Pressure in Pregnancy: The Current State of Pregnancy-Associated Hypertension

Join our special guest, Dr. Deirdre Mattina from Cleveland Clinic Hillcrest Hospital, for a review of the current state of peripartum hypertension. We review the current definitions, medical therapy, and lifestyle management, as well as discuss implications for future cardiovascular risk. 

For more information:

ACC.org Postpartum Hypertension Clinic Development Toolkit

ACC Course: Cardio-Obstetrics Essentials: Team-Based Management of Cardiovascular Disease and Pregnancy

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Transcript

Kanny: 0:09

So welcome back to the Cardio Ohio podcast. This is Canny Gral here in Columbus as usual, and I'd like to welcome my co-host as well from Cleveland, Dr. Ellen Seic.

Ellen: 0:21

Thank you. Can I. As you all might remember, we previously had a session on a cardio obstetric topic before. However, that was really looking at patients who had cardiac pathology prior to their pregnancy, trying to figure out what their risk for going through pregnancy would be and how we were going to manage them. And today we're gonna be tackling an issue that's. Probably gonna be more common than that. We're gonna be talking about how to manage patients with peripartum hypertension, and I'm actually very privileged today to introduce to you Dr. Deidre Martina, who is the medical Director of Cardio Obstetrics at Hillcrest Hospital, which is part of Cleveland Clinic. She is boarded in cardiology, nuclear cardiology, and echocardiography, as well as being a fellow of the American College of Cardiology. But Deidra, before we get started. We do have a lot of trainees who listen to our podcast. So I would love it if you could tell us a little bit about your professional journey and how you got interested in cardio ob.

Dierdre: 1:22

Yeah. Well thank you Ellen, for having me and so honored to be here to speak to all of your listeners today. You know, I think cardio, obstetrics, it has been around for a while and it's kind of taking off a little bit more steam now, but you know, there isn't a great pathway to get this. I think people that practice cardio obstetrics were kind of thrown into this somewhat willingly because there was just nobody else that wanted to take care of these pregnant patients. A lot of it born out of. Sort of in urban areas where there weren't a lot of contacts that could manage some of these patients. And then just in general, I think as both of you probably know, we kind of develop these specialty clinics out of a need for the patients, where someone has a particular interest in something and they start to focus their practice on that. So we're still in the infancy stages of creating sort of practice guidelines and centers of excellence for cardio obstetrics. And really it is kind of a learn on the fly still subspecialty of cardiology. And I think for me, a lot of this was going to conferences like a CC and a HA with topics of interest that were related to cardio, obstetrics. And I'm happy to chair, I am the vice chair of the a CC Cardio Obstetrics Essentials Course, which happens every year in October this year it'll be at the Heart House again in Washington DC and that's really where we take a deep dive into different aspects of cardio obstetrics, including valvular heart disease, arrhythmia, adult congenital heart disease. There's not yet a sort of a board certification or even sort of A-C-G-M-E criteria within fellowship that must be fulfilled. But we are working on that and meeting with a CC leadership now to kind of standardize some of the things that we think are important and need to be done by every general cardiology fellow and then people that are sort of practicing for centers of excellence or to consider themself a cardio obstetric center. Traditionally, a lot of it was born out of adult congenital heart disease practitioners that were dealing with these patients because they were. Patients that already had established heart disease and now because they're living longer with some of the therapies we have, both medications and interventions, they're now living to that age where they're having children of their own. So it was kind of born out of this you know, us doing a good job at keeping these young women alive. And so I think traditionally has been a lot of adult congenital specialist, but now the, the. Spectrum has kind of changed for these women, and we start to see, as you had mentioned in the preview today, is that a lot of this is not necessarily established heart disease before pregnancy, but chronic comorbidities like diabetes and hypertension and obesity. So we tend to be a little bit older getting pregnant now and have accrued some of these comorbidities. So this is the space now where general cardiologists can come in and really still kind of manage some of these things that are happening peripartum to minimize risk and make pregnancy safer throughout.

