Cardi-OB also known as Cardio-Obstetrics- What is it?

 Cardio Obstetrics: What is it?  | MedStar Health DocTalk

Pregnancy is often described as a natural stress test for the body, and especially for the heart. In this episode of MedStar Health DocTalk, host Debra Schindler sits down with cardiologist and cardio-obstetrics specialist Dr. Minhal Makshood to explore the growing field of cardio obstetrics and why pregnancy can reveal important clues about a woman’s long-term cardiovascular health.

Dr. Makshood explains how conditions such as preeclampsia, gestational hypertension, gestational diabetes, and peripartum cardiomyopathy can affect both mother and baby, and why these pregnancy-related complications may increase a woman’s risk of future heart disease, heart failure, stroke, and other cardiovascular conditions.

The conversation also highlights the importance of prenatal counseling for women with existing heart conditions, the role of multidisciplinary care teams, and why the postpartum period—sometimes called the “fourth trimester”—is a critical time for monitoring heart health.

In this episode, you'll learn:

• What cardio obstetrics is and why the specialty is rapidly growing
• How pregnancy can uncover previously undiagnosed heart conditions
• The warning signs of heart complications during and after pregnancy
• Why preeclampsia and gestational diabetes are more than temporary pregnancy complications
• How pregnancy history can help predict future cardiovascular risk
• The importance of coordinated care between cardiologists, obstetricians, and maternal-fetal medicine specialists
• What every woman should know about protecting her heart before, during, and after pregnancy

Whether you're planning a pregnancy, currently expecting, recently delivered a baby, or simply interested in women's heart health, this episode provides valuable insights that could have lifelong implications.

If you have a heart condition, experienced complications during pregnancy, or want to learn more about protecting your cardiovascular health before, during, or after pregnancy, schedule an appointment with the Women's Health and Cardio Obstetrics Clinic at MedStar Health. Call 301-570-7404 to learn more or make an appointment.

Guest: Dr. Minhal Makshood, Cardiologist and Cardio-Obstetrics Specialist
Host: Debra Schindler

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Transcript

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Comprehensive, relevant and insightful conversations about health and medicine happen here. When MedStar Health Doc talk, these are real conversations with physician experts from around the largest healthcare system in the Maryland DC region. Pregnancy is really one of the most transformative times in a woman's life, but it can place extraordinary demands on the body, especially the heart. During a healthy pregnancy, blood volume increases dramatically, heart rate rises, and the cardiovascular system works over time to support both mother and baby. In many ways, pregnancy acts as a natural stress test for the heart. For some women that stress test can reveal previously undiagnosed heart conditions or trigger new complications such as high blood pressure, pre-eclampsia, or even heart failure, that's where cardio obstetrics comes in. Cardio obstetrics is a rapidly growing new field of medicine that brings together cardiology and maternal-fetal medicine. It focuses on protecting the cardiovascular health of women before, during, and after pregnancy through a highly coordinated team-based approach. This specialized care is designed for women with preexisting heart conditions, such as congenital heart disease, valve disorders, arrhythmias, and cardiomyopathies, as well as women who develop pregnancy related complications that can affect long-term heart health. Today we're joined by Dr. Minhal Makshood, a cardiologist and cardio obstetrics specialist at MedStar Health, to discuss how this emerging field is improving outcomes for mothers and babies and why pregnancy can offer critical insights into a woman's future. Cardiovascular health. I'm your host, Debra Schindler. Dr. Makshood, Thank you so much for having me. Yeah. I didn't tell you this before, but this topic is a little close to my heart. My father's mother, now we're going back to the forties, she had something called rheumatic heart, which we now know to be a valve disorder from having rheumatic fever as a child. And after she carried my dad in her pregnancy and the untreated valve problem took its toll and at 25 years old, she died. And I was surprised to read as I researched this topic for this discussion today, that they only started really looking at rheumatic heart and cardio obstetrics in the nineties. So why now is it surfacing? Great question. So I'm sorry about that personal experience, but this is actually, you know, still the reality for a lot of women. So the truth is that maternal mortality and morbidity has been rising in the United States. And if you look at the reason why the primary driver of that is actually is cardiovascular disease. So then the question remains, why is that so? Well, a couple different reasons. We are seeing more and more women become pregnant with other comorbidities such as advanced maternal age, obesity, diabetes, high cholesterol. So PA patients are having preexisting conditions and choosing to have children at an older age. We are also seeing women who have preexisting heart disease, such as prior congenital heart disease, get pregnant'cause they're living long enough to go through pregnancy because of the advancement of medical care, which is fantastic. And then we are also learning that women who have adverse pregnancy outcomes such as preeclampsia, gestational diabetes, preterm labor, these are things that can happen during pregnancy as complications of pregnancy. And we are learning that these complications of pregnancy actually have long-term effects on your cardiovascular system. Well, you know, many listeners are probably hearing cardio obstetrics for the first time. And I heard you reference it as cardio B, which I thought is very clever. How do you explain that to patients? What exactly is cardio obstetrics? So cardio obstetrics is a field that was born as a result of that data