a growing field and we're forced luckily today to have a couple of cardiologists from here in central Ohio who amongst their various interests, specialize in, in cardio obstetrics. I'd like to first welcome Dr. Lauren Lassinger. She's here in Columbus at Ohio State University. She's part of the adult congenital heart disease program there. Lauren, welcome. And do you mind just taking a minute to kind of talk about your career path that led you to your current position and this, you know, the breakup of your current practice.

Lauren: 1:25

Yeah, sure. Thank you so much, first of all, for having us on. And I'm excited that you've chosen Cardio Obstetrics to talk about, because it's definitely a growing field, although it's not a new field. It's something that, as you mentioned we've been doing for a very long time, even preceding me. But it's becoming much more of a formal field. And I think anybody getting more education, this can only only be helpful. So I kind of, I wouldn't say I, I went into cardiology training thinking this was something I was going to do, but got exposed to it just through my training in adult congenital heart disease, because a lot of our patients, as you know, are younger women of childbearing age, and a lot of them have have pregnancies successfully, even in the most complex things. cases, but also as part of that, our program at Ohio State the, the cardio obstetrics program has really existed for a long time under the umbrella of adult congenital heart disease. And so as part of that, I got training in taking care of women with cardiomyopathy and aortopathy and other things. And really I came out of fellowship not thinking it would be a big part, but I realized what as a fellow sitting at a table during these meetings we have, and I recognize at the time that I was the only woman in the room having conversations about these women and their care plan who had actually given birth to a baby. And so I felt very connected to these women. You know, both professionally, but also personally because I've been through what they were going through and so that really has been a part of my career that has evolved. I'm now the director of the cardio obstetrics program at Ohio State, and it's something that I'm really passionate about both, care wise and then teaching others.

Kanny: 3:04

Well, that's great. And we're certainly happy to have you on the program and happy to have you as a resource here in Central Ohio. I'd like to also introduce our second guest, and this is someone I've had the pleasure of working with since 2016 when you joined OhioHealth, and that's Dr. Sharon Robel, who is based in Mansfield, Ohio, with OhioHealth, but also works here in Columbus as well, and is well known at Ohio State as well for your training. Sharon's a cardiac imaging specialist, but also runs the adult congenital heart clinic here at Riverside Hospital. Sharon, welcome and can you let us know a little bit about your path as well that led to you to Central Ohio and your current position?

Sharon: 3:47

Thanks. Thanks, Kenny. And thank you for having me on today. I appreciate the opportunity to talk about this is this is my favorite group of patients to take care of. So I have been a cardiologist now for 19 years, and it's been a great journey to see how adult congenital heart disease training has evolved. When I first started we had to do both adult and pediatric training. So as we did that there was some exposure to pregnancy, and that's really where I got interested in the field. It was very interesting because for a long time, women were told by their pediatric cardiologist to not even have children. And it wasn't uncommon that they were actually told to undergo permanent sterilization because it was just too risky for them to have children. And it really shocked me in my training to hear that. So when I went through my training, that was sort of when things were starting to change, and we realized that even some of the highest risk patients who never thought they could have children were given the opportunity to actually have children and to consider that opportunity. And it was just, An amazing experience having been med Pete's trained into see that and actually help be a part of that. So when I finished my training, I actually came back to central Ohio and and joined the adult congenital program at OSU and really helped with that program and it just really took off there and and we continue to develop that program and. When the opportunity came over here to help develop an imaging program with another colleague of mine, I, I took that, but still wanted to be a part of the pregnant population and, and it was certainly a need here as well as many patients wanted to deliver in the Ohio health system. So, I, I was a good opportunity to come here and continue with that patient population. And Lauren and I continue to share patients when they. Want to deliver one place and they're followed another place. So, so it's just a great population to work with.

Lauren: 6:16

It should also be stated that the program that I, I'm currently involved with is really built by Dr. Robles. So I have the benefit of just. Kind of taking over everything that she built, which is it's it's an amazing and robust program at Ohio State. Thanks to her.

