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CardioNerds (Amit Goyal), Dr. Natalie Stokes (Cardiology Fellow at UPMC and Co-Chair of the Cardionerds Cardio-Ob series), and episode lead Dr. Priya Freaney (Northwestern University cardiology fellow) discuss “The Fourth Trimester” with Dr. Malamo Countouris and Dr. Alisse Hauspurg, from the University of Pittsburgh Departments of Cardiology and Obstetrics and Gynecology, respectively. We discuss the cardiovascular considerations after adverse pregnancy outcomes in the postpartum and long-term follow-up periods. The discussion is focused mainly on hypertensive disorders of pregnancy (HDP), guided by a series of clinical vignettes. We cover a wide range of topics from cardiovascular complications and management considerations in the immediate postpartum period after a HDP, postpartum outpatient follow-up, long term cardiovascular morbidity related to HDP and related preventive strategies, contraceptive considerations for the cardiologist, and interdisciplinary care management pearls for cardiologists working in a cardio-obstetrics team.

Notes • References • Guest Profiles • Production Team

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Pearls – The Fourth Trimester

1. Blood pressures >160/110 should be treated like a true emergency during pregnancy and the postpartum period, as the cerebrovascular circulation is more sensitive to hypertension, due to hormonal changes related to pregnancy.
2. Women with pre-eclampsia are at higher risk for peripartum cardiomyopathy. Have a low threshold to do a clinical heart failure evaluation (i.e., natriuretic peptides, echocardiogram), and administer diuretics as appropriate to improve volume status and blood pressure.
3. Women with HDP should have their blood pressures monitored closely after discharge, ideally with a home BP monitoring program, as they can have exacerbations of their HTN for up to 2 weeks postpartum.
4. The American Rescue Plan Act of 2021 included a landmark policy to extend postpartum Medicaid coverage up to a year postpartum (from 60 days).
5. Remember to take a reproductive history for every woman you see in cardiology clinic! This can be done in one minute. At a minimum, include obstetric history [number of pregnancies, outcome of each pregnancy, gestational age and weight at delivery, pregnancy complications (HDP, GDM, etc), and delivery method] and menopausal history (age at menarche, age at menopause).
6. The Pooled Cohort Equations may underestimate ASCVD risk for a woman who has had pregnancy complications or premature menopause – consider obtaining a CAC score to aid in risk-stratification in middle-aged women who may have underestimated risk.
7. Low dose aspirin during pregnancy in women who have risk factors for pre-eclampsia reduces the risk of development of HDP by 15-20%.

Quotables – The Fourth Trimester

1. “Some of our traditional approaches to caring for women in the postpartum period just aren’t realistic…we need to think about how we can improve care from a policy standpoint to ensure women have access to care and think about how we deliver care.” – Dr. Alisse Hauspurg

2. “Silos are never good. Cardio-obstetrics is a space where you really want to have open communications, be truly collaborative – taking into consideration the expertise of multiple disciplines…because it’s really hard to do it alone.” – Dr. Malamo Countouris

Show notes – The Fourth Trimester

For more on hypertensive disorders of pregnancy enjoy:

• Episode #128: Cardio-Obstetrics: Hypertensive Disorders of Pregnancy with Dr. Jennifer Lewey
• Episode #66: Case Report: Severe Pre-eclampsia & Cardio-Obstetrics – UPMC

1.     What are some of the immediate postpartum cardiovascular risks and complications following a hypertensive disorder of pregnancy (HDP) and how do you manage these?

