 Thank you, Dr. Coulter and it is an honor to be able to present this and to be completely honest Making this presentation you learn a lot when you have to present something because you know You have to be the one that is the expert in the room And I think it's true that a lot of us don't really know much about how we treat pregnant patients With hypertension because quite frankly, it's just not that common that we are the one seeing them Especially in adult cardiology our patients are generally not of child-bearing age So I think this is really important for maybe the few patients that you do see that You know might be younger with hypertension Especially the African-American population where hypertension seems to be more prevalent at a younger age Okay, so I Have a little warm-up. I hope by the end of this talk we can answer these questions or at least come close to Getting the answers to these questions We have a 30-sex-year-old woman with no past medical history She underwent in vitro fertilization and became pregnant with twins at her 21 week appointment her OB Notice that her blood pressure was elevated to 155 over 85 for an OB. This is not going to be surprising They probably see this a handful or more times every day But for us, let's talk about some questions that we maybe don't know the answers to What is her likely diagnosis besides hypertension? What type and why? What's the most common form of high blood pressure when you're pregnant? What next steps do we need to take if you're the first person seeing her besides calling her OB and letting them know What might you be able to start doing in your clinic or your office? And then what medications if any she should be should she be prescribed? Immediately postpartum what she at risk for and then in the long term, you know 10 20 years from now But is she at risk for when she's in her 50s or 60s? So today aside from answering those questions a quick rundown I know you guys have heard a lot about hypertension today, but just to beat it one more time To be the dead horse. We're gonna talk about the guidelines one more time or just the basis of why we have the new update in the guidelines What is the prevalence and the importance of screening for hypertension and pregnancy? Why does it actually matter so much and why do the OB's really care? Why should we really care? What is the physiology that might be part of the cause of why this these things happen? Or what should we expect in normal pregnancy? And then we will discuss each type of hypertension Hypertensive disease in pregnancy. Hopefully the diagnosis the management the prognosis, etc And then work up and the treatment options for all those And then we'll just briefly talk about fetal outcomes and moms with high blood pressure and mom outcomes as well So the basics one more time. I'm sure you've seen this What is hypertension so we have that? 2017 update that was already talked about by this morning by dr. Taylor And dr. Aguilar Aguilar touched on that a bit too, but just just to remember at least in the my brain It's easy just to remember if you're normal if you're less than 120 over 80. That's normal Anything above that is abnormal and I think that's important to tell patients especially since the last Hypertensive by our blood pressure guidelines a few years ago, you know everyone said well, you know my blood pressure is 140 over 80 And my doctor said that's fine and it's really hard to have that discussion Especially with your patients who don't want any more meds that okay. Yes, we weren't lying We thought it was fine, but now we have more data and it's important that since we have that data that you use it And and whatever we can do to make our patients live longer. I think it's important for them to understand We're not just pill-pushing. We want to you know increase or decrease their morbidity and mortality So just telling them okay. What was fine three years ago isn't fine anymore Is a hard pill to swallow, but I think an important one for us to tell our patients Of course the patients For sure in clinic with the doctor colder. I heard this at least once or twice. No, no my blood pressure is never this high It's actually just when I come here And I think the best response to that that I found is I totally believe you because it might be true But to prove it to me and just go home check your blood pressure in the morning in the afternoon or in the you know Mid-morning in the evening and just show it to me the next time you come and some people are really surprised They're like, oh, it's actually high at home and I I thought it I thought it was way better than this or they'll bring back a log That's completely normal and you're like, okay fine you win. I'm not gonna give you any meds, but um, it's Important that you work with the patient so that they don't feel like you're just trying to give them more meds So the basics I'm sure that everyone knows sprint or at least has a General idea of what exactly this sprint trial was but why why the blood pressure caught off? So why did we make the changes? Well, of course, there's compelling data more recently that a tighter blood pressure control is better than a more lenient Blood pressure so this sprint study in brief just like the quick hitter on this is They put people into two categories. We're gonna either tightly control you with a systolic less than 120 Or we're gonna let be a little more lenient less than 140 They had almost 10,000 patients. So it was a large large study and it was a five-year plan to five-year follow-up And actually the medium follow-up was 3.26 years For a reason you will shortly find