Kanny: 6:33

Yeah, it's great to have both these resources here. Now, of course, in a in a system like Ohio State or here at Ohio Health, we're fortunate to have, multidisciplinary specialists in so many fields, including, adult congenital disease and also cardiac obstetrics, but of course. And a lot of our practice settings around Ohio, where our audience is listening, that's not necessarily the case. So, we thought the discussion would kind of be framed more from the standpoint of a general cardiologist or cardiac practitioner, like an advanced practitioner, who may not, have immediate access to subspecialists. So I think that's where Ellen and I want to kind of, you know, address some of these These common issues that come up,

Ellen: 7:14

So Lauren and Sharon, we are so lucky to have you here today for this discussion. And I'd like to start off the discussion thinking about. We have a lot of common general cardiology conditions we see in our young patients, particularly in this instance, young women, fabular heart disease, hypertrophic cardiomyopathy. We more likely deal with the simple adult congenital heart disease and aortic actasia, but which of these conditions, you know, are well tolerated in pregnancy and which ones raise the red flags when we really should refer to sort of the high risk cardio OB people. And also, can you give us some management. And so we're going to talk a little bit about how we can manage these people through their pregnancies, sure.

Lauren: 8:02

Yeah, you're right. It's a very wide spectrum of women who. With heart disease who get pregnant, you know, I think the some of the simplest things are the patients who have palpitations or history of PBCs or history of SVT or something like that. The simpler arrhythmias tend to be really well tolerated in pregnancy. And I don't have too many concerns about those patients. The rest of the cardiomyopathies and that sort of thing are really very dependent on what's going on. And I think the, the trickiest ones are the ones that you don't see coming that probably give me the most positive. You mentioned aortic ectasia. So one of the patient populations that, you know, that I think maybe get missed for those patients who have Marfan syndrome or Loewy's disease or some of those connective tissue disease that, that where pregnancy can really be. A risk factor for aortic enlargement. Rarely aortic dissection, but it happens. And and then the cardiomyopathies, like the hypertrophic cardiomyopathy can really be a mixed bag, and it kind of depends on what you're starting with. But those, those that give me pause or sort of those aortopathy, anybody with a significantly reduced EF and a cardiomyopathy and some of those hypertrophic cardiomyopathies, depending on what the underlying substrate is.

Ellen: 9:22

And as far as the different valvular heart disease, regurgitant versus stenotic, are there particular ones who you worry about a bit more than others?

Lauren: 9:33

Right. You know, anybody that doesn't have severe valve disease, tends to do okay in pregnancy. hemodynamic changes of pregnancy, the, the, the The extra volume that you have on board, the increase in heart rate, the change in your systemic vascular resistance. So, you know, anything that's mild, moderate, anything right sided tends to do fine. We see a lot of women with severe tricuspid regurgitation from a history of endocarditis. They tend to do just fine. It's a left sided obstructive lesions that can get you into trouble. And then So aortic stenosis, mitral stenosis can definitely get you into trouble. And oftentimes even really significant mitral regurgitation. If you have a sort of primary mitral valve disease, just because of the hemodynamic changes of pregnancy after delivery, there's a lot of changes that happen. And so some of those, but anything that's kind of mild, moderate, anything right sided tends to be pretty well tolerated.