that I just told you, that maternal mortality and morbidity is primarily driven by cardiovascular complications. It is the care of women with heart conditions before, during, and after pregnancy. So this could include women who already have preexisting heart disease, such as women with congenital heart disease, valvular heart disease, like the example you gave of your own family member, abnormal heart rhythms or existing heart failure. And these women, pretty straightforward, right? They have preexisting heart disease. So they're high risk during pregnancy, but it also includes taking care of women who de develop heart related problems, such as, like I mentioned before, hypertension, preeclampsia heart failure or abnormal heart rhythms. We need to understand that pregnancy places an extraordinary demand on the cardiovascular system. As you mentioned, your blood volume rises, the heart rate increases, and the heart now has to work much harder to support both mother and baby. So pregnancy like is a natural stress test to the body. So cardio obstetrics is really about anticipating that risk, recognizing problems early and creating a coordinated care plan so women can move through pregnancy and postpartum as safely as possible. And this is how we decrease that maternal mortality and morbidity that is driven by cardiovascular disease. So cardio obstetrics is where maternal health and heart health meet. So you mentioned these, these conditions pre-eclampsia, explain what that one is. So when we think of complications of, you know, pregnancy related complications, we think of hypertensive disorders of pregnancy. High blood pressure, High blood pressure, correct. So you can either develop high blood pressure, there are very diff strict definitions for each of these. You can develop gestational hypertension, which simply means you have elevated blood pressure during pregnancy, or an extreme form of that is preeclampsia or eclampsia. Preeclampsia essentially is not just elevated blood pressure, but now you're seeing consequences of that elevated blood pressure to the vasculature that results in end organ damage. So patients can start having kidney dysfunction, heart dysfunction, retention of fluid in their lungs, in their legs. So what you're seeing is that elevated blood pressure is now causing an inflammatory response and causing destruction to the vascular endothelial system that then results in through this cascade of complications that cause end organ dysfunction. So patients will start developing protein in the urine as a complication of kidney dysfunction and then they can start having, like I said, fluid retention. So it's an extreme form of hypertension, belated complications. And that's always an emergency, Typically. Yes. So been patients at preeclampsia, usually the treatment primarily for preeclampsia other than decreasing blood pressure and treating them with other ME medications, including magnesium, is delivery to save mom. Of course. I know some women who have been through that and they've had emergency cesarean sections. But what if the preeclampsia starts earlier in the pregnancy? Does that happen? Is it treatable? Would that be when the patient would come to you? So that's a very good question. So oftentimes preeclampsia we see closer later on in pregnancy, but it patients can have hypertension related complications, particularly preeclampsia earlier on, particularly in the second trimester and so on and so forth. So that is why it's very important to identify patients at risk and make sure that they're on the best management in terms of their blood pressure. But if they do develop preeclampsia, to your point, the treatment unfortunately is delivery. Okay. So it's treating the blood pressure and delivering because mom needs to be healthy for baby to Survive. Absolutely. So when these changes happen to the cardiovascular system during pregnancy, do they usually revert back to, to normalcy after the pregnancy? And does it reveal anything about the woman's future health? This is a really, really good question and a very important one. You know, oftentimes all these conditions that I mentioned, and I'm gonna repeat them again'cause they're important to know, preeclampsia, gestational hypertension, gestational diabetes, and preterm labor, they're often all just treated as pregnancy complications, right? So oftentimes you'll talk to women, they'll say, I had preeclampsia during my pregnancy, I delivered baby, and everything's done. But they're actually cardiovascular warning signs. They tell us that a woman's blood vessels may be more vulnerable to high blood pressure and vascular disease later in life. And we've actually looked at this and studied this. Patients with gestational diabetes also tell us about their future risk of diabetes and cardiovascular disease. So oftentimes, if you have an adverse pregnancy outcome, which is one of those conditions that I mentioned, this is a great clue about your long-term cardiovascular risk, because we know that patients with adverse pregnancy outcomes are at increased risk of heart failure, coronary disease, and overall bad outcomes, cardiovascular one. So this is why it's important to identify these patients early and in the postpartum period, intervene early and help with lifestyle modifications and risk assessment so that these things can be prevented in the future and that patients don't present in their forties, fifties with heart attacks or heart failure or other conditions because they weren't adequately screened or thought about in more detail or intervened upon earlier. Who are some of the patients that you see who's typically a patient who needs cardio obstetric specialty care? So it's a whole host of patients. So if I were to describe the typical patient with preexisting heart disease, right? So someone that already has a heart condition, like I said, that's a straightforward one. Typically I would see that patient for prenatal counseling, which is before they become pregnant. So these patients who are preexisting cardiac conditions should plan pregnancy, right? So they should go see their OB and also see a cardio obstetric specialist or a cardiologist and make sure that they're on the right medications, make sure that they're optimized cardiovascular