P4P Hypertension in Pregnancy
[00:00:50] Dr. Alicia Power: Well, Dr. Vanja Petrovic. It's so nice to see you. Vanja and I went to med school together and we were on the same orientation team, with Lee [00:01:00] Galsier and who else was on our team?
[00:01:02] Dr. Vanja Petrovic: Oh my God. I don't remember. Are you aware that was 20 ago?
[00:01:06] Dr. Alicia Power: No, I was going to say that it was just a few years ago, Vanja! Yeah. Both of us have aged. So well...
[00:01:13] Dr. Vanja Petrovic: I know 2003.
[00:01:14] Dr. Alicia Power: I know it's crazy time flies when you're having fun. And part of the fun we're having is doing this podcast together, and I'm really excited to do this. So this is some new and emerging. I don't know how new it is, but certainly it's not very out there information around pregnancy as a stress test and what that means for people from a longterm cardiovascular point of view. So Vanja, why don't we start off by you introducing yourself and who you are and what you do. And what's brought you to do this type of work, and then we'll get into the podcast.
[00:01:43] Dr. Vanja Petrovic: Sure. So thank you for having me. As you said, I'm Vanja Petrovich. I'm one of the general internists here in Victoria. And although most of my practice is general internal medicine and old people, and a bigger and bigger part of my practice [00:02:00] has been obstetrical medicine and looking after pregnant women. Primarily cardiovascular issues. And in particular, my interest is in following these within longterm. And seeing them through their life, after they've had a pregnancy associated complications. So yeah, I think that's what we'll talk about today.
[00:02:20] Dr. Alicia Power: Perfect. So why don't we get into it a little bit? We're not going to talk too much about the actual pregnancy part of it. We're going to focus more on the kind of the long-term prevention piece, but in terms of identifying those who are at risk for that longterm cardiovascular piece. What are the risk factors in pregnancy and kind of what numbers are we talking about? What percentage of the population are we looking at?
[00:02:41] Dr. Vanja Petrovic: So it's surprisingly common and incidence is rising. So pregnancy associated complications include hybrid, broadly speaking, hypertensive disorders of pregnancy, eclapmsia and preeclampsia. Yeah. Gestational diabetes. Preterm birth, IUGR, and pregnancy loss. I think from [00:03:00] internal medicine perspective, we talk a lot about pregnancy induced hypertensive disorders, and gestational diabetes. And we forget about those obstetrical things like preterm birth, IGUR, and pregnancy loss. So those are important to inquire about. And they're common. So incidents. Rising 10 to 20% of all pregnancies are affected by at least one of these complications.
[00:03:24] Dr. Alicia Power: We're doing a project together. We're just finishing up and I think we ran our numbers and it was almost close to 30% of our population. And part of that is we are the tertiary center for our kind of larger community, but yeah, it's incredible how many people are affected
[00:03:37] Dr. Vanja Petrovic: It is. Yes. So yeah, in Victoria, I was going to say one in every three or four pregnancies is affected, which is, incredible. And we know that all of these are associated with future maternal cardiovascular disease risk. Not long ago, when we trained, we were taught that. These are diseases or complications that are limited to pregnancy and [00:04:00] are short in duration. And we were taught that the cure for preeclampsia was to deliver the baby. And then we can forget about it once the abnormal parameters normalized. And women went on without any specific followup.
[00:04:13] So now there is mounting body of evidence that all of these adverse pregnancy outcomes are associated with increased risk to vary degrees. So identifying these women early on, it gives us an opportunity to intervene early and treat the vascular dysfunction in the subclinical phase potentially preventing or delaying onset of overt cardiovascular disease.
[00:04:34] Dr. Alicia Power: What kind of risks are we talking about? So what are the numbers that we're looking at? If somebody is diagnosed with hypertensive disorders of pregnancy, what is their increased risk over their lifetime?
[00:04:44] Dr. Vanja Petrovic: Just as a background, hypertensive disorders of pregnancy happen in six to 8% of all pregnancies and risk of hypertension later in life is greatest with gestational hypertension. 20% of women who develop [00:05:00] preeclampsia will be hypertensive within 10 to 15 years following that pregnancy. A fairly high number. And there's also, there seems to be a dose response relationship. So the more severe the pregnancy related complication, the more likely a woman is to develop cardiovascular disease or hypertension down the road. Or if there's more than one pregnancy with a pregnancy associated complication again, those women are at higher risk compared to those who only had one. When it comes to diabetes, again very common six to sometimes even 10% of all pregnancies, depending on the population. And this is a particularly important group of women to look at because their risk of diabetes is 10 fold compared to general population. And not only are they at high risk, but their risk starts very early. So within three to five years met at one third of these women will develop diabetes so important to offer them early and frequent surveillance. [00:06:00] And in addition to that gestational diabetes is an independent risk factor for cardiovascular disease, even in the absence of preeclampsia.
