Pregnancy and cardiovascular disease

• Published in: Nature reviews cardiology 2020-11, Vol.17 (11), p.718-731
• Main Authors: Ramlakhan, Karishma P., Johnson, Mark R., Roos-Hesselink, Jolien W.
• Format: Article
• Language: English
• Subjects: 692/4019; 692/699/75; Acute Coronary Syndrome - diagnosis; Acute Coronary Syndrome - physiopathology; Acute Coronary Syndrome - therapy; Adaptation (Physiology); Aneurysm, Dissecting - diagnosis; Aneurysm, Dissecting - physiopathology; Aneurysm, Dissecting - therapy; Antihypertensive Agents - therapeutic use; Arrhythmias, Cardiac - diagnosis; Arrhythmias, Cardiac - physiopathology; Arrhythmias, Cardiac - therapy; Aspirin - therapeutic use; Cardiac Imaging; Cardiac Output; Cardiac Surgery; Cardiology; Cardiomyopathies - diagnosis; Cardiomyopathies - physiopathology; Cardiomyopathies - therapy; Cardiovascular disease; Cardiovascular diseases; Cardiovascular Physiological Phenomena; Cardiovascular research; Diabetes; Diabetes, Gestational - diagnosis; Diabetes, Gestational - metabolism; Diabetes, Gestational - therapy; Disease Progression; Endocarditis - diagnosis; Endocarditis - physiopathology; Endocarditis - therapy; Female; Fetuses; Health aspects; Humans; Hypertension; Hypertension - physiopathology; Hypertension, Pregnancy-Induced - diagnosis; Hypertension, Pregnancy-Induced - drug therapy; Hypertension, Pregnancy-Induced - physiopathology; Hypoglycemic Agents - therapeutic use; Maternal Age; Medicine; Medicine & Public Health; Obesity, Maternal - metabolism; Obesity, Maternal - physiopathology; Physiology; Platelet Aggregation Inhibitors - therapeutic use; Pre-Eclampsia - physiopathology; Pre-Eclampsia - prevention & control; Pre-Eclampsia - therapy; Pregnancy; Pregnancy - metabolism; Pregnancy - physiology; Pregnancy Complications, Cardiovascular - diagnosis; Pregnancy Complications, Cardiovascular - physiopathology; Pregnancy Complications, Cardiovascular - therapy; Pregnancy Complications, Infectious - diagnosis; Pregnancy Complications, Infectious - physiopathology; Pregnancy Complications, Infectious - therapy; Pregnancy in Diabetics - metabolism; Pregnancy, Complications of; Review Article; Risk factors; Venous Thromboembolism - diagnosis; Venous Thromboembolism - drug therapy; Venous Thromboembolism - physiopathology
• ISSN: 1759-5002; 1759-5010
• DOI: 10.1038/s41569-020-0390-z

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. In this Review, Roos-Hesselink and colleagues describe how the physiological adaptations during pregnancy can induce cardiometabolic complications or an exacerbation of existing cardiometabolic disease, and discuss the epidemiology, pathophysiology, diagnosis and management of cardiometabolic diseases acquired or presenting during pregnancy, including hypertensive disorders, gestational diabetes mellitus, thromboembolic disorders and peripartum cardiomyopathy. 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