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Cardiovascular Health in Pregnancy and Postpartum with Emma Sutherland and Jane Hutchens

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Cardiovascular Health in Pregnancy and Postpartum with Emma Sutherland and Jane Hutchens

Jane Hutchens, naturopath and reproductive health and human genetics expert, along with fx Medicine ambassador, Emma Sutherland, raise awareness on the importance of understanding cardiovascular health implications during pregnancy and post-partum. This impacts 1 to 4 percent of women in Australia and is under recognized and underreported. In this discussion the naturopaths discuss the various types of cardiovascular diseases that may impact a pregnant or postpartum woman, the importance of understanding the mental and social impacts this may have on sufferers and some tools to aid practitioners in screening for risk in developing cardiac disease in pregnancy.  

Covered in this episode

[00:34] Welcoming Jane Hutchens
[01:46] Types of cardiac disease in pregnancy
[05:44] The amount of women with cardiovascular disease is dramatically underrepresented
[07:58] Diagnostic criteria for cardiac disease in pregnancy
[11:18] Some findings from Jane’s research
[15:53] Understanding genetic and general risks
[22:09] Signs and symptoms of cardiac disease during and post-pregnancy
[28:20] How oxidative stress affects the placenta 
[31:10] Long-term risks and ongoing struggles
[38:42] Treatment options and support
[42:20] Thanking Jane and final remarks

Key takeaways 

  • Cardiac disease in pregnancy for Australian women is rising and significantly increases the risk in developing chronic cardiovascular disease.  
  • Many women are unaware of any cardiovascular predisposition until becoming pregnant. 
  • Underreporting of cardiovascular disease in women is an issue, and as clinicians it’s important to understand that we may be seeing women with an undiagnosed cardiac issue. 
  • S.C.A.D. or spontaneous coronary artery dissections can arise during pregnancy and postpartum. 
  • Recognising and validating the mental health impacts of being diagnosed with or experiencing cardiac related issues during pregnancy/postpartum is paramount in the patient healing journey. This is a gap in the current healthcare system. 
  • Research shows dismissal of cardiac symptoms as pregnancy symptoms may occur in consults with GPs and cardiologists.  
  • A thorough maternal family history can help provide indicators for risk. Awareness of the following may also indicate increased risk to a CV diagnosis or event during pregnancy 
    • What is new for the patient and unusual health wise? 
    • Excess peak hypertensive state and cardiac output at ~26 weeks 
    • Early rise in blood pressure ~10 weeks 
    • Taking accurate blood pressure readings. Sitting still for at least 5 minutes, repeated 3x, taken AM and PM. 
    • Persistent dizziness, angina, SOB, anaemia 
    • Have there been changes in their regular physical activity to help manage symptoms? 
    • Baseline DASS and QOL scores compared to current 
  • Optimising placental health includes managing cardiovascular health, reducing inflammation and oxidative stress.  
    • Garlic, pre- and pro-biotics, selenium, zinc, vitamins A and C, fish oil
  • Long term impacts do not only include higher risk for cardiometabolic pathology but also elevates risk to mental health issues, decreased quality of life, mistrust one’s own abilities.  
  • Effective management includes a good team of health professionals who we can reliably refer to and work with. Starting with pre-conception care nutrition, stress management, good iron levels and general bloods.  
  • Naturopaths and holistic practitioners can provide a supportive, empathetic, and understanding space that can be lacking in the current medical model. 

Resources discussed and further reading

Jane Hutchens

Jane's website
Research: The healthcare experiences of women with cardiac disease in pregnancy and postpartum: A qualitative study (Health Expectations, 2022)
Research: Quality of life and mental health of women who had cardiac disease in pregnancy and postpartum (BMC Pregnancy and Childbirth, 2022)
Research: Is self-advocacy universally achievable for patients? The experiences of Australian women with cardiac disease in pregnancy and postpartum (International Journal of Qualitative Studies on Health and Well-being, 2023)

Related websites and articles

SCAD Research Australia
Article: What is Spontaneous Coronary Artery Dissection (SCAD)? (Victor Chang Cardiac Research Institute, n.d.) 
Article: Women and heart disease: Information on women and heart disease for consumers (Heart Foundation Australia)

Cardiovascular disease during and post-pregnancy

Research: Cardiac disease in pregnancy and the first year postpartum: a story of mental health, identity and connection (BMC Pregnancy Childbirth, 2022)
Research: Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association (Circulation, 2020)
Research: Maternal cardiovascular risk after hypertensive disorder of pregnancy (BMJ Heart, 2020)
Research: Assessing knowledge of healthcare providers concerning cardiovascular risk after hypertensive disorders of pregnancy: an Australian national survey (BMC Pregnancy Childbirth, 2020)
Research: Maternal depression and inflammation during pregnancy (Psychol Med, 2020)

Nutrients, diet and lifestyle

Research: The favorable effects of garlic intake on metabolic profiles, hs-CRP, biomarkers of oxidative stress and pregnancy outcomes in pregnant women at risk for pre-eclampsia: randomized, double-blind, placebo-controlled trial (The Journal of Maternal-Fetal & Neonatal Medicine, 2015)
Research: Effects of synbiotic food consumption on glycemic status and serum hs-CRP in pregnant women: a randomized controlled clinical trial (Hormones, 2014)
Research: Serum Selenium Concentrations Correlate Significantly with Inflammatory Biomarker High-sensitive CRP Levels in Hungarian Gestational Diabetic and Healthy Pregnant Women at Mid-pregnancy (Biol Trace Elem Res, 2008)

Tools for Practitioners

Depression Anxiety and Stress Scale 21 (DASS-21)
Australian QOL survey – Personal Wellbeing Index (available in various languages!) 