[00:06:07] Dr. Alicia Power: Which is interesting, cause I just assumed again, I make assumptions sometimes, that it's the gestational diabetes and the subsequent diabetes that increases the risk for cardiovascular disease. But in fact, they're two, they are independent risk factors.
[00:06:19] Dr. Vanja Petrovic: It appears that way. Yeah. It's hard to know because pregnancy, is so, associated complications in cardiovascular disease share similar pathophysiology and similar risk factors such as diabetes, and hypertension, and dyslipidemia. It's really difficult to know, and it is not known whether pregnancy simply unmasks these women who are at high risk, or does pregnancy kind of trigger or initiate a pathway that eventually culminates in endothelial injury that it manifests cardiovascular disease. Or is it all cumulative, you sustained some cardiovascular injury during that pregnancy. And then again, during another pregnancy [00:07:00] and then down the road again. It is very difficult to tease these things out because there's so many shared pathways.
[00:07:05] Dr. Alicia Power: Yeah, that's really challenging. So we talked about a few of the pregnancy associated complications and their risk factors, but certainly females women, people who identify as women, I guess people who have uteruses also have other risk factors that can be associated with longterm cardiovascular disease. Now, obviously pre-existing hypertension is going to be one of those, but what are some of those other things? So I'm thinking kind of PCOS, auto-immune diseases. And how do we take that into consideration when we're talking about risk with people?
[00:07:35] Dr. Vanja Petrovic: Yeah, that's a great question. There are lots and lots of additional risk factors that are specific to women that we don't typically account for when we screen for cardiovascular disease and they aren't part of any risk scores such as Framingham. But we know that timing of men are key either too early or too late, can be, can increase the risk of [00:08:00] cardiovascular disease. Premature menopause, either spontaneous or surgical. As you mentioned PCOS is a big risk factor. And once again, PCOS shares many that has many things in common with metabolic syndrome. And often these women have our risk for diabetes, hypertension, et cetera. Other risk factors are breast cancer, both disease and treatment for it, hormone therapy, auto-immune disease, chronic inflammatory diseases, such as lupus or rheumatoid arthritis. And lactation may be protective in terms of cardiovascular disease risk. So there are many variables that aren't routinely taking into account when we assess cardiovascular disease risk. That we should probably think about, at least.
[00:08:47] Dr. Alicia Power: I was, so I'm a family doctor, anybody who doesn't know that, and I'm an ish kind of medicine. I don't remember details. I was reading an article in the Lancet the other day, Vanja and I saw that auto-immune diseases increases your cardiovascular risk by 1.4 to [00:09:00] 3.6 times over your lifestyle. I've always wanted to quote something from the Lancet. There I did. Didn't actually read the whole article. I think I read the abstract, but it sounded pretty cool, but I think it is something that we don't really take into consideration, especially as primary care providers. We don't- I haven't anyways. And so I'm starting to really do much better kind of obstetrical history with my patients who are, in their forties, fifties, sixties that I just didn't necessarily ask before and starting to do some more screening. And then considering those, my patients with rheumatoid arthritis. So antiphospholipid antibody syndrome as a bit higher risk from a cardiovascular point of view because the screening tools that we use are not taking those into account either.
[00:09:39] Dr. Vanja Petrovic: Absolutely. Yeah. So current risk assessment really doesn't take any event to consideration.
[00:09:46] Dr. Alicia Power: Yeah. So we've identified those people who are potentially at higher risk for longterm cardiovascular disease. How do we counsel them? In primary care when you're seeing them, how are we counseling them on what they can do to decrease their [00:10:00] risk from a kind of a quote, unquote lifestyle point of view? So you mentioned lactation so breastfeeding for up to a year postpartum. Looks like it's protective. What are the other things that you talked to people about Vanja?
[00:10:12] Dr. Vanja Petrovic: So up until recently, we didn't have any guidance on this really. We would extrapolate from Canadian Best Practice Guidelines, but recently Dr. Nerenberg helped create the Canadian Post-pregnancy Clinical Network, which connected, I think 20 clinics across the country. And the goal was to, for this group was to establish best practices for caring, for pregnant people who have had a pregnancy associated complications, long-term follow-up. And the general recommendations are what you might expect. So lactation support, as you mentioned. Healthy nutrition. Physical activity greater than 150 minutes per week. Maintenance of health and body weight. Good sleep. Stress management. Encouraging [00:11:00] smoking cessation. And then we'll talk a bit more about cardiometabolic risk factor screening. All of these make perfect sense. There aren't necessarily, there isn't necessarily good infrastructure to execute this and support women in, healthy nutrition and maintenance of healthy body weight, and smoking cessation. I certainly go through these and try to emphasize how important it is. Because I think that women postpartum are particularly motivated to make healthy changes and they're a captive audience. So it's a good time to talk to them about this.