• Persistent hypertension: there can be a spike in BP in the days following delivery, and clinicians should remember that preeclampsia may develop de novo intra- or early postpartum. BPs >160/110 are considered severe HTN and should be treated urgently with an aggressive rapid-acting anti-HTN regimen to prevent stroke. BPs should be monitored at least every 4 to 6 hours for at least 3 days postpartum.¹ A return visit for BP monitoring should be arranged at 1 week following discharge; alternatively, a home BP monitoring program may be considered
• Pulmonary edema: Women with preeclampsia should be delivered if they develop pulmonary edema. This is more likely to occur in women who have more severe preeclampsia features. Clinical practice guidelines suggest limiting intrapartum fluid intake/replacement to 60-80mL/h to avoid risks of pulmonary edema, with a goal euvolemic fluid balance.¹
• Peripartum cardiomyopathy: Preeclampsia, gestational hypertension, and chronic hypertension all strongly predispose women to peripartum cardiomyopathy (PPCM). PPCM is defined as cardiomyopathy with reduced EF, usually EF <45%, presenting toward the end of pregnancy or in the months following delivery in a woman without previously known structural heart disease.² The two diseases are thought to share pathophysiologic mechanisms.³ If heart failure is suspected via clinical assessment in a woman with HDP in the intrapartum or immediate postpartum period, an echocardiogram should be performed immediately. Treatment of PPCM is similar to other forms of systolic heart failure – with control of volume status, implementation of neurohormonal blockade, and prevention of arrhythmic and thromboembolic complications.⁴
• Venous thromboembolism: Women with HDP are at higher risk for DVT/PE during pregnancy, postpartum period, and in the decades following pregnancy.⁵
• CVA: Severe uncontrolled HTN (>160/110) in the intra- and post-partum periods are associated with increased risk for stroke. BPs should be aggressively managed (see above) in the postpartum period to avoid this complication. 

2.     How should women who have had a HDP be followed in the postpartum period? What are the healthcare coverage considerations in the postpartum period?

• Blood pressures should be monitored closely in the postpartum period, especially in the 2 weeks following delivery – either via return in-person visits or a home BP monitoring program with remote visits
• Depending on the location of care, specialized postpartum cardio-obstetrics clinics may or may not exist. Regardless, women with HDP history should be counseled (whether by OB, cardiology, PCP, etc.) regarding their long-term risk for cardiovascular disease
• They should be counseled on the importance of optimizing their cardiovascular health (with maintenance of optimal weight and regular aerobic exercise).
• In addition to regular BP monitoring, these women should have periodic monitoring of their fasting lipids and blood sugars¹
• Until recently, Medicaid coverage for pregnant women extended only 60 days postpartum, leaving many women uninsured just 2 months after delivery. In March 2021, the American Rescue Plan Act of 2021 was passed and calls for extension of Medicaid coverage from 60 days to 12-months postpartum.

3.     What are the long-term cardiovascular complications related to HDPs?

• A history of HDP increases a woman’s risk of a diverse range of long-term cardiovascular risk factors and cardiovascular diseases (including HTN, CAD, Stroke, HF, and CV Mortality) (see figure below)⁶

• Heart failure: A wide spectrum of changes in LV structure and function have been described in association with HDP. This includes increased LV wall thickness, adverse LV remodeling, and diastolic dysfunction (see below).⁷ Women with HDP also have been shown to have lower global longitudinal strain without overt systolic dysfunction⁸, PPCM (as described above) and later life cardiomyopathy.⁹

• ASCVD: Women with pre-eclampsia are more likely to have atherosclerotic cardiovascular disease (CAD, CVA) than women without pre-eclampsia, independent of other traditional risk factors.⁶
  • Despite significant independent association of HDP with long-term ASCVD, there was no incremental benefit in 10-year ASCVD risk prediction when added to the Pooled Cohort Equations (see below)¹⁰

4.     How do you take a reproductive history in cardiology clinic?

• An optimal well-woman preventive cardiovascular visit should include a thorough reproductive history to identify adverse pregnancy outcomes and menstrual risk factors, amongst other sex-specific cardiovascular disease risk factors¹¹
  • Obstetric history: ask about pregnancies complicated by HDP (eclampsia, pre-eclampsia, gestational hypertension), low birth weight (<2500 grams), preterm delivery (<37 weeks gestation), or gestational diabetes
  • Menstrual history: ask about age at menarche and presence of premature menopause (defined by most as menopause <40years and others as menopause <45 years). If premature menopause present, ask about natural versus surgical menopause (removal of both ovaries)

5.     What methods of contraception are optimal for women with a history of cardiovascular risk factors or cardiovascular disease?