Emma: Hi and welcome to fx Medicine where we bring you the latest in evidence-based, integrative, functional, and complementary medicine. 

I'd like to begin by acknowledging the traditional owners of the land on which we record today. I would also like to pay my respects to elders past and present. 

With us today is Jane Hutchens, a Naturopath, Nutritionist, Herbalist, Registered Nurse, and researcher. She has a Masters of Science in Medicine, in Reproductive Health Science and Human Genetics from the University of Sydney and is nearing completion of her Ph.D. at the University of Technology Sydney on the experiences of women who have cardiac disease in pregnancy and the first year postpartum. Jane has worked for decades in women's health and is passionate about keeping healthcare accessible, doable, and effective. 

Welcome to fx Medicine, Jane. Thank you so much for being with us today.

Jane: Thank you so much for inviting me. I was a little bit unnerved by the decades in health though.

Emma: Well, you and me, I'll say the same. So, you know, we can do it together.

Jane: Good.

Emma: We probably have 40 years of experience between us. So there you go. 

Now the prevalence of cardiac disease in pregnancy is on the increase and ranges from 1% to 4% of total pregnancies. And that equates to between 3,000 to 12,500 Australian women with 1 in 4 of these women requiring hospitalisation. And actually, cardiovascular disease is the most common cause of pregnancy-related mortality. 

One paper I read found that 10.3% of women experienced hypertension in pregnancy. Now the long-term consequences of cardiac disease in pregnancy can lead to chronic illness. A 2021 paper stated that women with hypertension in pregnancy have a two to three-fold increased risk of cardiovascular disease later in life. 

Today, we're going to cover a lot of information about cardiac disease in pregnancy. And as usual, we will give you practical information on what we as clinicians can do to help these patients. 

But first of all, Jane, can you outline the types of cardiac disease in pregnancy and, you know, many of us are very familiar actually with preeclampsia, but there's much more to this than just that.

Jane: Absolutely. And in fact, the figure that you quoted of 1% to 4% of pregnancy has been complicated by cardiac disease, that doesn't even include hypertension and preeclampsia. So it's additive. 

So the non-hypertensive conditions are usually categorised into three groups, so congenital, acquired, or genetic. So the congenital ones are usually surgically repaired in early infancy. So the Tetralogy of Fallot or it might be something milder, sort of valvular prolapse or something. 

The acquired ones could be your garden variety heart attack, so an atherosclerotic heart attack, usually in an older mother. It could be idiopathic cardiomyopathy. So we don't know why, she's just got it. Some rhythm disorders are acquired. 

And then there's genetics. So again, a lot of the rhythm disorders are genetic, so Long QT syndrome. And there are some genetic forms of cardiomyopathy as well, so hypertrophic cardiomyopathy. And for the women, may be diagnosed at birth, some women are diagnosed in adulthood, some in pregnancy, and some may not be diagnosed until 11 months postpartum. 

Emma: Right.

Jane: So it's a really diverse mix of conditions, as well as timing of presentation. So it makes it a really difficult thing to talk about as a sort of cohesive whole…

Emma: Yeah

Jane: …but an interesting one. So when I said garden variety heart attack, I mean your normal plaque kind of atherosclerotic condition. But for pregnant women and postpartum women, they're more likely to have a thing called a SCAD or a Pregnancy Associated SCAD, which is a spontaneous coronary artery dissection. And all SCADs in all populations, about 85% to 90% are in women anyway. And those women have heart attacks at 50 instead of 75. And the presentation in pregnancy and postpartum is worse than if you had it at other times. So there's kind of a layering of issues, but lots of different conditions that can appear.

Emma: Yeah, and I think that umbrella term of cardiac disease in pregnancy is so huge, you know? You’ve got the non-hypertensive, the congenital, acquired, or genetic, and then you've got the hypertensive such as preeclampsia. It's so broad, isn't it?

Jane: It is, and it kind of makes it obvious when you think, "Oh, no wonder it's the most common non-obstetric issue in pregnancy." Because there are so many different things that can happen. And sometimes women will have an underlying cardiac disease, but they don't know. It's just revealed in pregnancy because of the added cardiac pressure, and increased cardiac load and output. Otherwise, they may have gone through life without necessarily realising.

Emma: Yeah. And look, I mean, I'm curious, and I know this is guesswork, but obviously, the reported numbers are a little underplayed. What is your guess on what the actuals are?