Kanny: 4:18

Uh, Thanks Dere. As you just alluded to, I think in a lot of practice settings, it is general cardiology who is often the first, cardiac practitioner, maybe the only cardiac practitioner. Who is evaluating some of these patients before we get into like the risk factors for peripartum, hypertension, and obviously eventually treatment and implications, can we just kind of start with the general definition or like what the current concept is as of how we define, how we define it, as well as some of the conditions that complicated, such as preeclampsia?

Dierdre: 4:49

Sure. So I think one of the things that we have sort of established recently that hypertension is hypertension, sort of across the board. We're really just defining hypertension in pregnancy as any blood pressure greater than one 40 over 90. Currently by ACOG guidelines. That just has to be two readings at least four hours apart. And then the timing of when that hypertension starts is how we kind of define either chronic hypertension, which is before 20 weeks of gestation. So that's usually saying that the woman had sort of preexisting conditions already and not necessarily to the pregnancy physiology. So chronic hypertension before 20 weeks and then we call gestational hypertension is the onset of hypertension after 20 weeks of gestation. This may be isolated to the pregnancy and some of the pregnancy physiology that's happening. And gestational hypertension resolves within three months of the pregnancy. So they may or may not have to take anti-hypertensives for a short course but usually resolves after them. If they do develop gestational hypertension and still require medications greater than three months postpartum, they then sort of move into the chronic hypertension realm again. We do define severe hypertension in pregnancy as a blood pressure greater than one 60 over one 10. And we sort of treat that as preeclampsia, even if they don't have proteinuria, just because it's severe range. And I think some of your listeners remember the CHAP trial, which came out now, I don't know, five or so years ago. We used to wait until pregnant women were in this severe range of blood pressure before we started to treat, but the CHAP trial really showed us that targeting a goal less than one 40 over 90 is best for baby and mom. And there were no adverse events of intrauterine growth restriction or preterm delivery. And so the target really should be less than one 40 over 90 in all patients, including pregnant patients. So then we move on to those standard sort of hypertensive disorders in pregnancy. Now, if we look at other end organ damage, we start to think about eclampsia and preeclampsia. So traditionally preeclampsia was thought to have, involvement of the kidneys where you would have urine leaking in the or protein leaking in the urine, and that would be measured by a 24 hour urine collection or spot proteins. We also can have other signs of end organ damage. What we can have fluid in the lungs causing pulmonary edema, even swelling in the brain, which leads to seizures or eclampsia. We start to see elevated liver enzymes, a rise in creatinine, and a decrease in our platelet count. So you don't need to have proteinuria necessarily to diagnose preeclampsia, but you have to have hypertension and at least one of these other abnormalities in the labs to diagnose preeclampsia. So these are, you know, just basic labs that people would get coming in a CBC or a chem seven, and then thinking about an x-ray or looking for lower extremity edema, shortness of breath on exam there. So essentially we're, there's a spectrum of these hypertensive disorders starting with. Chronic hypertension, gestational hypertension. Then moving into preeclampsia, eclampsia. And then also within that spectrum is the help syndrome, which is a, another sort of form of preeclampsia where we have other liver enzyme disorders and arrays from there, but treated very similarly to preeclampsia.

Ellen: 8:18

Wonderful. So Deidra, are there particular patients who are at highest risk for developing preeclampsia or eclampsia?