wise, if they need further imaging or testing to understand their disease process further, that needs to be completed. If they have conditions that require surgical intervention or anything like that, that needs to be handled before pregnancy, those things need to be discussed. So the prenatal counseling entails taking care of women of preexisting cardiac disease like heart failure or you know, valvular dysfunction or underlying arrhythmias, and essentially risk stratifying them or even chronic hypertension and diabetes and making sure that all these factors are optimized. So they're going in with their best foot forward into pregnancy. So that's the typical patient with preexisting cardiac disease. The second layer of patients I see is risk factors or prior pregnancy related complications. So if you have had preeclampsia in your first pregnancy or gestational diabetes in your first pregnancy or any of these other adverse pregnancy outcomes, it's good to have a prenatal counseling with a cardio obstetric specialist to make sure that these things are optimized prior to getting pregnant again and making sure we are on top of it and controlling blood pressure, controlling other risk factors, making sure for example, that you're on an aspirin for preeclampsia pro prophylaxis, and then making sure they're frequently followed throughout pregnancy so they can meet the demands of pregnancy without complication. So that's the second flavor of patients. Then the other flavor of patients are patients who are pregnant and then start having problems. So when you are pregnant, if you have severe chest pain, worsening shortness of breath, you're passing out, you're dizzy, you're feeling significant palpitations, then you should absolutely see a cardio obstetric specialist. A lot of people will say, well wait a minute, a lot of pregnant women get short of breath during pregnancy, they'll get a little dizzy. Do we panic every time we have these symptoms? Well, yes and no. So for example, it's very important to pay attention to trends and listen to your body. If something feels off, you are more short of breath than expected. You're noticing your legs are getting more swollen, your passing out is never normal, chest pain is never normal, right? Then you should immediately seek evaluation, right? Early intervention here is key. So those are patients who develop heart issues during pregnancy that then come and see me at that time, and then we follow them through pregnancy and then we transform into the third trimester postpartum phase where patients are more vulnerable, pregnant patients are more vulnerable at that time because of all the changes that occur at that time and can develop heart conditions then. And then I'll see a host of patients that either develop things like peripartum cardiomyopathy that typically occurs at the end of pregnancy or postpartum. What exactly is that? So peripartum cardiomyopathy is heart failure that occurs from pregnancy. And there's a whole host of reasons as to why that happens. You know, during the post the third trimester going into the postpartum phase, your body is going through a lot of hormonal changes. There's a lot of changes in the inflammatory pathways, the metabolic pathways and delivering in and of itself is a huge stressor to the body, specifically vaginal delivery. So patients going through these changes can develop heart failure. And there are some patients that are more prone to that. Like for example, patients who already have elevated blood pressure, right? They already have something that's vulnerable about their vasculature that increases their risk for endothelial dysfunction and dysfunction of their vascular system that can then down the line lead to heart failure. So for some reason, we see this most in the third trimester to the postpartum phase for that reason. Okay? And we are hypervigilant about this because a lot of times women can come in, they're short of breath, they'll have swelling in their legs and they'll be diagnosed with this, right? And they can even develop preeclampsia postpartum, you can be completely fine during your pregnancy and then you deliver a baby. Oh, and then your blood pressure is elevated and you're having swollen legs and it could just be from preeclampsia that develops postpartum And, and the risk for that is stroke. So yeah, it's, yes if preeclampsia is untreated, but the risk for that is also heart failure, right? So preeclampsia is also on a spectrum where it can end up causing destruction to the heart too. And you can end up leading to heart failure, which is the extreme form of that. So understanding that these are all things that cardio obstetrics takes care of in a collaborative fashion. So it's either preexisting heart disease, heart disease that you develop during pregnancy or someone that has risk factors to develop heart disease in pregnancy. So that's the entire host of patients we care for. And once you are a patient, you should be our patient forever. And now, if a woman has any of these conditions, pre-eclampsia, gestational hypertension, gestational diabetes, is the baby at risk, is there any impact to the baby's health? Yeah, so that's a great question. So for, for example, gestational diabetes can lead to large babies because of uncontrolled sugars, you know, because blood sugar is a toxin, right? So that can lead to LA large for gestational age. Preeclampsia itself, like I said, it's an issue with the vasculature. So it can result in the baby not getting enough perfusion. So when mother is not doing well, baby naturally won't be doing well.'cause the baby depends on mom to do well. Is is a large baby a risky baby? I mean, is that a danger to the baby? Yeah. So a large baby typically, so I'm not an OB GYNI Understand. So, But I would say that, you know, gestational diabetes can then lead to large gestational age that can then lead to labor and delivery related complications, right? Larger babies are harder to deliver, sometimes need to do C-sections, which Im important to know. And knowing that, you know, babies that are born with macrosomian who are larger, also an increased score of obesity and diabetes in the future and things like that. So there are obviously fetal implications for this as well. But it's important