Women’s Health: Pregnancy & Cardiometabolic Risk Factors

Welcome to Heart to Heart Nurses, brought to you by the Preventive Cardiovascular Nurses Association. PCNA's mission is to promote nurses as leaders in cardiovascular disease prevention and management 

Geralyn Warfield (host): Thank you so very much for joining us today. We're here with Dr. Emily Jones and we're going to be talking about diabetes, cardiometabolics during pregnancy, postpartum, all kinds of things that we just are so excited to learn more about. Dr. Jones, would you please introduce yourself to our audience?  

Emily Jones (guest): Sure. My name is Emily Jones and I'm an Associate Professor at the University of Oklahoma Health Sciences Center. And I also direct the PhD nursing program at OU. 

Geralyn Warfield (host): So, one of the things our audience, I'm sure, is interested in learning more about, is the cardiometabolic risk factors that emerge during pregnancy, and I'm hoping you can enlighten us today.  

Emily Jones (guest): Oh man. This is one of my very favorite topics. [00:01:00] This is really the, the area of my research interest, and it's where I've spent, over the last decade, really trying to do work that will shine a light on the risk factors that we often see emerge during pregnancy and the postpartum period. Even though that word, “emergence” to me, it really does represent that some risk was there all along.  

And so, you know, my own perspective, I think, when it comes to doing this research around cardiometabolic health promotion during pregnancy and the postpartum period, I know my perspective is influenced by the fact that I was a labor and delivery nurse. And so, I cared for diverse women from various backgrounds who often, you know, would develop conditions during pregnancy that would make them be considered “high risk.” And I'm [00:02:00] using air quotes here, “high risk” for, you know, obstetrical care providers and, and those of us who were caring for them in labor and delivery units.  

And what I recognized as a bedside nurse is that I thought we did a really great job of caring for them in that what we would call “intrapartum period” or during their stay in the hospital. During their pregnancy, you know, conditions like gestational diabetes and pre-eclampsia really got providers’ attention and care was targeted toward those conditions.  

But then something happened.  

After delivery, even sometimes before the mother would be discharged home, the conversation shifted and it went from caring for someone who had this quote unquote “high risk condition” to pretending like everything was back to normal, all with the birth of the baby.  

And what we know scientifically, and decades of research have told [00:03:00] us this, is that conditions like gestational diabetes and cardiova…and, excuse me, pre-eclampsia and gestational hypertension, these are really red flags that the stress test of pregnancy reveals. And we aren't doing patients a service by ignoring them as red flags that they are. So that's really where my interest in this area started, was from my, my bedside experience as a labor and delivery nurse. But there's so much more work for us to do in this area together. 

Geralyn Warfield (host): I can see where perhaps there's this disconnect between a woman who is seeing an OB-GYN during the course of pregnancy, and then, of course, during labor and delivery. And then returning to primary care. And it's not because it's the electronic medical records that are the issue. It's really just the follow-up and how the attention shifts from the mother to the child at that point. 

Do you see [00:04:00] any validity in that thought process and what can we do in our roles in making that better?  

Emily Jones (guest): Yeah, Geralyn, absolutely. What you just described is an emerging area of scholarship. This idea of missed opportunities for follow-up after complications of pregnancy that we just mentioned, like gestational diabetes, pre-eclampsia, gestational hypertension, or what we might call hypertensive disorders of pregnancy. 

And there really is this chasm. It's not just a gap. It is a chasm in our health system in the United States and, and across the globe, too, where women literally fall in this chasm because our systems are not designed to offer whole person, life course-oriented preventative care. And so, you may have someone, an obstetrician, who is providing excellent care during pregnancy and postpartum, and this [00:05:00] obstetrician, if they're following the science, may even make a referral to a cardiologist or to a primary care physician. 

But our health systems truly are not set up in a way that support that transition of care in ways that make it not just palatable, but accessible for women to make that transition easily. So yes, you're absolutely right that the follow-up itself is,a major concern.  

Geralyn Warfield (host): So, let's talk a little bit about women who have made that transition post-delivery and now they're no longer pregnant. The focus is then, oftentimes, on the baby. And those of us that are mothers know oftentimes you feel almost,invisible. When you go out in public, everybody's attention, or your family's attention, is all on the baby. And I think that sometimes the mother's attention is all on the baby as well and not on themselves. 

And so, in some ways it's even beyond the healthcare system that the mother [00:06:00] is not ignored per se, but all of the labor, literal and figuratively, that the woman went through is in that baby. All the attention's in the baby. So how do we reframe ourselves to let women know that they are just as important? 

Emily Jones (guest): That's a great question. The reframing, I think I mean that's a big question, Geralyn, because that's a societal-level of influence that you're talking about, and it's a deeper question of why are women not valued in this society? And so, from a perspective of thinking of nursing as a discipline and what can we do about that; and thinking about collaborating interdisciplinarily to really up our game when it comes to valuing women in society,and in our healthcare delivery systems. That's going to be reflected in [00:07:00] policy, social policy, health policy, and so, I think of, you know, this term that gets used a lot, “siloed systems,” and that's certainly what we have.  

We have, you know, a healthcare system in, at least in the United States where women get pregnancy-related care, depending on their insurance plan, they'll have a certain number of weeks of postpartum covered care and then, boom. Drop. And they won't enter the healthcare system again, generally, unless there's a problem.  