out on my next slide the inclusion criteria Rate of under equal to 50. They had high blood pressure and at least one respecter for heart disease The caveat to this was diabetics were not included The primary outcome which was a composite was basically any ACS heart attack a stroke any CV event was the primary outcome and the secondary outcomes which were selected pretty it was a pretty good way to kind of group the secondary outcomes as mortality which We'll see shortly was important for them And then the side effects to tighter blood pressure control which everyone was kind of thinking those might outweigh the benefits But syncope hypotension renal function getting worse from having episodes of hypotension and hyponatremia So the two groups the intensive group The ones that they were targeting less than 120 their their average of their mean blood pressure is actually 121.5 systolic and then the lenient group was 134.6 The average meds they were on 2.8 for the intensive group and then 1.8 for the lenient group So an additional pill per day on average for the patients that were in tight control The trial was stopped early which is really awesome when I think it's great and exciting when trials are stopped early Because that means there must be a really good benefit There must be a really compelling reason why they wanted to stop this trial, which was probably a lot of money Early, so why was it stopped early? Well the primary outcome there was a 5.2 versus 6.8 percent in the More tight versus the lenient control for the primary outcome It was driven which is an important part by CV death and heart failure. So two very Concerning things that we all are motivated to decrease. So those are two important endpoints of the composite And the number needed to treat was pretty reasonable actually for the primary outcome 61 death from any cause about 90 and then death from CV cause 172 so a bit higher The secondary outcomes and right here the one that was the most important mortality was also significant Some mortality was decreased in the more tightly controlled blood pressure group here on the left You can see the primary outcome here. They diverged early, which is why they could stop the trial early at about one year You could see them diverge the The composite endpoint intensive treatment group was improved early same death from any cause It took a little longer. You could see a divergence here at about two years Right and they did of course the subgroup analysis just for completion. I thought I would add this here But in almost all of these subcategories for patients almost all of them Except for here, you'll see female More tight tighter control was better. So that's another important part of this trial So now that we talked about hypertension and what is it for normal quote-unquote normal people non-pregnant people Let's switch over to what this talk is going to be more aimed at and it's pregnant people. So Again, like Dr. Culture said, it's very different the definitions we use for pregnant women compared to the general population so What the the big numbers to remember? Severe hypertension in a pregnant woman is 160 over 110 greater than or equal to 160 over 110 They call mild hypertension when it's 140 or over 90 or lower and then moderate is there in the middle So why these cut-offs you might ask Of course As at the beginning as we talked most pregnant women are younger So the risk of letting their blood pressure be a little bit higher for a brief period of time seems to be reasonable and then of course the the risk versus benefit of Overtreating a pregnant woman who's you know Growing a baby and the hypo perfusing that placenta is the the risk really worth it Versus the benefit of it, you know nine months of blood pressure control This has been looked at as you guys I'm sure can expect multiple times and the data is very conflicting But nonetheless, we still have these cut-off we still have these cut-offs. So 160 over 110 Another thing to remember is yes all blood blood pressure medicines cross the blood brain barrier. So There's nothing you don't it's like dr. Kulture always says you There's never free lunch or you know, you never really can give a therapy or do a treatment and not have some sort of side effects Um, so briefly some of that conflicting data that I just talked about on You know, why or why not the blood pressure is a tighter cut-off? So the chip study which was done in I think 2015 control of hypertension and pregnancy Study had 981 so almost a thousand pregnant women and they either Categorize them into a string like a strict blood pressure control versus more lenient and their Cut-offs were diastolic blood pressure. So they did a diastolic group of less than 85 and a diastolic group of less than 100 And they followed them This is the mean difference in blood pressure for the systolic was 5.8 and the diastolic is 4.6 because As you can imagine when you give someone a blood pressure medicine to control diastolic blood pressure It's also going to affect your systolic. So we would have expected the difference to the difference in both The outcomes in the tighter control groups of the women that had the diastolic goal that was less than 85 They actually had as we might expect a reduced severe maternal hypertension Which is correlated with events in the mom if you have severe hypertension you have poor outcomes So that's a positive thing and It actually interestingly didn't the medicines the therapies did not increase the risk of the small for gestational age in the baby So it didn't make the baby super small after you were treating them with a couple of