[00:11:33] Dr. Alicia Power: Yeah, I agree with you. And I think some things that we often don't think of, again, I'm speaking from a family practice point of view, and I know you do a lot of counseling around kind of dietary modifications. Is getting people more support for their weight loss. We know that obesity is a chronic disease and there's many hormones that come into play and there's lots of new medications coming out. So there's people who specialize in this. So if people are struggling doing their best with implementing dietary and [00:12:00] exercise, but they're just not able to do that, then make sure that we think about actually referring them off to somebody who specializes in that or looking into it ourselves as care providers for these patients, because it's, it's more than just diet and exercise. There's huge amounts of, mental health involved. There's huge amounts of coping skills. There's huge amounts of past trauma. And there's huge amounts of actually it being a chronic disease, like any other chronic disease, and sometimes we need more support. So I think just, let's not forget about that piece of the puzzle and the same goes around the mental health piece, because that's huge for all of it. Yeah.
[00:12:30] Dr. Vanja Petrovic: Absolutely. Yes. I in Victoria, sorry to interrupt you. I think there are quite a few, there are resources in terms of help with healthy weight management. I know that some of your colleagues are doing group sessions and counseling and there are quite a few positions who advocate for therapeutic carbohydrate restriction and I'm a huge fan of that. So I think locally, at least I know that we do have some resources to [00:13:00] help women with this.
[00:13:00] Dr. Alicia Power: I think it's becoming more and more that way. In other communities as well. So reach out to your networks and figure out what's available in your communities. Yeah, so we chatted about that quote unquote, lifestyle management. So let's get more to that kind of longer term followup from a primary care or a specialist point of view in terms of what should we be ordering for labs, what investigation should we be doing? What follow-up for blood pressure and cholesterol, et cetera, et cetera. Should we be doing for our patients?
[00:13:31] Dr. Vanja Petrovic: So let's talk about hypertension first, maybe. That immediate postpartum period is critical for blood pressure surveillance because if a woman was hypertensive, or had preeclampsia then she requires close follow up to make sure her blood pressure normalizes to make sure her antihypertensive therapy is waned as needed. Similarly she may be at risk for severe hypertension postpartum and up to six weeks. So I [00:14:00] think the first two weeks are absolutely critical for a blood pressure surveillance. And even more so with those, with severe hypertension and. an entrepreneur therapy. And then beyond the six months period, this is the point where we need to screen people for chronic hypertension. So if they were hypertensive at the six-month point, they have chronic hypertension. And at that point we need to start the workup essentially. They need to be evaluated for workup of secondary causes of hypertension. And this is often who I see is patients who are persistently hypertensive, to the beyond the six months. And then after that annual followup at a minimum. I think that's the short answer in terms of followup long-term. In terms of treatment, I don't know if you wanted to touch on that.
[00:14:56] Dr. Alicia Power: Yeah, I think I'm so important things to talk about. So you know that for that kind [00:15:00] of ongoing followup, we're taking their blood pressure in the office, we're doing a lipid profile, we're doing a sugar screen just to ensure that those are within the quote unquote normal expectations and using, talk about using the Framingham risk score. But it's hard to use the, some of these scoring calculators that we currently have because they really don't take into account.
[00:15:22] Dr. Vanja Petrovic: Yeah. If you use the Framingham risk score, which is really the only thing we have it, it is a risk. I'm sure everyone's familiar, but it uses the gender, age, blood pressure, lipids, smoking investigated diseases like diabetes. I think most women at, childbearing age would fall into the low risk category using Framingham. And none of the female specific risk factors are including there are a number of studies that looked at adding adverse pregnancy outcomes to Framingham and this results in improvement for cardiovascular disease prediction. And once again, risk is [00:16:00] culmulative. The current guide, the current lipid guidelines actually do include adverse pregnancy outcomes and consider them a risk modifier. So if we talk about treatment of lipids, then anybody who has a high risk obviously has indication for treatment. Those with moderate risk, I think you can use a pregnancy related complication as a risk modifier. And I think that that could sway you to think that perhaps that in therapy is indicated. So this is something to discuss with the patient when deciding to initiate that primary prevention in this group of women as we really have no data in terms of primary prevention. And women with pregnancy associated complications. I just wanted to mention in terms of lipid screening around the time of pregnancy. Any woman who has had a hypertensive disorder of pregnancy should have a screening with the panel six [00:17:00] months after delivery, regardless of breastfeeding status. If lipids are abnormal, then they should be repeated once breastfeeding is finished, as breastfeeding can elevate lipid profiles.