to understand that in, when you think of pregnancy, mom needs to be healthy because whatever mom is experiencing baby's invariably experiencing the consequences of that too. I have seen babies born when their moms were with gestational diabetes and they're fat and they're cute. They're just so cute. Yeah, they look pretty healthy, but they, they look just little chubby. Yes. Yeah, yeah, yeah, yeah. I think it's more important to sort of think of these things as a lens into the future, right? And I think that's kind of where the narrative sort of shifts a little bit, where we need to understand that pregnancy is not just an experience a woman has once in her lifetime, whatever complications she develops, she develops and then we forget about it. These are not just memories, these have long-term cardiovascular consequences. So the pregnancy history should be a huge part of a woman's history in terms of her health history. I tell women, know your health history really well. Know your pregnancy history. Oftentimes I will speak to patients and I'll ask them about their pregnancies, you know, even when they're in their fifties and they'll say, I think I had high blood pressure. I remember my legs were quite swollen. I think my sugars weren't great. It's just almost like it becomes this memory and it's, it's only I think a human response to sometimes shield things that are negative. And most people remember, you know, holding their baby for the first time and how that made them feel. And that's all beautiful. But it's important to remember the stuff that didn't go well too, because that stuff is really a clue into the future, right? It's telling you, you know, this is a window into your future. It's telling you how you may have issues 10, 20 years down the line. And I think that's really key because it's so valuable, that information and it really gives us that opportunity to intervene earlier on. So we can save women from a lot of cardiovascular complications later on. So cardiologists should be asking their female patients about their pregnancy history. They should be asking them, did you develop preeclampsia? Did you develop gestational diabetes? Did you have preterm labor? These things are important. Did you ever have uncontrolled blood pressure during pregnancy? Right? And if, and if the answer to that is yes, that changes how they risk stratify that patient and how they think about that patient. I mentioned my grandmother having had rheumatic heart and she delivered my dad, but subsequently was weakening and she knew that she was going to die. Sad story. But it was, you know, 1940. Yeah, one. Nowadays, if a woman came in with the same problem, we know now to be a valvular problem, what would they do with a situation like that? Could the woman undergo surgery for that? Yeah, while she's pregnant. Great question. In fact, I actually had an experience during fellowship where of a woman with mitral stenosis in the setting of rheumatic heart disease. And she got operated on, had it fixed, and then she went through pregnancy and we were able to carry her through that pregnancy. So this is where that prenatal counseling is really key, right? So then the question is, who needs prenatal counseling? If you know that you have a cardiac condition, then it's pretty easy to just go see a cardiologist, right? Because you have a cardiac condition, but you also need to be on top of it and make sure you talk to them before you decide pregnancy to make sure it is safe for you to get pregnant.'cause not all cardiac conditions are created equal in her situation. We were able to fix her mitral valve before she could go into surgery. But there are some cardiac conditions where pregnancy is truly contraindicated, where you shouldn't consider pregnancy because it is too high risk. But then there are conditions where you know, you have mild to moderate disease, you're pretty optimized and we can safely carry you through them. And and we do. So it's important that prenatal counseling piece is important for women with pre-existing heart disease. And if you are someone who is deciding to have a baby and your advanced maternal age, and even if you're not advanced maternal agent, know you have diabetes, obesity, high blood pressure, go see someone While a woman is pregnant, can she be on blood pressure medications? Absolutely. Or cholesterol me. Yeah. It doesn't affect you. Well, blood Pressure you do cholesterol is a little challenging. So let's talk a little bit about that. So blood pressure medications, there are safe medications studied in pregnancy. So that's another reason why if you have chronic hypertension, you need to make sure you see your cardiologist before you consider pregnancy because we need to ensure that whatever medicines you're on, it is pregnancy safe both for you and baby. So if you're on something that isn't pregnancy safe, we will switch you prior to pregnancy. So that's, that's one thing. Cholesterol is a little tricky. It's tricky because there's now newer data with a statin called Pravastatin, and we could use pravastatin in certain select high risk cases, but statins for the longest time were contraindicated in pregnancy. So women who have had, you know, issues with cholesterol, typically if they've not had a heart attack or stroke and they're going into pregnancy, we're okay with them staying off their statin. But then there are a few subset of patients who are high risk, who have had pregnancies, have had stents before, and in the past we would never put them on a statin because of high risk. But then this patient should also have a discussion with their cardiologist and whether pregnancy is truly safe, if they have stents and other heart disease, coronary disease. However, in in this population, now we can consider pravastatin if we need to use it. We do have that tool. What's important to understand is in pregnancy and not all cardiac medications are safe. So a cardio obstetrician is someone who specialized in understanding what medications can be used in pregnancy as well to treat specific cardiac conditions. So that's why it's important to make sure you're on all the right medicines before pregnancy and if you develop anything during pregnancy that you are treated with medicines that are safe. You and