blood pressure meds the less tight control group they actually had um Of course as you'd expect more patients develop severe hypertension So in those group in that group of females who did develop severe hypertension greater than 160 over 110 They had a higher rate of pre-term delivery that babies with a lower birth weight and they had a higher rate of As you might expect serious maternal morbidity due to having that super high blood pressure having More preeclampsia or having help syndrome the progression of preeclampsia So despite all this The cutoffs for pregnancy Hypertension and pregnancy still remain a little bit conservative So we're still not anywhere near changing the cutoffs for the blood pressure goals during pregnancy But like all things in cardiology like our blood pressure guidelines In adult cardiology Who knows to say like maybe in two years or next year we might be talking about a new blood pressure cutoff if there's more data so Here are the facts The most important part of I think this talk is why do we care so much? So hypertensive disorders and pregnancy They complicate up to 15 of pregnancies So you know almost You know one in five women will have some sort of hypertensive disorder while they're pregnant It's a major cause of morbidity immortality and women that are pregnant So up to 10 to 15 15 percent of all maternal deaths are due to these hypertensive disorders The mom risks that we could talk about the stroke the intracranial hemorrhage The placental abruption preeclampsia and of course organ failure, which is associated with preeclampsia and acclampsia And just in case you don't know the placental abruption Since you know most of us don't deal with pregnant people often is just there's a hemorrhage in the lining of the placenta Which disconnects the placenta from the uterus which causes not only harm to mom bleeding But can actually threaten the baby's life as well. So it's a big deal um The risks the baby for the hypertensive disorders heart is congenital heart disease So defects growth restriction preterm labor and treat her in death and then of course prematurity If if mom develops a life threatening hypertensive syndrome that needs that requires the baby to be delivered, which is usually The definitive treatment for preeclampsia that's severe anyway So our goal as general practitioners cardiologists Obes, etc We are trying to help both reduce the morbidity and the mortality For moms and babies that have these these disorders The screening of course usp stf recommends. It's a grade b recommendation, which I thought I would just stick that out there. That's where it lays right now But everyone is screened for preeclampsia and we'll talk about what exactly That screening is or what labs you need or what tests actually are the screening So before we get started in general and pregnancy The heat there's lots of hemodynamic changes among other things happening in the mom's body But I just want to point out it's pretty um The only thing that lots of things change, but the only thing usually they all go up You have an increase in plasma volume an increased cardiac output an increased heart rate Lots of things go up But the only thing that goes down really is um your systemic vascular resistance So you might say wow most people then should be a little hypotensive or relatively hypotensive during pregnancy And that's kind of true most people their blood their blood pressure drops Even if they if they're borderline hypertensive like you might be monitoring their blood pressure in the clinic When they get pregnant their blood pressure might be really normal, which is um something to keep an eye You know keep an eye on for them Or if you're treating someone who has borderline high blood pressure and they get pregnant, of course you might have to back off But these are all the Changes in the cardiovascular system that take place From from conception all the way to postpartum and you can notice here that at postpartum Your sbr is still not up to where you started immediately after you give birth so What is the work up for all the people all pregnant women who have hypertension any hypertension? They're in your office for the first time and they have an elevated blood pressure. Well, of course Like everything in medicine a thorough history And physical is the first step Do they have concerning symptoms now? Do they have a family history? That's concerning was mom and sister and your other sister where they all pre-eclampsic These are all important pieces of the history For a new hypertensive pregnant woman And then of course you move on to more of the objective data the labs Every female that's pregnant will have a quantity with especially with hypertension Hypertension diagnosis will get a quantitative analysis of urine protein. So what does that mean? It's a protein to creatinine ratio on a single sample or a 24 hour protein protein collection from urine, which is really annoying We've recently had someone that we sent to do that carry a jug around for 24 hours Not many people want to do that but it's Actually the first recommendation And then of course if you're in a place where you might not have these available, which is rare here in the us and You could do a dipstick and if there's Large amount of protein 4 plus then you can say surely there's something bad going on But it's recommended quantitative and then next you will always get a cmp and a cbc And the reason you're going to get that is because they those play roles in the diagnosis of what type of Hypertensive disorder the patient has a cmp you're mainly looking for renal function and liver