Ellen: 10:27

Wonderful. Thank you,

Sharon: 10:28

I think it's important to also think about the symptoms, not just or the conditions, not just during pregnancy, but during labor and delivery as well as after. So we have a problem in this country with maternal mortality in pregnancy, and it has to do both with acquired and as well as congenital heart disease. But, but certainly we need to think about those things. So whenever I assess. patients patient that comes to me, I think about, okay, how do we manage them during the pregnancy, during the labor and then afterwards as well? And I make sure that as I outline a plan for them, I address all those issues. Because My biggest nightmare is that they go home and something catastrophic happens after they deliver too. So we're not done after they deliver. We have to think about how do we manage them afterwards as well. Because as Lauren pointed out, there are a lot of hemodynamic changes that happen after delivery. The biggest risk is not the pregnancy and it's not the delivery. It's actually the it may be the week or two after they deliver as they go through the postpartum changes. So some may need to stay longer in the hospital for that. So I think it's thinking about all those things when we talk about yeah. managing these patients. And, and I think that the other thing we need to think about is maybe they only have to see the cardio V physician once or twice just to help kind of outline that it may not be that they necessarily need managed throughout the whole pregnancy by that person. But I think it's helpful to say, well, let's at least have one assessment and figure out where do we go from there? Because it is candy pointed out to, it's a multidisciplinary team. So we have to find out what the. OBs are comfortable with two at those local hospitals because sometimes what I think could be managed at a local hospital, the OBs don't feel comfortable with this either. So I think open lines of communication are also important.

Kanny: 12:34

So on that note, Sharon in a patient, a pregnant patient, say with mild to moderate valve disease, for example, or perhaps mild aortic ectasia in terms of imaging during pregnancy, are you, usually relying on a change or in symptoms to warrant imaging? Or is there a role for any kind of routine monitoring? Because I know there are challenges, of course, with imaging and pregnancy.

Sharon: 12:59

I routinely monitor my patients during pregnancy. So for example, aortic ectasia patients get monitored once a trimester. Current guidelines for Marfian's patients actually recommend imaging every four to five weeks because they are at a high, such a high risk for dissection. And if there's a significant change, C sections are recommended. The nice thing about. Some of our imaging modalities so non contrast MRIs can be performed during pregnancy and we get very nice imaging of the aorta. It's no contrast, no radiation, and so that gives us a lot of information. So that's a very useful tool. That we can use the biggest issue that I have had with MRAs actually is trying to do them in the third trimester and I've had a few women that have supine syncope from obstruction of the IBC with the gravid uterus, but imaging wise, you usually get beautiful images and we can do those pretty quickly.

Ellen: 14:04

Wonderful. You you also talked a little bit about sort of mode of delivery when C sections. Lauren, could you touch base with us as far as when do you all get involved as part of the planning of, can patients push? Do they, do they do a vaginal birth? When do we recommend C sections? And at what point do we, at which patients do we step in and sort of try and specify that to the OB?

Lauren: 14:29

Yeah, this is one of those, I would say, cardio obstetrics myths or myths has been floating around cardiology and still does in among providers that don't have much experience taking care of pregnant women, but I have patients that come to me all the time saying, Oh, my pediatric cardiologist said I would have to deliver by a C section or it tends to happen more in the congenital population or women who have, you know, Marfan syndrome say, Oh, I'm definitely been told I have to deliver via C section and that, Really across the board, there are almost no cardiovascular indications for a C section. And that includes patients with pulmonary hypertension, most patients with connective tissue disease, aortic disease. You know, most patients with heart failure. And because really the risk, the risk of C section, even in those patients where you're worried about pushing is greater than vaginal delivery just due to the risk of anesthesia, analgesia, the anorexial analgesia. a higher risk of bleeding, disrupting your hemodynamics with C section. And so the times that I recommend C section, I think Sharon mentioned, you know, if you were showing rapid aortic growth you might consider it the one slam dunk is if you're somebody who comes in on full dose anticoagulation. So maybe somebody with a mechanical valve whose INR is therapeutic that's a slam dunk C section just because of the risk of fetal intracranial hemorrhage with vaginal delivery. But by and large, for most patients, there's not a cardiac indication for C section because we can get away with things like an assisted second stage, so that would be like a vacuum or a forceps delivery where the patient doesn't actually have to push. They let them labor down until until the baby's, you know, pretty close to delivered and then just assist the baby out and that helps decrease, you know, that increase in afterload with pushing that we might be concerned about. The other indication, obviously, is somebody who's crashing and burning, cardiogenic shock, that sort of situation, obviously, if the mom is unstable, we for sure go for C section, or if there are obstetrics reasons. But from a cardiac standpoint, very few.

