ConditionHeart & circulation
Pregnancy With Heart Disease
Heart disease in pregnancy includes heart conditions present before pregnancy, such as congenital heart defects, valve disease and cardiomyopathy, and those that start during or after it, such as peripartum cardiomyopathy and preeclampsia-related heart strain. Pregnancy increases blood volume by about 40% to 50% and heart output by about 30% to 50%, which a weakened heart may not tolerate. Heart disease is now a leading cause of pregnancy-related death in the US. Planning before pregnancy and care from a cardio-obstetric team make most pregnancies safe.
Also called: Cardiac disease in pregnancy, maternal heart disease, cardio-obstetrics
At a glance
- Why it matters
- Pregnancy greatly increases the heart's workload, peaking in the second trimester and right after delivery.
- Higher-risk conditions
- Pulmonary hypertension, severe left heart valve narrowing, reduced heart function, Marfan with a dilated aorta, previous peripartum cardiomyopathy.
- Warning symptoms
- Breathlessness at rest or lying flat, chest pain, fainting, racing heart, sudden swelling.
- Care
- Pre-pregnancy counseling, cardio-obstetric team, medication review, planned delivery.
- Highest-risk time
- Late pregnancy, labor and the first weeks after birth.
When to get help
Call 911 or go to the ER
- Chest pain, severe shortness of breath, breathlessness lying flat, coughing up frothy or pink sputum
- Fainting, a racing or irregular heartbeat with dizziness, or a seizure
- Sudden severe headache, vision changes or confusion with high blood pressure
- Sudden one-sided leg swelling with chest pain or breathlessness
See a doctor within a day or two
- Breathlessness that is worsening or out of proportion to normal pregnancy
- Waking at night unable to breathe, or needing to sleep sitting up
- Blood pressure of 140/90 mm Hg or higher
- Rapid weight gain or swelling of the face and hands
Book a routine appointment
- Known heart disease and planning pregnancy, or newly pregnant (see a cardiologist early)
- Palpitations that come and go without other symptoms
Normal pregnancy changes vs warning signs
Pregnancy itself causes mild breathlessness, ankle swelling, tiredness, a faster heart rate and sometimes heart murmurs. These overlap with heart disease symptoms.
| Usually normal | Possibly heart disease |
|---|---|
| Mild breathlessness with exertion | Breathlessness at rest or getting rapidly worse |
| Ankle swelling late in the day | Swelling of face, hands or sudden severe swelling |
| Resting heart rate up 10 to 20 beats | Racing, irregular heartbeat, or fainting |
| Occasional skipped beats | Palpitations with dizziness or chest pain |
| Needing more pillows late in pregnancy | Waking up gasping for breath |
Heart conditions and pregnancy risk
Doctors use the modified WHO classification to estimate risk.
| Risk level | Examples |
|---|---|
| Lower | Small repaired septal defects, mild valve leaks, isolated extra beats |
| Moderate | Repaired tetralogy of Fallot, most arrhythmias, mildly reduced heart function, Marfan without aortic dilation |
| High | Mechanical heart valves, moderate mitral stenosis, Fontan circulation, unrepaired cyanotic heart disease |
| Very high (pregnancy often advised against) | Pulmonary hypertension, severe mitral or aortic stenosis, severely reduced heart function, Marfan syndrome with significantly dilated aorta, previous peripartum cardiomyopathy with ongoing weak heart |
Conditions that arise during pregnancy
- Peripartum cardiomyopathy: heart weakness developing in late pregnancy or in the months after delivery
- Preeclampsia and gestational hypertension, which strain the heart and raise long-term heart disease risk
- spontaneous coronary artery dissection, a cause of heart attack around pregnancy
- arrhythmias, which can appear or worsen
- blood clots in the legs and lungs
Planning a pregnancy with heart disease
- see a cardiologist and maternal-fetal medicine specialist before trying to conceive
- review medicines: some, such as ACE inhibitors, ARBs, sacubitril-valsartan, statins and warfarin (in higher doses), can harm the baby and may need switching
- assess heart function with an echocardiogram and, for some, exercise testing
- discuss the chance of passing on a congenital heart defect and fetal heart scanning
- plan effective contraception until pregnancy is advised
Care during pregnancy
- a cardio-obstetric team: obstetrician, cardiologist, anesthesiologist and neonatologist
- regular heart checks and echocardiograms
- blood pressure and fluid monitoring
- anticoagulation plans for mechanical valves and some arrhythmias
- fetal echocardiogram around 18 to 22 weeks if a parent has congenital heart disease
Labor and delivery
- vaginal delivery is preferred for most women with heart disease, often with an epidural to reduce heart strain and an assisted second stage
- cesarean section is used for obstetric reasons or certain high-risk conditions, such as a severely dilated aorta
- heart monitoring during labor
- delivery at a hospital equipped for cardiac care
After delivery
Fluid shifts after birth make the first days to weeks a high-risk time. Monitoring continues, and warning symptoms such as breathlessness, swelling or palpitations in the postpartum months need urgent attention. Breastfeeding is possible with most heart medicines. Women who had preeclampsia or peripartum cardiomyopathy should have long-term heart follow-up.
Frequently asked questions
Can you have a safe pregnancy with heart disease?
Yes, most women with heart disease can have a safe pregnancy with planning and specialist care. The level of risk depends on the specific condition and heart function. A few conditions carry such high risk that pregnancy is advised against.
What heart symptoms in pregnancy are not normal?
Breathlessness at rest or lying flat, waking up gasping, chest pain, fainting, a racing or irregular heartbeat with dizziness, coughing up frothy sputum and sudden severe swelling are not normal and need urgent medical assessment.
What is peripartum cardiomyopathy?
It is a weakening of the heart muscle that develops in the last month of pregnancy or within 5 months after delivery, without another cause. It causes heart failure symptoms such as breathlessness and swelling. Many women recover heart function with treatment.
Which heart medicines are unsafe in pregnancy?
ACE inhibitors, ARBs and sacubitril-valsartan can harm the baby's kidneys and are usually stopped. Statins are usually paused. Warfarin carries risks, especially early in pregnancy. Never stop a heart medicine without guidance; your team will switch you to safer alternatives.
Sources
This guide was written from current patient and clinical guidance, including:
- American College of Obstetricians and Gynecologists: Practice Bulletin 212, Pregnancy and heart disease
- American Heart Association: Cardiovascular considerations in caring for pregnant patients (scientific statement)
- European Society of Cardiology: Guidelines for the management of cardiovascular diseases during pregnancy
- CDC: Pregnancy Mortality Surveillance System
- World Health Organization: Modified WHO classification of maternal cardiovascular risk