Jane: You know, I have a very big line in my thesis, which I have bolded and italicised and said... It's along the lines of, “Why do we not know this?”

Emma: Yeah, that's a great question.

Jane: So if 1% to 4% is a conservative measure or estimate of cardiac disease in pregnancy, and that doesn't even include all of the postpartum presentations, that's a lot of women. And do we care that little that we haven't even thought to count them and work out what they have, and then what they need? 

So yes, it's really underestimated, and some of the reasons are because coding issues. So when you're looking at prevalence of disease, one of the big techniques to do that is to go through hospital records and see how many people came in or on discharge their medical record code was a Q10, 9, 3, or whatever. And if the overworked under-resourced intern who's sitting there at 11:00 at night doing all that coding gets it wrong, and why wouldn't they, then it completely screws your data.

Emma: Yes.

Jane: Then you have things like women in general and possibly more so in pregnancy and postpartum, their cardiac disease is under-recognised, under-diagnosed. So, if you're not even given a diagnosis, you will never appear in the statistics. And so many cardiac symptoms are kind of similar to pregnancy symptoms. So to some degree, it's understandable. 

And then you have things like some conditions were only defined in the last 15 years. So they're not going to be in older data. Or, you know, those SCADs, the coronary artery dissects, you need to have a really good imaging team and equipment to be able to read the angiogram properly. So if you're in an area where you don't have fancy equipment and the cardiologist doesn't have the extra expertise in that, it just may not be diagnosed.

Emma: Yeah. So the fact is that we are most likely seeing more women in our clinical practice with potential cardiac disease than we realise.

Jane: Absolutely 100%.

Emma: Yeah. So this is why I really want to dive into this because I feel like it hasn't had enough exposure, it hasn't had enough awareness. And we need to keep our eye out for these women sitting across the table from us. 

So I really want to go through today so many things, but potentially also some white flags that we as clinicians can be keeping our eye out for. I mean, what is the diagnostic criteria for cardiac disease in pregnancy? I mean, is there actually a diagnostic criteria?

Jane: No, there's no one kind of test or one set of tests that you can do because each condition is so different. So for instance, peripartum cardiomyopathy, or someone might present with heart failure. And it'll take a little while to work out whether it's a genetic form, an idiopathic form that no, we don't know, or if it's pregnancy-related, and the criteria sometimes is genetic material. So you've got to wait and go through that process. But at the start, you just know that their ejection fraction is less than 35%. You have to tease out the rest. 

Then, they're testing for rhythm disorders. You know, if she's having a dysrhythmia, when you've got leads on her, that's really easy. But if she has presented with kind of seizure activity a couple times in the last 10 years, usually, she'll get investigated for epilepsy.

So there is no one thing, but the really critical thing is to listen. I know that sounds a bit trite. But actually, really listen, and we need to also, I think, encourage women to trust themselves. And if they think something is not quite right, or something has changed, it's a bit vague, they don't have a word to describe it, to trust that and pursue it because clinicians dismiss women, and women dismiss women. So we need this kind of two-pronged approach. 

But no, there's no one discreet kind of assessment that we can do for all of those different conditions.

Emma: Yeah. And, I mean, I guess if you look at traditional cardiovascular disease research, pre-menopausal women are pretty underrepresented as well.

Jane: Totally, totally. And when they are, you'll find really fabulous things like if you get a 40-year-old man and a 40-year-old woman who goes into emergency department with exactly the same symptoms, he's more likely to get an angiogram than she is. And then even if they both have angiograms, and they're both diagnosed with, say, a mild heart attack, he is more likely to go to intensive care or coronary care, and she's more likely to be discharged.

Emma: Right.

Jane: And she's more likely to die.

Emma: Yeah, it's shocking, isn't it?

Jane: It's breathtaking. Every now and then, I look at it again and I just think, "Really?"

Emma: Yes.

Jane: So yes, it's really under-recognised. But I would say in Australia, there's a really strong and growing female cardiologist group, and a bit of a movement to really improve cardiac outcomes for women. And that includes a subset who happened to be pregnant or postpartum. But there are also some male cardiologists who are really invested in this as well. So whilst this is currently not great, there's some really good work happening, which gives me some hope. 

So definitely women are underrepresented through the spectrum until death in research.

Emma: Yeah. And talking about raising awareness, you published a paper earlier this year, massive congratulations. It's such a feat for any naturopath. And the aim is correcting this lack of visibility for women and cardiovascular disease in pregnancy. It's a complex and very stressful experience for women, so identifying key interventions is critical. So can you tell us a little about your findings?

Jane: So that paper was, in particular, looking at the mental health outcomes and the sense of isolation that women experienced. So the first research study that I did was interviewing women. It was open slather. There was less than a dozen papers I could find internationally on women's experiences when you consider how many millions every year are affected. Again, how come? Why don't we care? 

So it was really like, "So, hi, tell me what happened." And people told this story in however they liked, in whatever form, and they were very different. Some were diagnosed at two days old with severe congenital heart disease, someone had a heart attack, someone had a seizure, and really different, but throughout all of them, mental health was a key feature.