Dierdre: 8:27

Sure. Well, I think anyone that has chronic hypertension, so if you have hypertension prior to getting pregnant, the risk of preeclampsia is about 25%. So those are the pretty high risk patients that we're gonna follow very closely. And usually we're targeting to try to get to at least 37 weeks using aspirin for preeclampsia prophylaxis and making sure they have a good plan for blood pressure control and monitoring at home. Otherwise, here in the US black women are three to four times more likely to have hypertensive disorders in pregnancy. So we're also really targeting to make sure that they have all the resources that are needed and following directly from there. So that's definitely part of the things that we're targeting. I think it's important to say that, you know, in pregnancy, this is one of the only times where we, we are able to give women blood pressure cuffs for prevention. But even still at institutions like mine, a lot of this is not covered by insurance, which many of you may be familiar with this sort of bundled payment that happens in pregnancy. So there are some institutions that do. Provide blood pressure cuffs, but even here in my institution, this is done by grant funding, so the resource resources are limited and still, it may be sort of tricky to do remote monitoring or have patients sort of monitor at home and keep blood pressure tabs while they're taking medications. So these are all the things that we kind of work out when we're developing programs and plans for peripartum hypertension or postpartum hypertension clinics. And I think really, you know, I think the long and short answer is that a lot of Americans are at risk for hypertensive disorders or pregnancy. We are definitely not the healthiest females getting pregnant in the world. And I think when we look at the a HA study that was done in 2020 of very young women getting pregnant. There's only about 5% of women that are in ideal cardiovascular health before they get pregnant. So those that are meeting activity guidelines have their blood pressure at goal, their cholesterol at goal, their sugar at goal, and not smoking only 5% of women. So obviously that can create problems within pregnancy when you're not at your peak health getting pregnant to start with.

Ellen: 10:38

Mm-hmm. As far as the timeframe, what, what is the timeframe of when you expect to first start seeing these problems? Obviously, if people chronically go into a pregnancy with hypertension, that's one thing, but for someone who has not had high blood pressure prior to pregnancy, when do you start seeing the blood pressure go up?

Dierdre: 11:00

Yeah. You know, Ellen, so different for every patient. I think. I think commonly we see the blood pressure start to rise at the end of the pregnancy, and this will usually be 35, 36, 37 weeks. It's very common that women have had a perfectly normal pregnancy. They're going for their prenatal check and they're saying, oh, your blood pressure's high. We're gonna have to bring you in to monitor. And then. They decide to deliver if they're close to term, because they're either afraid that preeclampsia is starting or they're already in early preeclampsia from there. So that's a very common. Way that it presents, but it can present earlier for people sometimes. And so I think really educating women on the signs and symptoms of preeclampsia is one of the major things that we try to say. If you're having any swelling, visual changes, shortness of breath, and granted. These could be things that are part of n normal pregnancy physiology. So we're trying to sort of not freak women out during the pregnancy as well, but also keep them educated to look for things that may be more severe than normal. And I think it's important for your listeners to know too, that you know, just like you would for any patient that came in with hypertension or even concerns for heart failure. The same kind of workup applies for these pregnant women. You know, the BNP, the B type natriuretic protein should stay pretty stable even in pregnancy. And so if there's a concern about is this normal pregnancy physiology or not, we can do lab markers. I. You know, troponin should be normal in a pregnant patient. You know, obviously we have risks for blood clots and pulmonary embolism and it's not uncommon that we can screen for those things as well if they're presenting to an urgent or emergent care. But we can do that same workup of chest x-ray looking for pulmonary edema with low radiation. We can send labs like A BNP look for thyroid dysfunction that can be contributing. So, you know, I think it's important to really. Not forget our sort of ABCs of how we sort of start the differential first, and not always just chalk everything up to Oh, that's normal in pregnancy for you.

Kanny: 13:09

So Deirdre, you alluded to kind of the, the basic workup that many of us who are, spend our time on cardiology consult services are kind of used to, and I, I think. Obviously, the, the issue with hypertension is common enough in pregnancy that many of the, kind of milder cases or more routine ones are managed pretty well by the either the OB team or the high risk OB team. And usually the cardiologist in my experience, seems to get involved if there's, concerns about heart failure or another, challenging medication dosing. Is there any other pearls you have for like the, the consulting cardiologist in terms of what things might stand out that would, suggest a higher risk situation or a patient that needs more intensive monitoring or therapy?

