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............................................................................................................................................................................. comorbidities and also congenital heart disease-being more frequently admitted than in previous years.6 The admission rate to ICUs was 6.4 per 1000 deliveries, corresponding to 1 admission per 156 deliveries, in Vienna, Austria during the period 2011–14. A 5% mortality rate was also observed in the study and is considered as appropriate in comparison to the literature.6

Cardiomyopathies are rare, but represent severe causes of cardiovascular complications in pregnancy.32

3.2 Physiological adaptations to

pregnancy Pregnancy induces changes in the cardiovascular system to meet the increased metabolic demands of the mother and foetus. Plasma volume and cardiac output (CO) reach a maximum of 40–50% above baseline at 32 weeks of gestation, while 75% of this increase has occurred by the end of the first trimester. The increase in CO is achieved by an increase in stroke volume in the first-half of pregnancy and a gradual increase in heart rate thereafter. Atrial and ventricular diameters increase while ventricular function is preserved. In women with heart disease, left ventricular (LV) and right ventricular (RV) adaptation to pregnancy can be suboptimal.33–36 Maternal cardiac dysfunction is related to impaired uteroplacental flow and suboptimal foetal outcome.35–37 Systemic and pulmonary vascular resistances decrease during pregnancy. Pregnancy is a hypercoagulable state associated with increased risk of thrombo-embolism. Increased activity of liver enzyme systems, glomerular filtration rate, and plasma volume, protein binding changes, and decreased serum albumin levels contribute to changes in the pharmacokinetics of many drugs.36,38 Uterine contractions, positioning (left lateral vs. supine), pain, anxiety, exertion, haemorrhage, and uterine involution cause significant haemodynamic changes during labour and post-partum. Anaesthesia, haemorrhage, and infection may induce additional cardiovascular stress. Blood pressure (BP) and CO increase during labour and post-partum. In conclusion, the physiological adaptations to pregnancy influence the evaluation and interpretation of cardiac function and clinical status.

3.3 Pre-pregnancy counselling

All women with known cardiac or aortic disease who wish to embark on pregnancy require timely pre-pregnancy counselling.39 Informed maternal decision-making is crucial and there is a clear need for individualized care, taking into account not only the medical condition but also the emotional and cultural context, psychological issues, and ethical challenges. Especially in patients with a high-risk or possible contraindication for pregnancy, the risk of pregnancy and the necessity of careful planning of pregnancy should be discussed at a young age. However, it is also important to explain that many women can go through pregnancy with low-risks. For risk estimation, as a minimum, an electrocardiogram (ECG), echocardiography, and an exercise test should be performed. In case of aortic pathology, complete aortic imaging by computed tomography (CT) scanning or magnetic resonance imaging (MRI) is necessary for appropriate pre-conception counselling. Peak heart rate and peak oxygen uptake are both known to be predictive of maternal cardiac events in pregnancy.40 A pregnancy exercise capacity >80% is associated with a favourable pregnancy outcome. Several aspects must be discussed, including long-term prognosis, fertility and miscarriage rates, risk of recurrence of congenital disease, drug therapy, estimated maternal risk and outcome, expected foetal outcomes, and plans for pregnancy care and delivery. A multidisciplinary management plan should be constructed and discussed with the patient. In addition, attention to unhealthy habits including being overweight, smoking, and consuming alcohol is important, as these can have a clear impact on maternal and foetal outcomes. Pregnancy is a very suitable time for recommending a healthy lifestyle, including smoking cessation.

3.3.1 Risk of maternal cardiovascular complications The risk of complications in pregnancy depends on the underlying cardiac diagnosis, ventricular and valvular function, functional class, presence of cyanosis, pulmonary artery pressures, and other factors. Comorbidities, including for example rheumatoid and musculoskeletal diseases as well as mental disorders, should also be taken into account. Therefore, risk estimation should be individualized. To assess the maternal risk of cardiac complications during pregnancy, the condition of the woman should be assessed, taking into account medical history, functional class, oxygen saturation, natriuretic peptide levels, echocardiographic assessment of ventricular and valvular function, intrapulmonary pressures and aortic diameters, exercise capacity, and arrhythmias. Disease-specific risk should be assessed using the modified World Health Organization (mWHO) classification (Table 3) and as described in the respective sections dealing with specific diseases in these Guidelines. Risk estimation should be further refined by taking into account predictors that have been identified in studies that included large populations with various diseases, such as the CARPREG (CARdiac disease in PREGnancy), ZAHARA, and ROPAC (Registry Of Pregnancy And Cardiac disease) studies (Table 4).29,41–43 The mWHO classification is currently the most accurate system of risk assessment, although it is probably more appropriate for developed, rather than developing, countries.4,11,44 The general principles of this classification, and follow-up and management during pregnancy according to this mWHO classification, are presented in Table 3. Indications for intervention (surgical or catheter) do not differ in women who contemplate pregnancy compared with other patients. The few exceptions to this rule are women with at least moderate mitral stenosis and women with aortic dilatation. See also the disease-specific sections of these Guidelines. Fertility treatment is contraindicated in women with mWHO class IV, and should be carefully considered in those who have mWHO class III disease or who are anticoagulated.45 The risk estimation needs to be re-evaluated during each prepregnancy visit, because the risk of complications may change over time. Natriuretic peptide levels are associated with the occurrence of cardiac events, with N-terminal pro B-type natriuretic peptide (NTproBNP) >128 pg/mL at 20 weeks pregnancy being predictive of events later in the pregnancy.46,47 Pre-eclampsia is associated with HF in women with heart disease.43

3.3.2 Risk of obstetric and offspring complications Women with cardiac disease have an increased risk of obstetric complications, including premature labour, pre-eclampsia, and postpartum haemorrhage. Offspring complications occur in 18–30% of patients with heart disease, with neonatal mortality between 1–4%.29 Maternal and Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026