So then I kind of investigated that further. And then in a future study, I looked at the DAAS and some cardiac mental health tools. And it really just quantified what they were telling in their stories. So we know already in research on men that if you have a cardiac event, there's a strong increase in depression and poorer mental health outcomes after that.

Emma: Yeah. Yes.

Jane: So it's kind of hopefully routine. If you have a heart attack, they say, "Okay, now go have some rehab and have some counselling because you're going to feel rotten, and that's normal and we'll support you through it." So we already know that happens. But some conditions have worse mental health outcomes. So if you have a cardiac arrest, that's kind of ramping it up a bit. If you have a SCAD, so that dissection instead of a normal heart attack, that has a much higher rate of having severe anxiety, depression, and PTSD.

Emma: Right.

Jane: If you have a defibrillator, so an implantable cardioversion device, and if you're 20 just hanging out with your friends and that keeps zapping you, highly associated with poor mental health outcomes and poor sexual health outcomes. 

So we've got normal cardiac and mental health, then we've got these diseases or worse, and then add to that that it's happening when you're pregnant or postpartum. And you're already at risk and vulnerable for poor mental health outcomes. So it's kind of compounding that. 

Then think about her pre-existing vulnerabilities. Did she have an underlying General Anxiety Disorder already? Or had she had trauma in the past? So again, we're layering and layering. And then other vulnerabilities. So something like 25% of women in domestic violence situations, the first time they're physically assaulted is during their first pregnancy.

Emma: Yeah.

Jane: So, you know, they're not walking up to their appointments saying, "How big is my baby? By the way, my husband punched me." So there's lots of silence and isolation with things like that. Indigenous women, higher risk of mental health, poor mental health outcomes, women born overseas. So there's a whole lot of that layering. And then there's the, "Oh my God, am I going to live long enough to raise my child?"

Emma: Yeah, it's a big question. And you couldn't help but be faced with those thoughts of mortality.

Jane: Absolutely. Like, it's huge, and "I'm 30. Now my partner has to care for me and I'm not okay about that.” Or “I can't work anymore. I'm really compromised in what I can do." And then just the cherry on the top is that the majority of these women were offered absolutely zero mental health support.

Emma: Well, okay, that's interesting. Yeah, very significant here.

Jane: Yeah. And then the other really big one is probably close to half, depending on the condition, but close to half of women who do have some sort of cardiac event or exacerbation in pregnancy and postpartum, it's in their first pregnancy or their first pregnancy to term or to birth. So they may have had previous miscarriage of pregnancy, also with stillbirths. And then they're told, "It's too high risk. We don't think you should ever have another pregnancy."

Emma: Okay.

Jane: Yeah. So sorry to bring down your morning. It’s full on.

Emma: Yeah, and the multifactorial and the layers and the complexity of this leads to… there’s such a gap here for us to cover. And a lack of clear diagnostic criteria means that early preventative strategies may not be implemented either. So how can that gap be improved?

Jane: Yeah, absolutely. Like, just thinking of a couple of women I interviewed. So one worked full-time in a reasonably physically active job and played soccer three times a week, and had a heart attack. So there was nothing to prevent that. The genetic things, you can't do anything to prevent that. And, well, the majority of the women internationally in studies have none of those traditional cardiometabolic risk factors. They don't smoke, they don't drink, their diet's great. They're physically active. They're not even that stressed necessarily. You know, they don't have a lot of those.

Some women will have connective tissue risk factors. So fibromuscular dysplasia, which I always mess up. So that increases your risk of having arterial dissections, for instance. But the genetic one is interesting. And that is that thing around, "Well, what do you know about your family history?" I'm sure you've had the experiences. "So tell me about your mom." "Oh, she's fine." "Okay. Has she ever been to hospital?" "Yeah, I don't know what for." "Okay, go home and ask her."

Emma: Yes.

Jane: So as all of us, you know, I've written my family history down for my siblings when they had to go to hospital and they just read it and say, "So tell me, what was wrong with mom that time?" So as we get better at communicating that, and that's not necessarily something we're good at because it'd be private, and I am, and we don't necessarily want to tell all our stuff to people. But it's really important, the cardiovascular risk factors and cardiac risk factors. 

So one of the women I spoke with had a really, unfortunately, common experience in trying to talk to family about genetic conditions. And this certainly came up a lot when I did the masters in reproductive health, is that other people in the family don't necessarily want to know, and that's distressing, particularly if it's something that can make your drop dead. And hers was it was Long QT syndrome. And you know you have it when you don't wake up often. And people in her family, it was like, "Oh, you know, Uncle Bob, we didn't expect him to die at 40, but he was walking to the shop and dropped dead." And it became apparent when you look through history. It's like, "Oh, there's unexplained deaths all over the place."