function and then the cbc You're looking for platelets So let's start off with the big offender preeclampsia. It's the biggest The biggest group of hypertensive disorders that complicate pregnancy It might not be the most common disease in hypertensive disease in pregnancy But it's the one that complicates the most it's in 5 to 7 percent of pregnancies Which is actually relatively common if you think about it. I'm sure we all have all we can all name one person We know that was preeclampsic And there's lots of risk factors Null parity having prior preeclampsia having like I said a family history of Preeclampsia having some sort of autoimmune disease Which you'll see shortly might play into the etiology of why people have this disorder And then of course if you have chronic hypertension you're at higher risk of having complications leading to preeclampsia Advanced maternal age and obesity of course are respectors as well And as women start having babies later, which is now that more women are you know furthering getting Going to college and you know waiting to start families. We're going to see this more often I'm sure the obis have already noticed this So why does it happen? This is a fun fun little like mind game No one actually really knows the real reason why it happens, but there are multiple theories And if you look at the risk factors, you might be able to extrapolate how they How they cause this disorder So why would someone with lupus inflammatory disease be more prone to have preeclampsia? Well, preeclampsia might have something to do with inflammation in your vessels So people have made theories about this The the major the end of the road is preeclampsia is endothelial dysfunction And the most common Accept or most accepted theory of why it happens is in this cute little cartoon that I found So why why does it happen? Well you have some sort of defective spiral where you have inflammation from Whether it be lupus or you have a genetic predisposition, etc, etc Or you have a placenta that's being hypo perfused and you're releasing inflammatory cytokines and inflammatory mediators They all have effect on mom leading to the blood vessels becoming Dysfunctional or or tighter or less relaxable Which then has downstream effects on your the end organs the kidneys the liver the brain But it's a it's a whole body kind of Domino effect. It's not just The blood vessels it's all organs Which has Implications for monitoring mom and monitoring her symptoms very closely So how do we diagnose the preeclampsia? This goes back to What what's the blood pressure caught off and it has What are the results of those labs that you had ordered or you had the obi ordered? So the blood pressure caught off is greater than or equal to 140 over 90 After 20 weeks of gestation In a patient that was previously normo-tensive And they will have to have the protein in their urine above the cut-offs 0.3 protein degree and ratio are greater than 300 milligrams a day if you do that wretched 24 hour collection If they don't have the protein or protein area then the other Could have this is the platelets less than 100,000 creatinine that's 1.1 or double of what their normal creatinine is If their LFTs are much higher than they should be two times upper limit normal Or they have visual disturbances cerebral symptoms pulmonary edema And these are all things that you guys might remember help syndrome I'm not going to dive deep into help syndrome But those are all the complications of helps help syndrome low platelets elevated LFTs Hemolysis et cetera So if you even if the woman is not She doesn't have a protein ratio that meets your cut-off. She still might have preeclampsia So don't just dismiss that make sure you pay attention to the other lab studies that you've ordered as well and her symptoms So the management again, we're really lenient with pregnant women We want the blood pressure to be less than 160 over 110. That sounds crazy. If someone walks into our clinic We're like, oh my god 160 over 110. What are you doing? Like But for pregnant women, this is what we allow As long as they don't have endorium damage If they do need blood pressure medicines We all I'm sure can remember there's a big three a little triad that we all if we've seen pregnant women on blood pressure meds It's methyl dopo, which Weakish weak Lebeda law and niocetapine and dr. Culture. I've had I've been able to help take care of some of her pregnant patients out of high blood pressure On many meds not just one or two, but niocetapine seems to do quite the job It's probably the best and the strongest if you're looking for bang for your buck And it's a first line agent now um If that's if that's a high-risk patient with preeclampsia like they've had Multiple pregnancies with preeclampsia or they have a history of early labor Premature delivery You can consider a lotus aspirin and that's kind of like how we were talking about the lady That dr. A postallion was just discussing lotus aspirin is actually okay for pregnancy and apog the american college of Staturex and gynecology approves of its use so You can consider that for the higher risk preeclampsics and if they are severely preeclampsic And you can't control their blood pressure or they have some end organ damage They need to go to the hospital and get IV Lebeda law like heart api and magnesium, etc Um, the how does the preeclampsia kind of tie in with the heart? So that's what we're here for anyway You have all the things that we've discussed in the presentations prior You have a stiff vessels which can leave to lead to high blood pressure Which the high blood pressure leads