Dierdre: 13:53

Yes. So as I mentioned before, I think, the BNP level should be an indicator for most women that should be pretty stable and normal, even in pregnancy. So if we have an elevated BNP, I would probably just go ahead and do a quick echo to make sure that there's no major valve problems or stretch of the chambers, either atrial or ventricular. And granted that. You know, most women this age don't have chronic disease, and so you're very rarely gonna see any abnormal diastolic parameters in the acute setting.'cause you know, really diastal is really meant to be for kind of middle aged patients with chronic disease. So it's not uncommon that your diastolic parameters be completely normal, but yet women can still experience acute diastolic heart failure after pregnancy, right? If they're. Swollen, having edema, even after C-section or a vaginal delivery, they sometimes need a few days of Lasix to kind of get things moving in the right direction. So I think not to be afraid to image, and it seems like we image all the time for every other thing in cardiology that we shouldn't be stingy with our imaging if we're not sure if this is normal pregnancy physiology. And then I think the main thing is, there's no wrong answer on how to treat blood pressure and pregnancy except to avoid, obviously, teratogenic medications. So knowing that if you're pregnant and you're going to start a medication, our first go-to medications in general are Labbe Law and Nifedipine, both of which can be used in pregnancy and in breastfeeding very safely. We can also use diuretics in pregnancy. The only caution is we just wanna make sure that we're not causing dehydration, obviously, during pregnancy. And so just monitoring for dehydration and kidney function, and even afterwards in breastfeeding to make sure that they're getting enough volume to support their breastfeeding needs as well. So we can start with those other forms of beta blockers are also okay to use. The only one I tend to avoid is atenolol. That was one of the earlier medication study that did show some association with intrauterine growth restriction. And it is our only beta blocker that's excreted renally, so I usually tend to avoid that one. And obviously we're gonna avoid ace inhibitors and ARBs and the Nies Andras in pregnancy because they have not been studied in pregnancy. So if we just stay away from the bad players, you really can use what is needed, depending on how the patient is responding. And it can be, you know, multiple times a day, once a day dosing. If they have a fast heart rate or other arrhythmia, you may favor beta blocker or over Nifedipine. And just kind of go from there. So those are the main things. I usually just start with the lool and ine, but if you need hydralazine or diuretics or even clonidine, those things can be added. We're just avoiding the Ace arb, RNA and MRA class. Then just like everything, as long as we have a way to monitor the response, you know, the, the main thing is in pregnancy, we don't want too high blood pressure, but we certainly also don't want hypotension, right? So if we're monitoring at home, either remote monitoring or if they're coming in to check their blood pressure, just to make sure that we're keeping them in an even range, not to have those extremes, high or lows.

Ellen: 17:15

Wonderful. So once we're successful at managing their blood pressure through the pregnancy, I guess there are two aspects of my next question. One is, what would be the implication for the mother and how do you counsel them regarding future pregnancies? And then the second part is. What are the long-term implications for future cardiovascular risk in someone who developed high blood pressure during pregnancy?