And so this idea of life course care where we think about the whole person and not just think of this individual birthing person as just a uterus and, you know, ready to deliver and then a postpartum person, but to think of this as a life course trajectory: whatever was already in the vascular [00:08:00] system of that woman, or in the metabolic system of that woman prior to birth, you know, pregnancy served as a stress test.  

We saw something that was there. We saw a risk factor, and it would be, I think, a goal of interdisciplinary care to do away with this siloed system that produces the chasms and think more of disease process, if you want to call it that, or wellness process, as a continuum and we’re seeing certain things in the pregnancy period and in the postpartum period. But that's, if anything, an opportunity to do something about it. To prevent progression to full-blown Type 2 diabetes or full-blown cardiovascular disease or hypertension that doesn't resolve after pregnancy and, and requires, you know, medical management. 

It’s all an [00:09:00] opportunity, but we don't really seize those opportunities.  

Geralyn Warfield (host): We are speaking with Dr. Emily Jones about pregnancy as a stress test and what happens before and after. We'll be right back.  

Geralyn Warfield (host): We're back with Emily Jones having an amazing discussion about women and pregnancy and, Emily, I'd like to ask you specifically about gestational diabetes. 

This is a, an amazing. Influence on a woman's life, not just during pregnancy. So, I'm hoping you can enlighten our listeners just a little bit about what it takes to identify, to manage and help women have a long, healthy lifespan even after having gestational diabetes.  

Emily Jones (guest): So, any woman who has been pregnant and received prenatal care will remember that there is a screening test that happens usually around the 24th to 28th week of pregnancy, and [00:10:00] it's called the glucose screening test. And what this involves is drinking some really sugary beverage and then waiting a certain amount of time—usually an hour or two depending on the, the provider who's,using the diagnostic test—and then you see how…this is, this is our way of screening to see how the pancreas responds to this bolus or this overloaded dose of sugar. 

And so many women in pregnancy—which, by the way, pregnancy is sort of a glucose intolerant state, that's just a normal metabolic process and change, physiological change that happens during pregnancy—but many women will quote unquote “fail” that test, or just not pass it at the threshold that we're looking for. And so, when that happens, they are told, they are told that they have gestational [00:11:00] diabetes mellitus. So, we often talk about this as GDM, or we just call it gestational diabetes, but it's literally diabetes that is first diagnosed during pregnancy. 

So, this would not be someone who actually had preexisting diabetes, but this is diabetes that is truly just first diagnosed during pregnancy. And for many women, in fact, many times the majority of women who develop gestational diabetes during pregnancy, once they deliver and their body is no longer in this altered metabolic state, many times their glucose regulation will go back to what we think of as normal levels and they won't develop Type 2 diabetes. 

But what we know from the last two decades of science is that upward of 40 to 70% of women, depending on race, ethnicity, especially, and depending [00:12:00] on social and economic resources, especially, many women will go on to develop Type 2 diabetes, and that's because of what I mentioned before as this sort of underlying cardiometabolic milieu, so to speak, that was there all along. 

And the pregnancy just gave an opportunity to sort of, see it, that stress test. And, so gestational diabetes, Is one of those conditions that we've treated for a long, long, long time, and we have really well delineated management for it.  

Geralyn Warfield (host): That was a wonderful overview of gestational diabetes and how it impacts the, the woman who's just had a baby. And, as we were discussing earlier, may or may not receive treatment for, depending upon what the healthcare options are for that individual. 

So, I'm wondering if you are thinking about our [00:13:00] listeners and what they can take away from our conversation today. Are there any key takeaways that you would have them considered knowing that they come from a wide variety of backgrounds—some of them might be in acute care, some might be, you know, primary care providers. So there's not going to be one answer that of, course, fits everyone, but what kinds of things would you ask them to consider?  

Emily Jones (guest): Well, because this is the Preventive Cardiovascular Nurses Association, I feel like I should also mention that the condition of gestational diabetes really confers cardiovascular risk that is not just linked to the future Type 2 diabetes risk. And this is science that's really developed in the last decade to help us see that there is this stand-alone cardiovascular risk that is, that exists because of the process of gestational diabetes during pregnancy. 

And, certainly, also I want to mention the risk [00:14:00] of preeclampsia, which often is, includes hypertension, high blood pressure during pregnancy, and certainly hypertensive disorders of pregnancy and even preterm labor. All of these now are recognized risk factors that show up in pregnancy that really should get providers’ attention. Clinicians should be paying attention, and the guidelines are very clear now. And these are guidelines from both the American Heart Association, American Diabetes Association, and the American College of Obstetricians and Gynecologists. 

Everybody is on the same page that we should be following the history. We should be asking women at any healthcare point in time, any time that this person is entering the healthcare system to seek care, we should be asking about a history of pregnancy complications and then doing something about it in a preventative [00:15:00] approach. 

So, I suppose, Geralyn, the takeaways are to ask the right questions, and then to think about ways that –in your own practice—you can do something to bridge that chasm. Because it's going to take all of us. And unfortunately, we don't have, we're not operating within a,national health system that's going to help us naturally do these transitions of care. So, the onus is truly on the providers to pay attention and to do their best to connect patients, women, to others, other providers in the healthcare system who can help prioritize prevention from this point forward.  

Geralyn Warfield (host): We've been listening to Emily Jones and she has provided us a call to action. Each and every one of us have a responsibility to these women in our care. 

We are really grateful to you for your [00:16:00] time. The Preventive Cardiovascular Nurses Association thanks you for all you do each and every day. And I'm your host, Geralyn Warfield, and we will see you next time. 

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