baby, We know that black women in the United States face significantly higher rates of pregnancy related death. How can cardio obstetrics help close the gap? Yeah, so this is actually a very, very important topic when it comes to maternal health. And the disparities are actually quite profound and heartbreaking. Black women have a higher rate of maternal mortality and morbidity compared to other women. This disparity is actually true across income and education as well, which is what makes it shocking. And it also sort of highlights the importance of system level inequities. A huge part of it is delayed diagnosis or that they present early and their symptoms are not taken seriously. So there is a so sort of systemic inequity component here as well that plays a role. Cardio obstetrics can actually help by creating earlier access to specialized care, early recognition that is key. Understanding the demographic, understanding the dis disparity exists taking their symptoms seriously. They have higher rates of preeclampsia knowing that, and importantly, it's this care coordination piece with OB and cardiology to make sure that these high risk women are taken care of during pregnancy and are not lost after delivery. So it's, it's about listening, trust, access and advocacy, which cardio B allows for. So closing the gaps actually start with listening to women and acting early because we know that we don't do a good job at that. And that's another reason why we're seeing this disparity. Which makes me think of the case that we were discussing prior to our recording where you have a mom who's in her fifth pregnancy, never before knew that she had a hole in her heart. Yeah. How is that possible that she has had four healthy pregnancies, never knew that she had this anomaly in her heart? Yeah. So you know, that's, that's an interesting case because she actually did not present with any symptoms during her first few pregnancies. And you know, when people say lots of people are having babies for years and years and years, not everyone has a terrible outcome. Pregnancy is a huge stressor to the body. But you would be surprised by how well your heart adapts to it. And some people adapt so beautiful in her situation. Yes, she had a hole in her heart and she likely was born with this. Right? And this is something that progressed over time. So interestingly, for whatever reason that I cannot explain, for the first four pregnancies, she didn't have any symptoms. She didn't have the shortness of breath, the swelling in her legs. But her last pregnancy, she's a little older, she's had the condition a little longer. She likely had more stretch of her heart, increased shunting from the left to right because of that hole in the middle of her heart. And eventually when she went through pregnancy, which was the ultimate stressor, it kind of tipped her over the edge. And she's a great example of someone who also presented in the postpartum phase. She didn't actually present during pregnancy. She presented towards the end when her heart couldn't take the stressor anymore, particularly delivery. And that's actually another great area where you could learn more about a woman's heart. Because when women go through vaginal delivery and go through labor, there's a lot of hemodynamic shifts that occur there to your blood pressure, to the fluid shifts, right? That your heart has to adapt to and work well. Right? And some women, when they show you that they're not doing that as well, that's another clue of something probably isn't. Right. Right. So this is where it's important to understand that pregnancy unmasks or can unmask underlying cardiovascular disease, which her case was a phenomenal example of that. Someone that has disease didn't know about it, she gets pregnant, goes through that stress test of increased blood volume, heart rate around delivery goes through those hemodynamic shifts and our heart says, Hey, I can't take this. And it starts retaining fluid and causes symptoms. And then there she's diagnosed. So sometimes pregnancy actually isn't the cause, it's just showing you what your underlying vulnerabilities already are that were already there to begin with. Well she attributes that pregnancy and that baby with saving her life. Yes. Just to finish off that story, she delivered the baby just fine and she Yeah. And then what happened? So I actually saw her in the postpartum phase. That's when I was first introduced to her. And you know, she was having heart failure symptoms and we ultimately diagnosed her with a hole in the heart. And we had a phenomenal structural heart team here. And it was something that we were easily able to fix through non-invasive surgery or minimally invasive surgery. She didn't need an open heart surgery. So we were able to fix it with a minimally invasive surgery. And I actually just saw her yesterday and she's doing fantastic, Wonderful, wonderful news. I mean, all Her symptoms have resolved and she's already on the trajectory of full recovery. I think it does make sense that she can go for pregnancies now that we we're talking about it and, and not, not reveal any issues in her heart because of the strain that is constantly being put on her heart through all these, the, the many pregnancies. I mean, I can't imagine these women who are 12, 13 babies, what's going on with them cardiovascular wise. Yeah. And then also we need to understand that, you know, the whole agent, advanced maternal age also does play a role. I mean, there are women who will present in their early twenties also with heart failure, but you're less likely to have more complications if you don't have chronic hypertension, diabetes, you're not obese, you're young girl with none, no other comorbidities. Not that you can't, and it does happen, but typically most of those women do well. But there's a reason why we worry more when women sort of progress in age and then start developing other chronic conditions because then you're sort of piling on risk factors and more stressors to the heart. So when you put someone through pregnancy, they may not be able to deal with that stress. And a lot of women, you know, the really nice thing about this is a lot of women do recover. They do well, they go home to baby and they just live their lives. And