Kanny: 16:38

Yeah, thanks, Lauren. I thought maybe we could turn our attention now, not to patients like we've been talking about with known cardiovascular or congenital disease who get pregnant, but some of the common symptoms we encounter during a pregnancy, maybe in a patient with no prior cardiac history. Of course, anybody who does. general cardiology consultations in the clinic, or even in the hospital, knows that, it's very, very common to see patients who report things like palpitations or near syncope, sometimes atypical chest discomfort. We obviously can't talk about all those in detail, but I thought, Sharon, maybe you could just give us a few of your pearls, for example, in a patient, say, with palpitations or episodic tachycardia, maybe a few things in the history that would Kind of set off a red light in your mind that the patient might need further evaluation versus the more common run of the mill nonspecific things we tend to see.

Sharon: 17:31

Sure, so it's very challenging sometimes because many of the symptoms that people have can be just normal pregnancy. But I think history taking is very important and listening to what their symptoms are. I have a a low threshold to do cardiovascular testing in my patients. So patients are getting pregnant at older ages. They have more cardiovascular risk factors. So I take shortness of breath seriously. because we don't want to miss things like peripartum cardiomyopathy. Obesity is obviously an epidemic. We see a lot of patients with diastolic dysfunction. They come in with risk factors with chronic hypertension. And so, so I have a low threshold to get an echo during pregnancy, if they complain of shortness of breath palpitations, I really try to tease out what's going on. And you know, I see a lot of women where if you get a good history, you can tell that they're just premature atrial or ventricular complexes and I won't necessarily monitor those patients and I try to provide reassurance. patients who give me a little bit better history of what sounds like arrhythmias, they may get a monitor. We see a lot of tachycardia complaints nowadays. And, and I think there's been more in the lay press about dysautonomia or POTS. And so I see a lot of those patients come in. My biggest concern when they come in with tachycardia is to make sure that they have normal heart rate variability. So, If patients have normal heart rate variability, then I just provide them reassurance that the that the fast heart rate is not going to be dangerous and that that's a normal part of pregnancy. So again, a 24 hour Holter monitor just to show them that. So, so we do provide a lot of reassurance to people.

Ellen: 19:46

Wonderful. If we turn a little bit more towards sort of mundane things we deal with, with our everyday cardiovascular patients, a lot of our patients have cardiovascular medications. And I guess one question I have is, how should we counsel our younger women patients? Are there certain medications we warn them ahead of time saying, well, if you're on this medication, it's not great in pregnancy, you need to stop it or contact us before you decide to get pregnant.

Lauren: 20:15

So usually the women that we're seeing who are on these medications are women who have pre existing heart disease. So a couple of common populations are like our morphine population who are often on atenolol. Which is a beta blocker that is felt to be contraindicated in pregnancy or angiotensin receptor blockers. The other population would be patients who have heart failure, who are on similar medications and spironolactone. And then the third population that I see where we're usually talking about medications that might be dangerous, at least cardiac medications are patients who are on systemic anticoagulation with warfarin or, or DOACs. So that might be a patient who has a mechanical valve. And so when we, this is something I talk about, any woman that comes into my clinic at the childbearing age, we have conversations about pregnancy and what are you using for contraception and, and if they are using durable contraception and they're on medications that can be triatogenic and just to name a few of those, so I mentioned that those few, but spironolactone is another one we have conversations about, well Even if you're on durable contraception, if you're going to get pregnant or you decide to stop your contraception, these are the medications that you need to stop. So you need to call me if you have Marfan syndrome and you're on atenolol and losartan, and I will switch you to metoprolol or cravetolol, which have better safety profiles in pregnancy. Warfarin in particular is a tricky one because obviously if you have a mechanical valve you need to stay therapeutic. And so if you're trying to get pregnant, we don't want to mess around with your anticoagulation until you're confirmed to be pregnant. But Warfarin, if you are on more than five milligrams a day in the first trimester is teratogenic. And so. What I typically tell those patients to do is to take pregnancy tests regularly if they're off contraception. So maybe once a week, check for a pregnancy test if they're actively actively trying to get pregnant. And the second that pops up positive, call and we'll switch you to Lovenox. It can be tricky in that particular situation, but usually we give those recommendations. And most of our patients are pretty good about calling when they come off birth control if they're trying to conceive and we switch around the medications.

