Pregnancy and cardiovascular disease

Abstract

Cardiovascular disease complicates 1–4% of pregnancies — with a higher prevalence when including hypertensive disorders — and is the leading cause of maternal death. In women with known cardiovascular pathology, such as congenital heart disease, timely counselling is possible and the outcome is fairly good. By contrast, maternal mortality is high in women with acquired heart disease that presents during pregnancy (such as acute coronary syndrome or aortic dissection). Worryingly, the prevalence of acquired cardiovascular disease during pregnancy is rising as older maternal age, obesity, diabetes mellitus and hypertension become more common in the pregnant population. Management of cardiovascular disease in pregnancy is challenging owing to the unique maternal physiology, characterized by profound changes to multiple organ systems. The presence of the fetus compounds the situation because both the cardiometabolic disease and its management might adversely affect the fetus. Equally, avoiding essential treatment because of potential fetal harm risks a poor outcome for both mother and child. In this Review, we examine how the physiological adaptations during pregnancy can provoke cardiometabolic complications or exacerbate existing cardiometabolic disease and, conversely, how cardiometabolic disease can compromise the adaptations to pregnancy and their intended purpose: the development and growth of the fetus.

Key points

  • Cardiovascular disease complicates 1–4% of pregnancies — with a higher prevalence when hypertensive disorders are included — and accounts for 16% of maternal mortality, making cardiovascular diseases the leading cause of death in pregnant women in developed countries.

  • Advanced maternal age, obesity, hypertension, smoking and diabetes mellitus are all major cardiovascular risk factors that are increasingly prevalent in the pregnant population.

  • Profound haemodynamic changes, such as a 50% increase in cardiac output, place a burden on the maternal cardiovascular system during pregnancy and can provoke new-onset or an exacerbation of existing cardiovascular disease.

  • When prescribing medication, the altered pharmacokinetics during pregnancy should be considered in addition to fetal safety, and regular serum measurements can be beneficial because drug concentrations can change.

  • During pregnancy, a high index of suspicion and a low threshold for investigation of cardiometabolic diseases is warranted.

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Fig. 1: Physiological changes in pregnancy.
Fig. 2: Onset of cardiovascular events during pregnancy.
Fig. 3: Pathogenesis and pathophysiology of pre-eclampsia.
Fig. 4: Risk of cardiometabolic disease after pre-eclampsia.

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Ramlakhan, K.P., Johnson, M.R. & Roos-Hesselink, J.W. Pregnancy and cardiovascular disease. Nat Rev Cardiol 17, 718–731 (2020). https://doi.org/10.1038/s41569-020-0390-z

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