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............................................................................ offspring events are highly correlated.29,42,43 Though predictors of offspring complications have been identified (Table 4), there are no validated prediction models.4

3.3.3 Pregnancy heart team In women with a moderate or high-risk of complications during pregnancy (mWHO II–III, III, and IV), pre-pregnancy counselling and management during pregnancy and around delivery should be conducted in an expert centre by a multidisciplinary team: the pregnancy heart team. The minimum team requirements are a cardiologist, obstetrician, and anaesthetist, all with expertise in the management of highrisk pregnancies in women with heart disease. Additional experts that may be involved, depending on the individual situation, are a geneticist, cardiothoracic surgeon, paediatric cardiologist, foetal medicine specialist, neonatologist, haematologist, nurse specialist, pulmonary specialist, and others where appropriate. In this team patients from other centres can also be discussed, so not every hospital needs to have its own pregnancy heart team. The conclusions and recommendations should be filed and made available 24 h per day.

3.4 Cardiovascular diagnosis in

pregnancy During pregnancy it can be more difficult to diagnose HF, for example, because the physiological changes that occur during pregnancy (section 3.2) may mimic CVD. However, many disorders can be identified by taking a careful history and a thorough physical examination. When disproportionate or unexplained dyspnoea occurs during pregnancy and/or when a new pathological murmur (all audible diastolic murmurs are abnormal) is heard, echocardiography is indicated. BP should be measured using a standardized method (section 10). Proteinuria should be sought, especially with a history or family history of hypertension or pre-eclampsia. Oximetry should be performed in patients with congenital heart disease.

3.4.1 Electrocardiography In most pregnant patients, the heart rotates to the left with a 15–20

leftward axis deviation on the ECG. Common additional findings include transient ST/T wave changes, a Q wave and inverted T waves in lead III, an attenuated Q wave in lead aVF, and inverted T waves in V1, V2, and occasionally V3. Changes may mimic LV hypertrophy and other structural heart diseases. Holter monitoring should be performed in patients with known previous paroxysmal/persistent arrhythmia [ventricular tachycardia (VT), AF, or atrial flutter] or reporting palpitations.

3.4.2 Echocardiography Transthoracic echocardiography is the preferred imaging method in pregnancy. This reproducible, widely available, relatively cheap diagnostic modality can be used both in the outpatient clinic and at the

Table 4 Predictors of maternal and neonatal events

Predictors of maternal cardiovascular events Predictors of neonatal events Prior cardiac event (heart failure, transient ischaemic attack, stroke, arrhythmia)4,28,43,47,48 NYHA class III/IV or cyanosis during baseline pre-natal visit NYHA class III/IV29,42,43,48,49 Maternal left heart obstruction Left heart obstruction (moderate to severe)29,42 Smoking during pregnancy Reduced systemic ventricular systolic function (ejection fraction <40%)29,43,49 Low maternal oxygen saturation (<90%) Reduced subpulmonary ventricular function47,50(TAPSE <16 mm)49,51 Multiple gestations Use of anticoagulants throughout pregnancy Systemic atrioventricular valve regurgitation (moderate to severe)42 Cardiac medication before pregnancy

‘At birth’ cyanotic heart disease

Pulmonary atrioventricular valve regurgitation (moderate to severe)42 Mechanical valve prosthesis Pulmonary arterial hypertension43,48,49 Maternal cardiac event during pregnancy Cardiac medication before pregnancy42,46 Maternal decline in cardiac output during pregnancy Cyanosis (O2 saturation <90%)29,49 Abnormal uteroplacental Doppler flow

Natriuretic peptide levels (NT-proBNP >128 pg/mL at 20 weeks predictive of event later in pregnancy)42,46 Smoking history51 Mechanical valve prosthesis42,47 Repaired or unrepaired cyanotic heart disease42

Predictors identified in references29,35,42,43,51 NT-proBNP = N-terminal pro B-type natriuretic peptide; NYHA = New York Heart Association; TAPSE = tricuspid annular plane systolic excursion. Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026