Sharon: 22:29

I think one other medication to talk about is statins. Because that recently changed. So with all the hyperlipidemia that we have nowadays, so familial hyperlipidemia, we do put some younger patients on statins, which used to be a bigger deal. They do need to stop them once they become pregnant, although there is some data that for these very significant hyperlipidemic patients, you could potentially continue it. I stop it, but I, I don't get as concerned. So it used to be, you know, very It was really bad if they got pregnant on it. It was almost up there with Coumadin. Nowadays, if they get pregnant on it, we obviously stop it, but just because of how significant some of these familial hyperlipidemia patients can be it, it, I think we're a little bit more liberal in starting these patients on them and continuing them in certain cases. Now, again, I would have that discussion with a cardio obstetrics patient and, and not just leave that up to the general cardiologist, but there is newer data out there about using statins in women of childbearing age and being a little bit more liberal with that use.

Lauren: 23:47

And our MFM department here at Ohio State is doing a whole lot of research on this. But paravastatin, if you're going to use a statin, is the one that seems to have been getting more of the green light. These days, even during pregnancy.

Sharon: 23:59

It would really be the familial hyperlipidemia patients that you either have have genetic testing or you have a strong family history of early atherosclerosis that I would, I would put Pravastatin on during the pregnancy.

Kanny: 24:15

Thanks. I think a lot of us in general cardiology, that's not the first thing we would think of when we see a patient who's on a statin. So that that's very helpful. One condition we wanted to take a little more of a deep dive into because I think very interesting and really hits on all the key aspects between, high risk OB and cardiology is peripartum cardiomyopathy. Now, most general cardiologists, I think, are familiar with how it presents clinically and, you know, the, the nuts and bolts of, of initiating therapy, but we were wondering there's any updated information about the incidence of PPM, or if there's anything that stands out the age and history of the patient themselves. I would lead you more to lead, to a higher suspicion of that when someone presents with, dyspnea, for example.

Lauren: 25:04

Yeah, I think, you know, the news, I wouldn't say a whole lot new in the incidents. It's still pretty rare. And I would say that anybody presenting during pregnancy or within a five months postpartum coming in to the ER with new shortness of breath and swelling. It's always up there. We've actually talked about and in our statewide, you know, maternal mortality review committee. It should we should we have a bracelet on somebody who's given birth to people take them seriously when they come to the ER shortness of breath and that postpartum period, because a lot of times that gets missed. But you know, I think one of the new things that's popped up is. That are at least that are being investigated are a couple of things. One, how does, how does things like preeclampsia play into this? Because there seems to be an association there. We see a ton of preeclampsia, fortunately, not as much peripartum cardiomyopathy, but there seems to be a potential link there. And so some of the research we're doing is looking into things like echo strain. Is there something that we can pick up on all these women with preeclampsia that might predict that they might be at higher risk for developing peripartum cardiomyopathy. And the other new thing that I think is interesting is that there seems to be in some patients with peripartum cardiomyopathy, when they actually go through the genetic testing, they are finding higher incidences of pre existing Gene mutations like in a Titan gene. And some of these patients. So is there a crossover between maybe a familial dilated cardiomyopathy syndrome and patients who develop peripartum cardiomyopathy? So I think we will continue to learn a lot more about it. Keeping an eye out for, you know, symptoms in that postpartum period is key peripartum cardiomyopathy. Anybody that's taking care of these patients, whether it's in primary care clinic or the E. R. when they present.