• It is important to discuss contraceptive options in women with history of HDP, cardiovascular RFs, and cardiovascular disease
• Often, in these women, long-acting reversible contraception (LARC) such as IUDs and implants are best. Permanent sterilization procedures can also be considered if a woman has completed desired childbearing.
• Dr. Hauspurg highly recommends the following app from the CDC for those interested in medical eligibility criteria for various contraceptive methods, sorted by specific medical conditions:
  • https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html
  • Screenshots below of app in iPhone App Store and example of output from app for woman with history of HDP:

References – The Fourth Trimester

1.         Brown MA, Magee LA, Kenny LC, et al. Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice. Hypertension. Jul 2018;72(1):24-43. doi:10.1161/HYPERTENSIONAHA.117.10803

2.         Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail. Aug 2010;12(8):767-78. doi:10.1093/eurjhf/hfq120

3.         Bello N, Rendon ISH, Arany Z. The relationship between pre-eclampsia and peripartum cardiomyopathy: a systematic review and meta-analysis. J Am Coll Cardiol. Oct 29 2013;62(18):1715-1723. doi:10.1016/j.jacc.2013.08.717

4.         Arany Z, Elkayam U. Peripartum Cardiomyopathy. Circulation. Apr 5 2016;133(14):1397-409. doi:10.1161/CIRCULATIONAHA.115.020491

5.         Scheres LJJ, Lijfering WM, Groenewegen NFM, et al. Hypertensive Complications of Pregnancy and Risk of Venous Thromboembolism. Hypertension. Mar 2020;75(3):781-787. doi:10.1161/HYPERTENSIONAHA.119.14280

6.         Ying W, Catov JM, Ouyang P. Hypertensive Disorders of Pregnancy and Future Maternal Cardiovascular Risk. J Am Heart Assoc. Sep 4 2018;7(17):e009382. doi:10.1161/JAHA.118.009382

7.         Countouris ME, Villanueva FS, Berlacher KL, Cavalcante JL, Parks WT, Catov JM. Association of Hypertensive Disorders of Pregnancy With Left Ventricular Remodeling Later in Life. J Am Coll Cardiol. Mar 2 2021;77(8):1057-1068. doi:10.1016/j.jacc.2020.12.051

8.         Shahul S, Rhee J, Hacker MR, et al. Subclinical left ventricular dysfunction in preeclamptic women with preserved left ventricular ejection fraction: a 2D speckle-tracking imaging study. Circ Cardiovasc Imaging. Nov 2012;5(6):734-9. doi:10.1161/CIRCIMAGING.112.973818

9.         Behrens I, Basit S, Lykke JA, et al. Association Between Hypertensive Disorders of Pregnancy and Later Risk of Cardiomyopathy. JAMA. Mar 8 2016;315(10):1026-33. doi:10.1001/jama.2016.1869

10.       Stuart JJ, Tanz LJ, Cook NR, et al. Hypertensive Disorders of Pregnancy and 10-Year Cardiovascular Risk Prediction. J Am Coll Cardiol. Sep 11 2018;72(11):1252-1263. doi:10.1016/j.jacc.2018.05.077

11.       Brown HL, Warner JJ, Gianos E, et al. Promoting Risk Identification and Reduction of Cardiovascular Disease in Women Through Collaboration With Obstetricians and Gynecologists: A Presidential Advisory From the American Heart Association and the American College of Obstetricians and Gynecologists. Circulation. Jun 12 2018;137(24):e843-e852. doi:10.1161/CIR.0000000000000582

12.       Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. Sep 10 2019;140(11):e596-e646. doi:10.1161/CIR.0000000000000678

Guest Profiles

CardioNerds Cardioobstetrics Production Team