Dierdre: 17:43

Sure. You know what? I kind of treat all hypertensive disorders in pregnancy the same when I'm kind of talking about risk for future pregnancies.'cause I think once you've had hypertension in one pregnancy, we should monitor you closely. And I think you're either at risk for chronic hypertension or at least having gestational hypertension again. And I think, you know, those things kind of increase our risk for preeclampsia going forward. So. In my view, the two types I'm looking at are women who either they had this pregnancy complication and they're not having any more children, so I'm gonna focus on the long-term cardiovascular risk reduction, or if a woman is still childbearing and planning more pregnancies, my main focus to say, how can we make the the next pregnancy more safe for you? For the most part, for both of those types of patients, we're really talking about lifestyle intervention. We have to start early with getting a healthy diet, low sodium, getting them on a Mediterranean diet.'cause we know that has decreased rates of intrauterine growth restriction and preterm delivery. And a 28% reduction in preeclampsia the more tightly that you follow a Mediterranean diet. So I'm really focusing on educating them about those things. And so, you know. In general, ACOG guidelines say any woman that has had hypertension in pregnancy needs a reassessment of her blood pressure control within 72 hours of delivery. So a, you know, we're checking to make sure that blood pressure is staying well controlled and that we don't develop postpartum preeclampsia as well, which is not uncommon. And so we have that within 72 hours. And then there's several different models of how you can follow blood pressure in that two to six weeks postpartum. When they still may, may need some medications to manage the blood pressure that can be done remotely with text messaging, video calls. Here at Cleveland Clinic we have a shared medical appointment where we see groups of patients together and sort of make decisions about their blood pressure management if they need to and go over cardiovascular screening for the future as well. I, I will point your readers to a CC released a, a postpartum hypertension toolkit last year, which is available free to download on the a CC website. And it goes through many different clinic models and how you can bill, how you code, gives you sort of templates for notes and for talking about how to counsel patients. So I think it's a very useful resource for your listeners as well. I think talking about those two sort of courses, the immediate risk for next pregnancies, and then the longer term, we're talking about 15 to 20 years really about cardiovascular risk and usually how I start that conversation with women too is to say, you know, even when I'm talking 15 to 20 years, if you're 30 something or late twenties, getting pregnant. We're still talking about premature onset of cardiovascular disease in women since this would be happening pre menopause for most of them. And so really it's the foundation of prevention is we're saying we're recognizing this risk now and we want you to work now to reduce those risk factors. So I spend a lot of time educating them about how we can sort of mitigate those risk factors for metabolic syndrome, how to get the cholesterol controlled, the blood pressure controlled, and the sugars controlled. That kind of. Milieu of know your numbers. So you should be seeing a primary care doctor so you know where your cholesterol numbers are, where your hemoglobin A1C should be, is your blood pressure at goal from there and educate them so they know what to look for.'cause I think, you know, especially for young women, it's kind of, we, we get a lot of stuff from social media and you're supposed to take supplements and do all these. Things that we can buy and do and shake, you know, to keep ourselves healthy. But it's really focusing on what are the sort of, you know, the, the, the guideline directed sort of measures of how we consider ourself in ideal cardiovascular health and how you get there may differ by some people, but knowing what metrics they should be measuring. And then as far as this long-term cardiovascular risk you know, there's very few indications I would think for many of these young women to be on a cholesterol medication. You know, as you all know, we're not really starting the screening for the atherosclerotic disease until the age of 40, but I do think these phenomenons of preeclampsia and even gestational diabetes. This is a microvascular dysfunction and it probably means that there's some sort of predisposition for microvascular disease in sort of all of our organ beds later on. And I think the coronary calcium score is a great way to kind of restratify these women starting early. So I usually will start doing that in the early forties to kind of have a baseline, because there is some data showing, especially even with gestational diabetes, that women have elevated coronary calcium scores. Despite where they are after their delivery, if they have U glycemia or if they're still pre-diabetic or they turn into chronic diabetes, their coronary calcium scores can remain elevated over time. So I think there's tools we can use about, it's not all just about the numbers and the labs, but we can risk stratify with high sensitivity CRPS for inflammation. We can use coronary calcium scores and obviously we still use stress testing for symptom management. If we're saying we're short of breath or have decreased exercise tolerance and really introducing them to that way of how we can maintain a healthy lifestyle from a very young age throughout.

Ellen: 23:19

That's wonderful. I think we could also maybe throw in not only a fasting lipid panel, but also lipoprotein little A, which as we all know is a, is a heritable risk factor, which although we aren't treating it directly now, we certainly would be more aggressive at other risk factor modification, sort of a more holistic approach.