But people can treat the person who's communicating that information as if they're bringing a black death into the family. And, you know, it's not contagious, it's genetic. But from a clinician point of view, we can start asking more questions. We can say, "So how old was your mum when she had babies?" "Oh, she's had a heart attack or she's taking medication. Do you know what for?" "Okay, so she got hypertensive disorder at 40. That seems a bit young." So I'm picking some of that, and don't forget dads and other family members, but obviously, the female line can sometimes give us a little bit more information about it.

Emma: Yes.

Jane: And then just general cardiometabolic risk. So the prevalence is increasing because, one, we know more, so we're diagnosing more. Because people who had congenital heart disease and now treated and cured, basically, and getting to be old enough to have children. So 20 years ago, they weren't. So now we've got this whole new bunch of information. And also people with really severe congenital heart disease are surviving and having children.  

Then there's the ones that we're kind of more familiar with, they're the women who are 40 and a little bit overweight who finally say, "Yep, I found someone or I've found some sperm. I want to have a baby. And yeah, I've got type II diabetes, but I think I'm on top of it." So they're the kind of classic cardiometabolic risk. She's got a touch of hypertension, she doesn't exercise, she's pretty stressed. She's working two jobs to save money to buy the sperm to have the baby. So they're the kind of garden variety things that we just know without even thinking about. Okay, we need to get your blood sugar under control, your inflammation, your blood pressure, all of that stuff.

Emma: Yeah. And look, doing research for this episode, the American Heart Association published a 2020 statement called Cardiovascular Considerations for Caring for Pregnant Patients. But when I read through it, it seemed to focus on women who already had a known cardiovascular issue. And it was great, you know, they focused on pre-pregnancy counselling and developing that care team. But there was really no mention, I mean, women that don't have pre-existing conditions, they really do fall between the gaps at every level.

Jane: Absolutely. And so let's say she's diagnosed with some type of cardiomyopathy in third trimester, the cardiologist may not necessarily be baby aware. And the obstetrician is even less likely to be cardiac aware. So you really need at that point to find someone who is and there are two, or two and a half cardio-obstetric clinics in Australia. But in other hospitals, there are obstetric physicians, and they're a growing crew. And I think they're brilliant. When I worked at the Royal Hospital for Women, Professor Sandra Lowe was there and she's still there. And she is a fabulous resource. And she's kind of that fantastic midpoint between obstetrician and cardiologist and is invaluable and has really been part of setting up a number of guidelines, I guess. 

But yes, you're right. If you're not already diagnosed, you're still facing that issue about getting diagnosed and not being dismissed as, "Well, of course, you're tired. You're pregnant. Yes, you've just put on 10 kilos, no wonder you're puffy."

Emma: Yes.

Jane: And as I said before, the cardiac symptoms and pregnancy symptoms can really overlap. And we just have to try to avoid defaulting to, "Well, you're pregnant."

Emma: I mean, but what signs and symptoms, like, if we're sitting there and we've got our patient on Zoom or across the table from us, what can we have on our radar that can really indicate that a cardiovascular disease may be developing? 

Jane: I would also add that postpartum women are even more lost because often, they're now just going to their GP or their child and family health nurse. So they get even more lost in the picture. 
So the sorts of things are, what is new for her and what doesn't make sense for her? And really trying to get her to increase her awareness of what is happening in her body. So early in pregnancy, you'll be a bit hypotensive. Then around 26 weeks, you'll reach peak hypertension, but it's still not that bad. But you have a 50% increase in your cardiac output. So that's a good time to start thinking what's happening for her. If she does have preclinical gestational hypertension or preeclampsia, they will often have an early rise in blood pressure, so like 10 weeks and they shouldn't be. So looking for things like that. And at the same time thinking, "Well, is she just really panicked and nervous?" And, you know, your normal blood pressure assessments. 

And this is a really simple one, to accurately take blood pressure, the person needs to be sitting still for a minimum of five minutes and not talking.

Emma: Uh-huh. That doesn't happen very often.

Jane: And you have to do it three times.

Emma: Okay.

Jane: I know. And I'll confess, I found that out because I wasn't convinced my partner was having his blood pressure checked properly. So I contacted someone who researches hypertension.

Emma: Okay, great insight there.

Jane: And I said, "Is this the right way?" And she said, "No. And you have to do it morning and night." So that's not always doable. 

But also symptoms like, is she dizzy? And again, that's common particularly in early pregnancy, but is it persisting? Does she have chest pain? Does she have shortness of breath? So the cardiac changes in pregnancy, as we said, create those, but is it excessive? And she might say, "No, I'm not really short of breath." Then ask that next question, "So have you changed what you're doing?" And she said, "Yeah, I can't go upstairs anymore." Okay, so you are short of breath, it's just that you're not moving now. So she's moderated what she's done to reduce her symptoms, which is, yay, smart. But you need to unpack it a bit to find that because actually, she is really short of breath. She's just controlling it.

You know, thinking about if she was really anaemic beforehand. So we ideally want someone not to be anaemic, of course. But if you are anaemic, you've got a heart that's working one and a half times as hard. And then you're adding an increased pressure because it's got to work harder again to get what little red blood cells and iron you have around the body. 