to a stiff heart and diastolic dysfunction And then you have maybe you have a little bit of mr And when you add on the high blood pressure and a stiff heart now you have more mr so What seems to be just a pregnancy induced disorder or you know state of being can also have real implications on how your patient Feels because the heart's also feeling it as well Um, so things to look for in an echo and in a pregnant patient who's symptomatic Short of breath out of proportion to just having a large pregnant uterus is the diastolic dysfunction the rbsp RV systolic pressure And the overall function which can be effective Um definitive therapy, of course for this disorder is delivery and the acog And their guidelines try very hard to keep the woman pregnant as long as possible Until they until they really need her to deliver the baby so that the mom The risks of delivering the baby early, um, don't outweigh the benefits of keeping her pregnant Okay, so what is superimposed preeclampsia? This is kind of a complicated topic because it's patients who have chronic hypertension So they have hypertension before they got pregnant and or gestational hypertension what they develop when they're pregnant that is then superimposed by Or they in addition develop preeclampsia. It can be difficult to tease out, especially in the chronic hypertensive patients But up to 10 of the chronic hypertension patients might have preeclampsia without the protein area So it's that group of patients that doesn't fit. Um, you know, isn't the cookie cutter preeclamp tech It's a patient who you've seen in the clinic for a while But their blood pressure starts to creep up and it either creeps up to a point where it's like wow You only required two blood pressure meds now we have you on four and it's still not controlled This should be a red flag, um, especially if they're otherwise, um, you know asymptomatic Again, if they become symptomatic with increasing shortness of breath pulmonary edema That's a red flag that they're now moved on to preeclampsia from the chronic hypertension Um, this is a little controversial, but uh in those patients Uh in patients who might be at risk for preeclampsia you might say well, why don't why don't we have a way to monitor The chronic hypertensives to like maybe have a marker earlier that they're going to develop preeclampsia Well, um, there is a lot of work done being done and has been done on biomarkers That might be circulating that can cue you to say this chronic hypertension patient will have Preeclampsia in the future But the acog does not endorse them because they're just not as specific as they need to be right now Doppler of loss symmetry, which is doffloring The uterine artery actually is helpful, but again, it's not recommended So just close history physical and monitoring of labs, etc. It's the way to Check when these women's transition to preeclampsia The chronic hypertensive which will you guys will probably be the most interested in is mostly adult practitioners For them again the standard the diagnosis is 140 over 90 which For us is not true, but for them Chronic hypertensive is that cut off and it's hypertension diagnosed before pregnancy or before 20 weeks So if it's after the 20 weeks and they've never been hypertensive before it's not chronic hypertension, obviously Or you can diagnose someone as chronic hypertensive tension if they Remain hypertensive for greater than 20 weeks after they deliver their baby What's the overall incidence? It's really low like I said because usually people with chronic hypertension are too old to have a baby But the incidence the highest and older patients African-american and obese Ideally any person you treat for hypertension in your clinic You should counsel them if they're still of childbearing age or able to have kids that You need to address the medic medications before they get pregnant because of the tredogenous All right, so what is the increased risk for pregnant patients with chronic hypertension? Up to 25 1 in 4 again will move from chronic hypertension to have that superimposed preeclampsia Um, and then for the uncommon uncomplicated chronic hypertension that don't develop preeclampsia They're still at a higher risk for having a C-section or postpartum hemorrhage So you might have you know smooth sailing off their pregnancy with your chronic hypertensive patient But know that there's still risks even if you made it to the finish line. We still have risk stirring a delivery Again, if you have the superimposed preeclampsia, it's worse Higher risk for placental abruption small for gestational age premature delivery, etc In patients with chronic hypertension This is one of the things that I learned we'll try to prepare this is There's an up to greater up to 80 greater risk of your fetus having a congenital heart defect If you have chronic hypertension and what came first the chicken or the egg We don't really know is it because What we do know that the risk is higher of having the congenital heart defect Even if you're not on therapy and medical therapy, so it's probably not all just Being treated with pills that's causing this It's probably a little bit of both the risk goes up if you need to be treated But is it because the blood pressure is higher that the defect is there? Is it because you're treating that blood pressure? It's not certain But counseling of course on these risk is is required really to be required If you have a patient who can have a baby who is chronic hypertension. They need to know this That if they get pregnant, there's a risk The management for chronic hypertension This diastolic is the goal