Dierdre: 23:41

Agreed. That is my sort of only, you know, we've all moved kind of away from primary prevention, aspirin. But in my sort of own practice, you know, I do use aspirin in these events when we get coronary calcium scores greater than a hundred, or if I have these lipoprotein little as greater than a hundred. This is my sort of like, okay, you win. I'm gonna give you aspirin moments for these patients. I still tend to hedge a little bit, even for young patients. Sometimes I'll do intermittent dosing for aspirin just to kind of minimize bleeding risks for there. But I do think that is one of those areas where aspirin's not completely dead to us for primary prevention and has some benefit.

Kanny: 24:21

So I think what you're saying really Deidre, is that basically once you know the acute period of the pregnancies passed that. Our approach should really be the same way we would approach anyone that we kind of consider a more high risk kind of primary prevention category in terms of using, lifestyle, using, selective use of screening and right, and, and the selective application of preventive measures. I am curious though, obviously they'll, I'm sure there's plenty of women who have what you would consider mild, gestational hypertension, maybe, maybe they respond to lifestyle changes in the end of pregnancy or maybe even a low dose of one of the medications you mentioned. I assume most of them never see a cardiologist during the pregnancy or the delivery. Do you feel like the OB community's pretty educated now, that someone like that should still, benefit from closer monitoring? Or do you still see some patients who kind of fall through the cracks for a while even when, there was kind of a red flag in pregnancy that they, may have needed to be followed more closely?

Dierdre: 25:21

Well, I think the short answer is there's definitely a lot of people falling through the cracks. I mean, I can speak from my own experience with the postpartum hypertension clinic. I mean, right now my requirement to be referred is any hypertensive disorder in pregnancy, so it can just be gestational hypertension, it could be chronic hypertension, preeclampsia, eclampsia, health syndrome, any of those qualify. I also see patients with gestational diabetes and so. That can be thousands of patients. If we think about the incidences of gestational diabetes is on the realm of five to 14%, and we have similar incidents of that for hypertension and pregnancy as well. So thousands of patients yet. You know, when I fill these spots and sometimes they are filled, there tends to be a very high no-show rate. So I have like 35 to 45% no-show rate for these women that are even scheduled. And these are the women that we've identified and asked to come not, and there's a whole other slew of patients that you know, have not been identified and not referred from there. So I think. I have worked very closely with the OB community and my maternal fetal medicine colleagues to try to educate them. We've made flyers to kind of go through the basic, this is what preeclampsia is, and these are the risk factors in the future, and you need to follow up with us so that we can make sure X, Y, and Z. And really, you need a primary care doctor who's going to follow long term. We do the same for gestational diabetes. I just think part of it is in the nature of what it is. You know, you're catching women at this very eventful time in their life. They have a newborn. There's a million things to learn, especially if they're a first time mom. I think many women can identify your health is not always the priority if you're leading a household. And now if you just have a new baby, you may have other babies at home too. And so trying to make them prioritize this when for the most part they feel relatively fine, especially if it was something that resolved quickly. I think that part is a little hard, and that's where we rely on our OB GYN colleagues to kind of. Even if it's at the six week mark postpartum going forward to say, Hey, you know, now that things have settled down, we wanna remind you that you have this appointment with the cardiologist so that you can, you know, think about screening or if there's other pregnancies from there. So it is a group effort. I then when I see them in my postpartum cardiology clinic, I really am referring them to a primary care.'cause many of these women don't have a primary care provider. They have their OB, GYN, that they either had been using for birth control, pap smears, and then pregnancy care, but not necessarily a primary care that's doing all their screening exams and things like that. So I think we're like a stepping stone to trying to get primary care and our hope that is that then this screening will continue long term.

Ellen: 28:12

So Deidre, thank you. You have taught us so much about this topic already, and you've alluded to your postpartum cardiology clinic. I was wondering if you could just fill in a little bit more about how you've set that up.