So they're kind of clues. Is she really pale? Is she sleeping excessively? I had a client on the weekend who in her pregnancy, lucky for her, she had an exceptionally good boss, she would get up, go to work, do two hours' work, sleep for an hour.

Emma: Wow, okay.

Jane: Eat, do an hour's work, sleep for an hour, go home, take her partner to soccer or something, some sport, sleep in the car for an hour, come home, have dinner, and go to bed. It's like, "Hello." Like, there's tired and there's tired.

Emma: I know, but particularly, and I hear it all the time in clinic, when it's a woman's first pregnancy, they presume that that's normal.

Jane: Yes.

Emma: And this is the danger zone here.

Jane: Yeah, exactly. And you don't know what you don't know.

Emma: Yeah, yes.

Jane: And we need to come back to increasing people's awareness and making them tune in to what's happening in her body and making her feel okay about reporting it.

Emma: Yeah. And I think there were some really good insights there. You're asking, what is new for her? So new behavioural patterns, and what doesn't make sense for her. And I love that tip on the peak hypotension should be at around 26 weeks. So if we're seeing blood pressure increasing before that point, we need to prick up our ears and listen to it. And the dizziness, the shortness of breath, particularly before, I'd imagine, that third trimester where women do get a bit short of breath, but they shouldn't be getting short of breath earlier in the pregnancy. And I love that little clinical pearl there. Have you changed what you're doing? Have you moderated what you're doing, even unconsciously, in order to not be short of breath? I mean, I think there's some great insights there.

Jane: Yeah. And they're simple and they're kind of core listening to your patient stuff.

Emma: Yes.

Jane: And getting that full picture. And the other thing that we should have on our radar is going back to that family history again. And do your analysis for protein.

Emma: Yes.

Jane: Particularly if she says, "I think mom had high blood pressure." “Oh, go and do a wee,” you know, we're going to see if there's an issue. Yeah. I think there's a lot that we can do. But I also think, you know, we're not treating her peripartum cardiomyopathy, but we're helping her get the right care and we're supporting her through that.

Emma: Yes. We're bringing to her awareness that we may need to ask more questions of other people here.

Jane: Absolutely.

Emma: You know, bringing in experts in that space where we can just facilitate and help and support her in doing that.

But, you know, this is where possibly we could write a letter to her GP raising our concerns. We may not express them to the patient themselves in case we create anxiety, but we could flag it with their care team, their GP, their obstetrician. So I think we still have a really good place to be listening to women and doing that.

Jane: Absolutely. And, you know, sometimes it's just a matter of being really...have a stand-out dot point and be really clear in that letter about, "Her blood pressure today was,” or “We have spoken about..." Yeah. So definitely, it's not a you either act dramatically or do nothing. You've got lots of options.

Emma: I agree. Now, in my research for this episode, several papers that I read noted that women have higher levels of high sensitive CRP than men. But how does placental dysfunction and oxidative stress affect cardiovascular health in pregnancy? Because I can imagine there's a lot there.

Jane: And there's a fair bit of kind of chicken and egg stuff going on as well. So the high sensitive CRP is thought to be related to percentage of body fat, and women generally as a rule have a higher body fat. And, interestingly, studies for adults with high CRP and cardiovascular risk, if you reduce it, only women have reduced cardiovascular events. Men don't, makes no difference. So there's some other something that's happening with women. It's not just the amount of it, but it's the sensitivity to it. 

So the placenta is very delicate. It's an extraordinary organ, and there's a massive amount of research going into it. I went to PSANZ in early May. So it's Australia and New Zealand Perinatal Society Conference and the first one for years and there was hundreds and hundreds of presentations and posters, and it blew me away how much of it was on the placenta. It was fascinating and great.

So when you have placental dysfunction or insufficiency, you're more likely to have placental abruption, so loss of the pregnancy or premature birth, intrauterine growth restriction because you've got poor blood flow through to the foetus, and oxidative damage. So inflammation and oxidation we know damages proteins, your DNA, lipids particularly, all that microvascular tissue and the placenta is teensy-tiny microvascular tissue. And the endothelium in all vessels, but particularly in the placenta because it's so small and vulnerable, it's highly susceptible to oxidative stress and inflammatory stress. 

So when you have that inflammation and oxidation, you're more likely to get damage and dysfunction of the placenta. When you have that, you're going to get preeclampsia. But if you have hypertension to begin with, then you're more likely to get oxidative stress in your placenta. That's why I say it's kind of a bit chicken and egg.

Emma: It is. It is very chicken and the egg, isn't it?

Jane: Yeah. Which is probably the only time that analogy is useful when you're talking about the placenta.

Emma: It's very relative.

Jane: Hadn't thought about that until then. So yeah, we really need to just reduce that inflammation and the oxidation.

Emma: Yeah. I mean, as clinicians, there's so many things we can do in that space. You know, food really is medicine from that inflammatory side of things.

Jane: Absolutely.

Emma: I know everyone will have some good ideas on that front. What are the long-term risks of cardiovascular disease in pregnancy? So what happens long-term to these women?