Ellen: 26:48

That's actually really quite interesting. So 1 question is for patients who have a family history of. A cardi, a dilated cardiomyopathy. Are those patients, are those people at a higher risk, you think? And should we have a higher level of suspicion when they're going through pregnancy that they might end up developing a peripartum cardiomyopathy?

Lauren: 27:09

I do watch them closer. I mean, we see a fair number of those in our clinic and I keep an eye on them usually once a trimester with an echo, which sometimes can be difficult to get insurance to cover. But, I, I mostly counsel them, so a lot of the counseling is for them to be able to educate other providers who might encounter them on how to what they have going on and what they've been counseled on as far as risk.

Sharon: 27:34

There's also a subset of patients who may not meet full criteria for preeclampsia, but they have volume overload and. Those are a subset of patients where they may incorrectly get labeled as peripartum cardiomyopathy, and they get referred to us for, you know, pre pregnancy counseling, they had peripartum cardiomyopathy. But when you really dig into what happened, it is more, they didn't tolerate these postpartum fluid shifts for some reason. And I think, you know, they're. technically didn't have systolic dysfunction, but it may have been a component of diastolic dysfunction. And I don't think we quite know yet what that means. And it would be interesting to look at genetic testing in those patients to see if they do have some sort of mutation or what happens with these patients down the road. But that's another subset of patients that we see a lot of that come to us. For pre pregnancy counseling, and I think the counseling for those patients is a little bit different than it might be for somebody who has a true peripartum cardiomyopathy. But I also think that those patients need to be monitored closely through pregnancy because they are at risk for volume overload in that peripartum period again,

Kanny: 28:55

Sharon, I'm glad you brought that up because, in my experience on the consult service, that's actually a more common scenario than actual confirmed peripartum cardiomyopathy, which is a patient maybe either in the third trimester or even soon after delivery who develops, pulmonary congestion that's not severe but enough to warrant, diuretics, and everyone is expecting, a low EF and of course the echo looks fine or maybe impaired diastolic filling. So I'm glad you brought that up because I think a lot of times we don't know what to do with those patients or what we should label them as. And it sounds like they might still be a higher risk group is what you're saying.

Lauren: 29:31

But that label is so important. And that was the point I was going to bring up because as far as counseling on subsequent pregnancies, there is a big difference in how you counsel somebody who has true peripartum cardiomyopathy with a reduced compared to somebody. who had volume overload, because we don't have any data showing that those patients with, you know, just the volume overload, the diastolic dysfunction, yeah, they're probably at risk for having similar problems, but not that they are going to suffer, you know, a drop in their EF again, or in the case of peripartum cardiomyopathy, if it doesn't recover their EF, you know, There's some studies, studies show a 20 percent mortality with subsequent pregnancy. So that, that label is huge because the patient that didn't have true peripartum cardiomyopathy who gets labeled with it often, and I see this all the time, they come to me and they're saying, I was told I should never get pregnant again, or I got my tubes tied because they told me I had peripartum cardiomyopathy and getting pregnant again would kill me. And that's where I think a lot of this education is very important because for, you know, anybody out in the community seeing these patients, the label matters because of the counseling and subsequent pregnancies.

Ellen: 30:41

So, could you actually go over, how do you counsel patients with postpartum cardiomyopathy and what do you do with, what is their duration of heart failure medications?