Dierdre: 28:26

Yeah, again, I'll say the a CC, postpartum hypertension toolkit is a great resource because there are many different ways that you can do this, and it really kind of depends on your local environment. For me, because I was trying to maximize the amount of people that I could see, and also because I. In my particular postpartum heart clinic, we do do a lot of education, and as I'm sure a lot of your listeners know, a lot of this education and prevention you can't really bill for, right? In a general cardiology sense, so. The way we do is a shared medical appointment. So we have 10 to 20 patients scheduled at a time. We do this in a conference room that has some cordon off areas where we can do private exams. So a patient will come in and I will see them and I have a nurse practitioner that also works in our clinic and one ma. So we are a three woman show essentially, and we are seeing all these patients at one time. The shared medical appointment is a 90 minute visit. We spend about an hour getting all the people checked in, they get EKGs, vitals, weights, and physical exam. And then about 30 to 40 minutes is a didactic session talking about hypertension cholesterol, diabetes, and how to minimize metabolic syndrome, risk factors in the future. And so essentially how this is billed to insurance is just individual office visits for each patient, because in a shared visit, as long as you're doing an exam, you're taking an HMPA, you're still reviewing the medications, and I am actually adjusting medications for many of them. The ideal timing that I see them is two to six weeks postpartum. Some of them stretch out a little bit, two to three months, just depending on when they can get scheduled. But we're still managing medications for them too and getting them connected to chronic care. So in that sense, it's just billed as a regular office visit to their insurance and based on your level of care. And then essentially they're getting this education piece bet from me and my nurse practitioner just thrown into the visit. So. We say a lot of the same things, but this is helpful. We, we have like a PowerPoint presentation. They can see images. We say, this is what, you know, coronary artery disease is, and this is how it relates to your cholesterol. So they're sort of putting those connections together earlier and hopefully that keeps them more informed going forward.

Kanny: 30:46

Well, Deirdre, that, that's a fantastic summary. We're kind of up against our time, I think. Mm-hmm. I was hoping we could put some links to the course you alluded to, as well as that toolkit in our s Sure. So we're happy to do that. Just to quickly wrap up though, are there any, you know, what you would consider like newer frontiers? And cardio ob in some of the meetings and stuff. What, what do you think are some of the areas that as cardiologists will start you know, potentially incorporating into practice in this area in the next few years?

Dierdre: 31:17

Well, I'm not sure newer frontiers, but I think that, you know, like most things in cardiology, we see higher and higher risk patients doing these things that we wouldn't think possible, you know, 10, 20, 30 years ago. So, you know, do we see transplant patients having babies? Do we see LVAD patients having babies? Occasionally, a lot of adult congenital. Patients having babies. So I think that intersection of heart failure, adult congenital, and cardiology is ever growing and how those links and sort of figuring out better ways. I do think there is a lot of space for, you know, in general maternal mortality and how we're gonna move that needle and maternal mortality. And I think as a call to. Some of your listeners here is that one of the things is that every state has a maternal mortality review committee to that face, and many of these states don't have a cardiologist. In fact, the grand majority of these maternal mortality review committees don't have a cardiologist on the, the review committee. And as you know, heart diseases now becoming the. Leading cause of pregnancy related mortality. So I think there's a call for us to get more involved in this space so that we can reduce maternal mortality.'cause a lot of this is due to hypertension, heart failure, things like that, that we are, you know, obviously experts at managing. So I think that's one of the things going forward. Then I think as I alluded to before, we'll start to see that we actually have, you know, practice guidelines, centers of excellence on how you do this. And you know, as cardiologists we love a checklist and a guideline that we can follow and say we did X, Y, and Z. And so hopefully we'll get that within the next 10 to 15 years as well.

Kanny: 32:56

Well, we look forward to that. And we just wanna thank you again for helping educate our, our colleagues here in Ohio not just on the podcast today, but also with your excellent recent lecture at our spring summit. And we look forward to hearing about your clinic and future endeavors as well.

Dierdre: 33:11

Great. Thank you guys so much. I'll definitely send out the links to the a CC cardio BCME and then a call for the fellows.

Ellen: 33:18

Wonderful. Thank you so much, Deidre, for spending time and sharing your expertise with us.

33:23

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