the truth is, I can't tell you the number of times women are shocked in my office when I tell them, oh, you had preeclampsia that increases your risk of, you know, cardiovascular disease in the future, whether that be heart failure or coronary disease. They look at me just shocked like, but I feel fine. I went home, I feel fine, you know, but does that really increase my risk? And then I try to explain to them like, yes, because this is a clue about what things would be 10 years down the line, 20 years down the line. So if someone had an adverse pre pregnancy outcome at the age of 30 during a pregnancy, 10, 20 years down the line, they can come in with long-term cardiovascular issues if they were not seeing a doctor and not caring for themselves during that time. And I think that time is so crucial because you can really intervene and make sure their blood pressure is well controlled to make sure their blood sugars are not, or they don't develop diabetes because all these things in the long run are gonna affect their heart.'cause women also then go through menopause, which is another huge shift in their bodies that also increases their risk of heart disease. So it's important to kind of think about pregnancy and pregnancy related complications as not just a clue, but also just something that you have to think about deeply for a patient in terms of how you're going to manage them and how you're going to prevent really, you know, stroke heart attacks and things like that early on in their lives. Is it your suggestion then that anyone who's listening now who had experienced preeclampsia during their pregnancy have a cardiologist? Yeah. Should they follow up with a cardiologist even if it's 10 years later? I think they should see a doctor, whether it's a primary care doctor or a cardiologist, depending on the situation. So at at the least, see your PCP, make sure you're getting your blood work, knowing all your numbers. Make sure your blood pressure's under control. Know what a good blood pressure is supposed to be. Understand the cutoff of blood pressures and make sure that you're below the cutoff and you don't develop hypertension. Pay attention to your cholesterol numbers. So look at them, look at the good cholesterol, look at the bad cholesterol. Make sure you're optimized. Ask your doctor questions about that. Look at your A1C, make sure your diabetes is under control. A primary care physician is very much capable of doing all of those things. And yes, you can certainly follow with a cardiologist as well, particularly if you had more adverse complications. But even for primary prevention, you know, either a cardiologist or a PCP, but it has to be a physician that you need to see for your routine care and that you're working on lifestyle things, whether that be diet and exercise as well. You mentioned those heart health numbers and I wanted to make sure that we, we emphasize knowing those heart health numbers. Are there any other ones that people should be aware of? I would say weight trends as well. So blood pressure, cholesterol. So know your lipid panel, what's your LDL, your A1C, and then know how your weights are trending. I would say those are some big ones that you should know When you have a patient come in and you know that this patient is high risk. How does your care team and, and who makes up the care team, how do you prepare for a case like that? Yeah, so this is really very, very important because cardio obstetrics is primarily a collaborative multidisciplinary team. And that's what makes it amazing. So it's a team that is a combination of cardiologists for high risk pregnancies, maternal fetal medicine, OB obstetrics, maternal fetal medicine, anesthesia for delivery planning, nursing, and sometimes genetics if patients have genetic conditions. Advanced heart failure specialists if patients already coming in with heart failure or developing heart failure or cardiothoracic surgery. Even sometimes if patients need surgery before pre, before pregnancy if they have valvular issues, so on and so forth. So it is really a pretty large team. But I would say the core members are cardiology, MFM, which is maternal fetal medicine, obstetrics anesthesia, and nursing. I think these are the core folks and we all work together to take care of the patient. Does that mean when the woman comes in for her monthly checkup during her pregnancy, everybody is there or is everyone talking about her case at some point? That's an excellent question. So I would say it's a combination of both depending on where you practice. So where I trained, we had a cardio obstetrics clinic where it was combined care where a patient would come and see the cardiologist and the OB person at the same time. But that would only occur once a month. And then sporadically, if they need to see each of them individually, they will as well. And then patients will also be discussed as part of meetings. They'll go through different patients and delivery planning and what's going on and updates. In some places it's exclusively messaging, you know, you, you make sure that all the people involved in the care of the patient are talking to each other. Right? And we constantly talk to each other. I can tell you when I'm taking care of pregnant patients, I'm talking to ob, you know, and if, if they're high risk and we are worried about the delivery and what their delivery plan is. So most of the talking happens also closer around delivery, then we talk to anesthesia, we ask them about their concerns. So this is something we constantly discuss and mostly happens behind the scenes in a lot of programs where patients may not be privy to those conversations, but they will know when they come to visits and we will tell them about what we discussed. And those things are repeated multiple times at each of the visits. So they know that everyone is on the same page. And I think patients deserve care where their doctors talk to each other and we know the best care comes from that. Nothing is worse than when a patient comes to see multiple doctors and they're all telling them different things and they're just not talking to each other. Right, right. And that's not gonna be effective. Cardio OB is only effective in doing its job of reducing, you know, bad