Jane: So, again, it's a bad answer, but we don't really know because there haven't been a huge number of longitudinal studies, but of the ones that we have, often, they're about specific diseases. So what will happen after having a ischemic heart disease or a heart attack. And we don't have the full picture for all of them. And, you know, some of them are really uncommon. So there's a particular genetic type of cardiomyopathy, that there's about 10 women in Australia who have it. It's harder to get really solid data on 10 women.

Emma: Of course.

Jane: You're not getting the big numbers. But, you know, we know from that Claire Arnett study that you mentioned earlier, so the 10-year risk of having some cardiovascular disease, some heart attack, TIA, something for a woman who had high blood pressure in pregnancy was two and a half times higher than if she didn't have high blood pressure in pregnancy. And that's 10 years. So if she was 30, she's doing that at 40. But that risk continues. It's not like she turns 50 and everything's hunky dory. Then she goes through menopause, and that's a whole other story.

Emma: Yes.

Jane: Actually, that is a whole other story. So things like the arterial dissection and peripartum cardiomyopathy, in particular, we know that both of those have some relationship with hormones. So the SCAD is increased when you're breastfeeding and increases when you stop breastfeeding, which is very unhelpful. There's direct kind of hormonal links, but we're not quite sure of the details. So understandably, women in those conditions are going, "What the hell's going to happen when I go through menopause?"

Emma: Exactly, yes.

Jane: So that's just kind of one group of diseases and that was quite big. She had, I think, a couple 100 people in Australia on that, but there's a bigger one in the states that came out last year, and they followed women for 20 years. And most of these women had lower-level cardiac disease. So it wasn't the super high-risk heart failure, it was a milder heart failure and that sort of thing. But at 20 years, the women who had cardiac disease in pregnancy, a third of them had either had a death from a cardiac condition, some type of arrhythmia, AF, they’d had a stroke or heart attack, or they've had to have a stent inserted or hypertension, or developed diabetes, compared to 2% of women who didn't.

Emma: That's astounding.

Jane: That's a really big jump, and with women who didn't necessarily have really majorly bad cardiac disease. Part of that, I think, we'll be able to moderate because we know more about it now. So if that study came out last year, they probably collected the data 4 years before, which means the women had their cardiac issue 25 years ago, and who knows how that was managed?

Emma: True.

Jane: So the outcomes in 20 years' time, if we repeated that study, should be much better. So that's from a cardiac point of view. And we know women who've had corrective surgery for congenital heart disease, there is some research to show by five years, maybe a third of them will need to have further surgery. But again, it's all really variable, and age, whether they have more pregnancies, a whole bunch of stuff. But that's the kind of cardiac stuff. We know mental health is poor.

Emma: Okay.

Jane: So my research, didn't intentionally but it was just kind of open book and included people up to 10 years after their pregnancy in the interviews, but in the online survey, which included the DASS, the Depression, Anxiety, Stress Scale, as well as one called the Cardiac Anxiety Questionnaire, and some quality of life surveys. That went up to 16 years after the event. And the issues were still there. And there's one other study that went to 10 years just on peripartum cardiomyopathy that was from Germany, and at 10 years, women still had mental health issues even if their heart function was back to normal.

Emma: Right. So the long-term impact can be so profound in these women.

Jane: Yeah, and I really think a big part of that is the lack of support.

Emma: For sure.

Jane: And lack of resources around that. So the other thing that included in my research was quality of life and the quality of life is really subjective. And it's, you know, age-related, so someone who's 80 might say they've got a quality of life, but when you're 20, you don't want to live like that. But it's reduced. So often, they will have reduced career opportunities. They won't be able to run after their children. They can't go hiking, you know, whatever it is, is they've had to change how they live their life. One third of the women that I surveyed were really scared having sex would hurt their heart.

Emma: Yeah, right.

Jane: So it's really hard to have a wild, crazy sex life if you're thinking, "This is fun, hope I don't die,” you know?

Emma: Yeah.

Jane: So then that impacts on the relationship which has already been impacted by the fact that your partner may have seen you near death. So lots of trauma for partners as well. 
And then, you're feeling vulnerable and lacking confidence. Your body's done all this stuff that you weren't expecting because you're young and fit and healthy with no risk factors. So you don't trust your body. And your confidence as a mother takes a huge hit. And first-time mothers, in particular, confidence usually isn't high. And you've got so much self-doubt and so much rubbish on social media, and contradictory and conflicting information. And a lot of these women are told they're not allowed to pick up anything heavier than two kilograms.

Emma: Not helpful when you have a baby.

Jane: And a toddler. So the baby can deal with it, but the toddler can't. Because you've gone to preschool and everyone else is jumping into their mom's arms, and you're just saying, "No, walk along beside me." So lots of grief in there as well. Financial impacts are really significant, relationships. And it's invisible. You know, you look fine. You don't have a leg in a plaster cast.

Emma: Yes.

Jane: So people think, "Okay, you're fine now," and don't really get that you're still really struggling. So long-term, that's the stuff that I really wanted to bring to people's awareness because these women need more support. 