Sharon: 30:51

So to, to Lauren's point people who are, are a true peripartum cardiomyopathy have An increased risk of recurrent systolic dysfunction with subsequent pregnancies and, and some centers, some physicians will counsel them against future pregnancies due to the risk of Recurrent LV dysfunction. And some studies have said that that can be as high as 20 to 50 percent depending on what study you look at. And depending on the recovery of the LV function with with the first pregnancy where you had LV dysfunction. The other thing is that. medical therapy for the LV dysfunction. So years ago it was you could stop after six months if there was recovery of function. some studies have suggested that you actually should not stop medical therapy. So the question I think has come up, you know, with heart failure, if you have recovery of function, should you stop goal directed medical therapy or you should continue it? And I think there's been some push to continue Goal directed medical therapy indefinitely. So, if it's a true peripartum cardiomyopathy, we do counsel that there is an increased risk of of LV dysfunction with pregnancy, subsequent pregnancies. And I monitor their ejection fraction very closely with echoes each trimester. And then beginning in the second trimester, they'll get echoes every four to six weeks. Once you see a decline in the LV function, it's really recommended that you deliver. So you're talking about potential preterm delivery if the LV function falls again. So, so the implications of that diagnosis. As Lauren said, it's very significant versus somebody who had volume overload and diastolic dysfunction and needed a dose or two or Lasix. So I frequently am sitting in these visits trying to tease out what really happened with the previous pregnancy. Was it, oh, you needed a dose or two of Lasix? Or were you on goal directed medical therapy for three to six months after you delivered and you really did have a decline in your LV function because the counseling and the treatment for the subsequent pregnancy is going to be very different.

Kanny: 33:13

Thanks. That's a, that's great information. Helpful to know. Before we wrap up, I did think of one other topic that maybe I can ask Lauren. We podcast actually with Dr. Heather Gornick, it was a great topic, you know, covering fibromuscular dysplasia and spontaneous coronary dissection. But I just thought, just in a, very briefly if you could address, you know, how often you actually see that initial presentation of someone with FMD, or you actually see a coronary dissection during pregnancy, and is there any pearls about, you know, the presentation that would raise the red flag that that could be happening?

Lauren: 33:52

Yeah, I mean, we do see it. I would say a couple of times a year. We have a pregnant patient who presents with spontaneous coronary artery dissection or maybe 23 times a year. Somebody who comes in with a legitimate STEMI and STEMI, even just do it a regular old fashioned. atherosclerotic cardiovascular disease. But this is, this is why I think education is important because any woman who presents with chest pain, when they're pregnant, you really kind of have to take it seriously and take a history and do do additional work up when, when someone presents and you have some indication that there's something going on, whether it's, a troponin elevation, which can be like in any case, nonspecific or EKG changes. The first thing to know is that I think about is like, okay, well, how stable is the patient? if somebody is Really having a big STEMI, you, you don't have any other option. You don't sit there and say, Oh, you're pregnant. We'll just treat this medically. They, they go to the cath lab and they get a coronary angiogram one consideration just because you can, you know, further propagate SCAD with by just engaging the coronary is, is there a role for just a root shot before to get a kind of look at the lay of the land? In general, we don't intervene, if unless somebody has a very high risk lesion or is unstable, but I, I would think about it. And anybody that comes in with chest pain in a trip on elevation, how you proceed a lot depends on how significant that elevation where they're ongoing symptoms. So, you know, it's especially in that 1st month postpartum, the vast majority of of pregnancy associated scan actually happens postpartum in that 1st month.

Kanny: 35:34

Well, I think that was a fantastic discussion. I think in. 35 minutes, we covered a lot of, a lot of material. And I think it kind of shows why this is a growing field and why we're fortunate to have specialists in cardiopstetrics and adult congenital disease and in our communities. So I guess I want to thank you both. I want to put a quick plug in for our Ohio ACC annual meeting. It'll be coming up on October 19th, not too far from now here in Columbus. And we have many experts just like Sharon, Lauren, and others who are going to be sharing their knowledge. with our practitioners statewide. So thank you both for joining us and we look forward to your participation in future Ohio ACC activities.

Sharon: 36:21

Thanks for

Lauren: 36:21

having us. Really enjoyed it. Thanks so much.

36:25

Thank you for joining today's podcast. For more information about the speakers or the topics, please go to Ohio acc.org,