cardiovascular outcomes. Only if you work as a team. Right? I can see a patient in clinic and tell them to do something, but if I'm not communicating that with the OB team, the maternal fetal medicine team, when they see the patient, if not, probably more frequently than I do because especially towards the end of pregnancy where they're seeing them weekly and so on and so forth, then they're not gonna be looped into the care. So none of that stuff is really going to come to fruition. So in order for all this to work, well we all need to come in 'cause we all bring very expertise and we're all thinking about a different aspect. OB thinks about a different aspect, cardiology thinks about the cardiovascular consequences, anesthesia will, will think about labor, delivery, sedation, that aspect of it, right? So all of us come in with our own sort of, not agenda, but our, our own concerns and our own plans. And then we come together, put it together and come up with the best plan for that patient. And that's when we see this working And then the baby is born, everything goes well and we're in the, what some people have called the fourth trimester. And I love that you had mentioned before or I appreciate that you had mentioned before that sometimes women get preeclampsia after the delivery, which is a surprise to me actually. Yeah. Tell me what that fourth trimester is and why is it such a critical time for heart health? Yeah, so a lot of times when women give birth, you think the hardest part is over, no, I'm gonna go home with my baby and everything's fine. But unfortunately that's not how it works in terms of your just cardiovascular risk and overall just how your body works. So towards the end of the third trimester transitioning into delivery, your body is going through a lot of changes, right? We're seeing a hormonal shift, we're seeing changes in metabolic and inflammatory pathways, right? Which is huge. And then you go through the whole process of delivering labor, right? Labor primarily. And that itself is causing, you know, variations in blood pressure, variations in fluid shifts that are going in the blood vessel, outside the blood vessel that can cause issues if they have underlying preeclampsia or underlying propensity to develop heart failure. So during this time it's really critical to pay attention to the patient and understand that even well after delivery days and even up to weeks, patients can still have face consequences of the pregnancy. In fact, peripartum cardiomyopathy can be diagnosed up to five months and even longer postpartum. Wow. And some patients also develop, it's very rare, but can develop this condition called spontaneous coronary artery dissection. Which for some reason we see happen closer to the end of pregnancy in that postpartum period for all those changes because of all those changes I just Mentioned. What, what is that? What happens? So it's basically spontaneous coronary dissection is the blood vessel supplying your heart, the wall of those blood vessels can dissect and it can lead to a heart attack to patients will present with heart attacks. And you know this, this is something that is treated very different differently from a traditional heart attack in some ways, but it's nevertheless a heart attack and patients can present with that and it's, and there's an entity that's pregnancy associated and that's something we also think of if patients present, which crushing chest pain or concerning symptoms, it's rare but it can happen. So it's important to understand that preeclampsia can happen, postpartum heart failure can happen postpartum. So many changes can happen because your body is still recovering. And so, so important for women to pay attention to those symptoms. What symptoms should a new mother never ignore after giving birth? Yeah, definitely don't ignore chest pain that is severe. You are having significant shortness of breath with swelling in your legs and you're not able to lay flat. You have to sit up and sleep because you're having fluid going into your lungs. That's very concerning. You're dizzy and you're passing out alright, these are all terrible symptoms. And if, if you are noticing that the swelling in your legs are getting worse, that's never good because the swelling in your legs should improve right after delivery. You will see more swelling immediately after delivery'cause of all the volume you get.'cause you get a lot of fluids and things like that during labor.'cause women lose blood naturally when they, when they give birth. So a lot of times, you know, women will get fluids and things like that so you can feel a little more puffy right after delivering. But that should get better. You should start noticing your lengths kind of shrinking back and you know, you're feeling like you're holding onto less fluid than you did towards the end of your pregnancy. But if you're noticing that that's getting worse, your legs are puffier, I'm lying down and I just find it hard to breathe. I can't breathe when I lay down. I need like two or three pillows to prop myself up. I wake up in the middle of the night sometimes short of breath. Those are all terrible signs I'm having crushing chest pain. This is so strange. It's odd. Get checked. I can't walk up a flight of stairs or two flights of stairs without really getting short of breath. That's, that's odd. I feel like I'm gonna pass out. That's odd, right? Is is this the purpose of a six week checkup after the baby is born? Yeah, so you know, the six week checkup happens with OB and they're screening for many things, including postpartum depression and other things that that women experience. But it, this is also part of it, you know, checking the blood pressure, making sure that you know the exam looks okay, that they're not having any concerning symptoms. Women with preexisting cardiac disease who have used cardio obstetrics during their pregnancy should also see their cardio obstetrics specialist or their cardiologist right after delivery. I oftentimes will see women within weeks after delivery just to make sure that their trajectory is, you know, heading in the right direction. Maybe there should be a three month checkup as a routine routine. And you know, that sometimes does happen depending on what complications