And they just need someone to say, "Oh, you went through it too?" Women would go on to a Facebook group if they found one in the middle of the night where they're having a panic attack. And they'd say, "Yeah, some of the information was different because they were in America or Spain or somewhere else. But I was just really excited because she had her event 10 years ago, and she's alive. So that just gave me hope." It’s like, "Oh my God, is that the best we can do for these women? That they get reassurance by logging online in the middle of the night?"

Emma: Yeah, yes.

Jane: We've got to be able to do better than that. And I think as health professionals, we can provide some of that. There's a whole other level of support you can only get from a peer.

Emma: Yeah, that's true. I mean, what treatments can be helpful? What do you see clinically working well, or helping support these women? 

Jane: So I think the first thing that I really want every woman to do is be really clear about who's in her team.

Emma: Yeah, perfect.

Jane: You need a team. And we need to know that we are a player in a team. And depending on the woman, she might have a really big team, she might have a pretty mild team. And that's any woman, like, that's just garden variety preconception. Okay, let's talk about who you need to see.

Emma: True, yes.

Jane: And if someone had a fabulous pregnancy, I still say, "Okay, now go and see a pelvic physio." Just get used to referring. And sometimes you refer on because someone has health conditions that you're just not that confident with. And sometimes it's referring to but still keeping that patient as yours. So it's just adding to the mix. So I think that's a really important thing. 

I'm really all for people being able to advocate for themselves and demand is a strong word, but to ensure that they get the healthcare that they need. And they need information to do that. So we can provide some of that, but also, we need to know that there's a whole heap of stuff that we don't know. Like, we need to be upfront about that, about our role and our scope.

And, you know, as natural therapists, nutritionists, integrative practitioners, we often take this approach of, okay, we really want to get to, what's the core issue here? We don't just want to treat the symptom, we want to get to the basis of it and treat it. And we have to sometimes reframe that when we're looking at cardiac stuff in pregnancy and particularly in postpartum because there is no core for some of it. Or if it is, it's a genetic thing. And, you know, good luck trying to change that. So being okay with, "Okay, well, what can we do here?" And we can do what we do really well.

Emma: Of course. Yes.

Jane: So we can listen to the woman. We can provide her really good, awesome life support. So nutrition, stress management, all of the supplementation that you want for the oxidation. So if you can get someone with a half-decent ferritin before she gets pregnant, yay.

Emma: Yeah.

Jane: I think that's just such a...you know, that's my goal half the time. Whatever happens, just have some iron or meat or something, you know?

Emma: Yes. Yes.

Jane: So, yeah. Preconception, and normal, excellent preconception care. We want to make sure her blood sugar is great. We want to make sure her thyroid's okay. If she's got a vaguely simmering underactive thyroid, that's going to increase her blood pressure and increase cardiac pressure. So just tidying everything up before she even conceives.

Emma: Yeah. That's a great expression, just to help support tidy everything up. And as practitioners, that is what we do, holistic, functional type of approach. I mean, I think that that sort of says it all.

Jane: Yeah, and I think that is our strength. And, you know, sometimes people get frustrated that the cardiologist didn't prescribe a diet or a nutrient. It's like, "Well, that's because they're a cardiologist."

Emma: Exactly.

Jane: That's not their scope, that's our job.And likewise, we don't do cardioversion. So it's around working to our strengths and acknowledging and celebrating that, not thinking it's bad that everyone doesn't do the same as we do.

Emma: Yeah, exactly. Exactly.

Look, thank you so much for joining us today. There's a few key points that I've taken - well, there's a lot - but a few that come to mind. From an importance perspective, is that cardiovascular disease in pregnancy, it's a little bit like the canary in the goldmine. And don't take it lightly that pregnancy magnifies underlying health risks and it provides an opportunity for diet and lifestyle interventions that may help reduce long-term risks, and that we're actually more likely to see more women than we realise in clinical practice with potential cardiac disease. So keep those eyes open. And also, as clinicians, we can support these women by doing simple things like running a DASS, by checking her blood pressure, as you said, by taking it properly, sitting down five minutes, not talking, and taking it three times, not just once. I mean, there's so many things that we can offer these women and helping them work in that care team environment.

Jane: Absolutely. And you mentioned around the oxidative stress and C-reactive protein, all of our anti-inflammatory antioxidative strategies.

Emma: Yes.

Jane: Garlic has been shown to reduce preeclampsia. Prebiotics, probiotics, make sure you've got selenium, and zinc, and fish oi,l and vitamin C, and vitamin A and all of those things. And hopefully through diet, so you don't just super load up. But yeah, there's definitely a lot we can do and a lot with the mental health as you say.

Emma: Exactly. Once again, Jane, thank you so much.

Jane: My pleasure.

Emma: Everyone, it's been an amazing episode. Thanks for listening today. Don't forget you can find all the show notes, transcripts, and other resources from today's episode on the fx Medicine website, fxmedicine.com.au. I'm Emma Sutherland, and thanks for joining us. We'll see you next time.


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