[00:17:14] Dr. Alicia Power: Interesting.
[00:17:14] Dr. Vanja Petrovic: Yeah. So if you see an elevated liver, or, sorry, elevated lipid profile postpartum, then consider repeating it at a year mark or whenever they're done breastfeeding.
[00:17:24] Dr. Alicia Power: I think another piece of information to add into this discussion is talking about of the family planning piece of the puzzle, because some of the things that we're going to be chatting about is medications and when to start and how to start and what to choose. And if this person is sitting in front of you at six months and planning on having another baby and looking at getting pregnant in the next three to six months, you're probably going to modify your recommendations based on that fact. And the other really important piece is these people should be offered preconception counseling with a specialist in the area for decreasing the risk of subsequent pregnancy. So just something to think about at that six month, mark is talking around family [00:18:00] planning and what their goals are. So you can keep or - is that the right term, cater, modify your recommendations based on that.
[00:18:06] Dr. Vanja Petrovic: Absolutely. Absolutely. You know, statins in pregnancy are, I don't want to say contraindicated because we do use them in certain situations, but there are significant considerations there. If there is going to be another pregnancy in close proximity, one may consider a lipophilic statin such as Pravastatin or Rosuvastatin which are associated with fewer malformations, congenital malformations then for example Atorvastatin or Simvastatin, definitely a need to take that into consideration. Similarly with treatment of hypertension, if you need to put somebody on an ACE or an ARB for proteinuric hypertension, one should take into consideration their family planning.
[00:18:49] Dr. Alicia Power: Yeah. So in pregnancy often for antihypertensives we use nifedipine or we use labetalol, are the two that we choose. Perhaps if they're going to be having another pregnancy soon or just letting them know that they need to switch [00:19:00] over and come see you, as soon as they get that pregnancy test, that's positive.
[00:19:04] Dr. Vanja Petrovic: Yeah.
[00:19:04] Dr. Alicia Power: And I certainly had a patient that we did that with back and forth and back and forth. And it worked fine for her and she was responsible about it. Okay, great. And then the other piece of the puzzle is we talked more about hypertensive disorders of pregnancy. Let's talk a little bit about gestational diabetes and kind of the ongoing screening for that management for that. And then any kind of -
[00:19:25] Dr. Vanja Petrovic: Yeah. Yeah. So as we already mentioned, these women are at very high risk for developing over diabetes, very soon after their pregnancy. So they should have a screening test as soon as six weeks to six months postpartum. And then annually. And the frequency can depend on their personal risk that can be assessed. And I think that, Dr. Nerenberg's guidelines will include like patient convenience factors for screening recommendations, such as doing an A1C instead of an OGTT. Or a fasting glucose in the [00:20:00] postpartum woman, which is very kind. And otherwise, the recommendations are the same as for a non pregnant people. So health behavior modifications. Pharmacotherapy targeting an A1C of less than 7%. And counseling on probate control and counseling on loss of gestational weight by when your postpartum, if possible.
[00:20:21] Dr. Alicia Power: Awesome. Anything that we have not touched on that you think is important for our listeners to hear before we wrap up?
[00:20:31] Dr. Vanja Petrovic: I think the main message I have is that adverse pregnancy outcomes offer a unique window into a woman's future cardiovascular health. And recognizing that cardiovascular disease risk is up to four times higher in these women, offers us an opportunity to screen early and intervene early. And we should remember that this risk increases immediately postpartum. We have a lot of time[00:21:00] to modify that risk and to potentially improve outcomes down the road.
[00:21:04] Dr. Alicia Power: Yeah. And I think a big piece of that is patient education. And so we've created a few handouts for patients, posters for offices. So we'll link those on our website, our Pregnancy for Professionals website. We also created a couple of patient focused podcasts on our She Found Motherhood Podcast. So we'll link those below if people are looking for kind of reliable information and we based our podcast, essentially off of this similar information. So they're relatively up-to-date and patient focused. So make sure to check those out. But yeah. So thank you Vanja for coming and talking today, we reviewed the risk factors for long-term cardiovascular risks. We chatted about what that actually means from a increased risk point of view and lifestyle modifications. Long-term kind of screening and management of these people. And how important it is and what a wonderful opportunity it is to be able to recognize these people and make significant changes in their trajectory, if by working with them, with this information. So really appreciate your time today![00:22:00]
[00:22:00] Dr. Vanja Petrovic: Thank you for having me.
[00:22:01] Dr. Alicia Power: Anytime.