Maternal Cardiac Disease in Pregnancy

Maternal cardiac disease in pregnancy covers the structural and functional heart conditions — congenital heart disease, valvular disease, cardiomyopathies, and arrhythmias — that complicate pregnancy because the cardiovascular adaptations of pregnancy impose a load the diseased heart may not tolerate. It is a leading category of indirect maternal morbidity and a paradigm for pre-conception risk assessment and multidisciplinary care.

Definition

Maternal cardiac disease in pregnancy refers to congenital or acquired heart conditions — including valvular disease, cardiomyopathy, and arrhythmia — that are present or arise during pregnancy and increase maternal and fetal risk because of the cardiovascular demands of the gravid state.

Scope

The topic covers how the haemodynamic changes of pregnancy interact with pre-existing and pregnancy-associated heart disease, the main disease groups encountered, and the principle of structured maternal risk stratification. It is a reference entry on the cardiovascular physiology and disease categories relevant to pregnancy, not a management protocol.

Core questions

• How do pregnancy's increases in blood volume, cardiac output, and heart rate stress a diseased heart?
• Which lesions carry the highest maternal risk, and how is that risk stratified before and during pregnancy?
• How is peripartum cardiomyopathy distinguished from decompensation of pre-existing disease?
• Why is pre-conception counselling central to cardiac conditions known before pregnancy?

Key concepts

• Haemodynamic adaptation of pregnancy
• Congenital heart disease in pregnancy
• Valvular heart disease
• Peripartum cardiomyopathy
• Maternal cardiac risk stratification
• Pregnancy heart team / multidisciplinary care
• Pre-conception counselling

Mechanisms

Across pregnancy, blood volume and cardiac output rise substantially and systemic vascular resistance falls, with further abrupt shifts during labour and immediately postpartum. A heart with limited reserve — from a stenotic valve, a systemic right ventricle, pulmonary hypertension, or impaired systolic function — may be unable to meet this increased demand, producing heart failure, arrhythmia, or, in the most severe lesions, maternal death. Peripartum cardiomyopathy is a distinct entity in which systolic dysfunction develops in late pregnancy or the months after delivery. Because the load is greatest in the third trimester, during labour, and just after delivery, risk is concentrated in these windows, which is why structured antenatal stratification and planned peripartum care are emphasised in cardiovascular guidelines.

Clinical relevance

Maternal heart disease is a recurrent contributor to indirect maternal morbidity and mortality, which is why cardiovascular guidelines describe risk-stratification schemes and multidisciplinary 'pregnancy heart team' models. This entry explains those concepts as reference material on the disease category and its physiology; it does not provide individualised risk thresholds, drug choices, or delivery-planning advice.

Epidemiology

Heart disease is among the more frequently cited causes of indirect maternal death in high-income settings, and the spectrum has shifted as more people with congenital heart disease survive to reproductive age. The 2018 ESC guidelines synthesise the risk patterns across congenital, valvular, and cardiomyopathic disease in pregnancy.

History

Care of the pregnant cardiac patient evolved from rheumatic valvular disease dominating the twentieth-century picture to a contemporary spectrum increasingly shaped by adults with surgically corrected congenital heart disease. Successive European Society of Cardiology guidelines, including the 2018 dedicated document, formalised maternal cardiovascular risk assessment and the multidisciplinary team approach.

Seminal works

• regitz-zagrosek-2018
• arbelo-2023

Frequently asked questions

Why does pregnancy stress the heart?

Pregnancy markedly increases blood volume, heart rate, and cardiac output while lowering vascular resistance, with further sharp changes during labour and just after delivery; a heart with limited reserve may be unable to meet this added demand.

What is peripartum cardiomyopathy?

It is a form of heart failure in which left-ventricular systolic dysfunction develops toward the end of pregnancy or in the months after delivery, distinct from worsening of a heart condition that pre-dated the pregnancy.