according to acog is a little bit lower than for your preeclampsia or your gestational It's 105 but 160 over 105 And it's the same It's kind of like, uh, I'm a broken record up here, but the same medication you would use and not the local libato on my fetipine The big thing to remember for the chronic hypertensis is Anyone who's on an ACE inhibitor an ARB etc and um, al daphthrone receptor Antagonist They need to be taken off that if they're planning to get pregnant It's just as simple as that. I think in my practice When I am finally done training if I have someone who can have a baby I'm going to do everything to avoid prescribing them an ACE and ARB or an al daphthrone antagonist because that risk is just You might as well avoid it if you can um, and then of course the chronic hypertensives. They're at high risk as were the Uh, the previous group that we discussed so you can consider a lotus aspirin if you are worried about them being complicated Moving on to gestational hypertension hypertension, it's the most common Reason that a pregnant woman will be hypertensive. Um, it's a temporary increase It's often called pregnancy induced hypertension And it occurs just like preeclampsia after 20 weeks, but there are no lab abnormalities. It's um, six to 17 percent in Null Paris woman and two to four percent multiple breasts The increased risk is Multifedal pregnancy obese overweight all the common kind of risk factors for The hypertensive disorders we previously discussed That cut off for therapy again If I could I feel like I've said a million times 160 over 110 and don't treat them unless you really have to What is their prognosis if you have a female that you see for this? Uh, gestational hypertensive hypertension in your clinic 25 percent with the chronic or gestational hypertension developed the preeclampsia So they're just kind of like the chronic hypertensives. They're at risk 20 percent will probably have gestational hypertension again if they get pregnant again. Um, it's For me being a adult cardiologist. I think A very important point is asks your women your female patients if they were preeclampsic if they had just a Stational hypertension because it actually does affect their risk in the future. Um, it is a Definitely a marker. We don't know exactly why but for chronic hypertension developed and cardiovascular disease to be present in the future Um, and we'll dive a little bit deeper into that. So the baby is delivered We got her through now what don't forget that the preeclamps uh preeclampsia and eclampsia can still develop post delivery so up to four weeks And monitoring the blood pressure up to 72 hours is the recommendation the official recommendation from acog and again in seven to ten days And really patient education is where this fits in because as any of us know had kids They don't keep you in the hospital for very long anymore. So you're out on your own um, so uh educating patients and symptoms of uncontrolled blood pressure or eclampsia very important headaches abdominal pain visual changes all very important um, and then The cv outcomes that I briefly mentioned later in life for the gestational hypertensive patients and even the preeclamps Apparently there's a apparently a two-fold increase in cv disease for all women with a history of preeclampsia And preterm delivery less than 34 weeks in the setting of preeclampsia. It was an eight to 10 fold increased cv risk Um, they tried to adjust for preeclampsia being the main driver of this versus other you know other reasons and They they couldn't they couldn't attribute it just to preeclampsia And maybe it has to do with the risk factors that exist in patients with preeclampsia But nonetheless when you see a patient ask them, did you have preeclampsia? Did you have high blood pressure? Did you have any sort of disorder of your blood pressure when you were pregnant? It matters um, and then recurrent preeclampsia had an increased cv death and disease earlier in life than women who only had preeclampsia in their first pregnancy um, so Pregnancy history matters. That's the take home point from from all those Aside from how to manage them it matters when you see a new patient You should be asking a have they when did they have menopause? How many babies did they have and what were the cause or the complications if any of those pregnancies? so back to the warm-up because I'm getting tired of talking about 160 over 110 probably as much as you're sick of hearing me say that So this the 36 year old lady with the IVF and the twin pregnancy with the blood pressure of 155 over 85 What is the most common form of hypertension and pregnancy? And I hope we can all say that's gestational But preeclampsia is the most common one to complicate it What are the next steps? cbc it's kind of like when someone gets admitted to the hospital. What are you gonna do cbc cmp? Maybe get some urine studies But every single person with high blood pressure and pregnancy needs that What's her likely diagnosis again gestational as long as her blood all her labs are okay What medications if any would you prescribe none because she's relatively uncomplicated if her labs are okay And her blood pressure is less than the cutoff last time of 160 or 110 And immediately postpartum what you at risk for of course no matter what she's still at risk for the preeclampsia Anyone with elevated blood pressure during pregnancy And she's at risk for recurrent gestational hypertension hypertension in the short term But long term hypertension and cbc is which she should be a counsel on Here are my references And thank you and there's my little one that I had