that they have. So if they do, if they are high risk, I will see them a lot more frequently in the first six months postpartum just to make sure that everything is going as planned and making sure their blood pressure is stable. If, if there was preeclampsia involved, you know, if a lot of women, you know, who also have preeclampsia end up getting a heart ultrasound at some point, especially if they had concerning symptoms to make sure that the heart's squeezing and functioning normally, if there's ever a concern, you know, we need to look into it with further workup. So a lot of times I will see patients in the immediate couple weeks and then after that, a couple months out after that. And if they're completely fine then I might see them in six months and then go to a year after that. And what steps are you recommending to those women that they take to reduce long-term cardiovascular risk? So that's a good question. I would say in general would start out by saying outside of even pregnancy, there are things that we all can do to reduce our cardiovascular risk, right? So that's weight management, making sure you're exercising according to the, you know, guide guidelines. We recommend at least 150 minutes of moderate intensity exercise per week. That's roughly about 30 minutes a day. So what is moderate intensity? You can, you know, you can talk, but you can't sing. If you wanna do high intensity, you can, that's up to 75 minutes per week as well is what we recommend. Adhering to a Mediterranean diet that is, you know, high in fruits and vegetables, low in saturated fats and so on and so forth to make sure that you know your cholesterol is good. Make sure you don't develop diabetes, do not pick up smoking. These are all things that you can do to help with your overall cardiovascular risk, which in turn will also help you when you decide to get pregnant. But I also want to sort of say that there are women who don't have any of these risks and are actually doing pretty well and doing all the right things and could still develop issues during pregnancy for whatever reason. Right? So that's also important to keep in mind. But in terms of what can be done and putting the onus on the patient, I would say the best would be modif, those risk modification factors mainly make, you know, hypertension management, making sure you don't develop diabetes, you know, managing your cholesterol. So optimizing all those numbers prior to pregnancy is always a good idea. All of your advice is so important. And with the fetal morbidity numbers being what they are, I really have such respect for what you're doing and what your focus is on cardio obstetrics. How did you find yourself into this niche? Yeah. Medicine. Was there a certain case? Did you know that you wanted to do this or did you, were you in cardiology medical school and what happened? Yeah, no, that's an interesting question. No, I actually did not know from the very beginning. I knew I wanted to become a cardiologist when I was doing residency. And I will say I was a first year cardiology fellow at Johns Hopkins when I first did my cardio obstetrics rotation. And I was really amazed by how complex the patients were and how collaborative care worked and how it impacted positively the outcomes of these patients who are young and high risk for pregnancy. And I was so fascinated by that. I was also shocked to know that maternal mortality and morbidity were high and it was driven by cardiovascular disease. And it sort of informed me a bit more about the gap we have, not just in patient education, but also within medicine that how many of us within medicine as physicians really know, knew that. Right. And that was shocking to me that that statistic or knowing that. And then I was also on a personal front going through my own journey into motherhood and I was pregnant during my first year of Cardiology Fellowship. And it just sort of made me more sensitive to how vulnerable women are during pregnancy and how important this time in life is. Not just because you are making life inside of you, but also because of what that could mean for you in the future. And to me that was really humbling. So it was really a combination of looking at the science, the collaboration, the advocacy, the prevention and really that human connection. And so many, so many cases during my one training in at Hopkins of patients that I've seen and sort of seen how up this particular specialty has transformed their lives and given the ability for them to have children and have children safely and navigate that safely was, was really, really special. And that was when I knew this is what I wanted to do. What is the one message you hope every woman hears about pregnancy and heart health? I guess my biggest message is that women should feel empowered to speak up. If you're having the severe symptoms like shortness of breath, chest pain, fainting, persistent palpitations, or symptoms that just feel out of proportion, please never brush them aside. Right? So that's the most important thing I will say. Empower yourself to seek care. The second thing is know your history, know your pregnancy history, and know your health history really well so that when you do decide to get pregnant, you seek prenatal counseling and you make sure you're really optimized prior to pregnancy. And for clinicians, we need to ask more about pregnancy history as part of our cardiovascular risk, because pregnancy can give us some of the earliest warning signs we will ever get. So when we protect a woman's heart during pregnancy, we actually protect her health for life. Perfect ending message. Because pregnancy can reveal more than how a baby is developing. It can offer a powerful glimpse into a woman's future heart health. And by identifying risks early and supporting women before, during, and after pregnancy, cardio obstetrics is helping save lives. Thank you, Dr. Chu. We've been talking with Dr. Minhal Makshood, a cardiologist and cardio obstetrics specialist at MedStar Montgomery Medical Center in only Maryland. Thank you for sharing your expertise with us on Doc Talk. If you'd like to make an appointment with Dr. Makshood and be seen at the Women's Health and Cardio Obstetrics Clinic at MedStar Health, call 3 0 1 5 7 0 7 4 0 4.