Acute cardiovascular complications of pregnancy

Cardiovascular disease (CVD) is the leading cause of maternal morbidity and mortality, accounting for over one-third of pregnancy-related maternal deaths. In 2017, the World Health Organization estimated that there were nearly 295,000 maternal deaths globally, with a maternal mortality rate of 211 per 100,000 live births. [1] Rising rates have been linked to increasing chronic conditions such as obesity, diabetes, and heart disease, delayed childbearing, higher cesarean delivery rates, the opioid epidemic, and persistent gaps in access to maternal care. [2] Notably, up to 68 % of pregnancy-related CVD deaths are considered preventable, underscoring the urgent need for early recognition and intervention. [1]

The physiological adaptations of pregnancy begin as early as six weeks of gestation and persist through to delivery. To support fetal development and maintain adequate utero-placental perfusion, the maternal cardiovascular system undergoes a hyperdynamic shift. Heart rate increases by 15–25 %, stroke volume rises by 20–30 %, and cardiac output increases by 30–50 %, while systemic vascular resistance decreases by approximately 30 %. [3] Pregnancy is also marked by hypercoagulability, with increased clotting factors, reduced fibrinolysis, and physiologic hemodilution, all of which predispose to thromboembolic events. [3] While most individuals adapt without complication, these changes may unmask previously undiagnosed cardiac disease or precipitate acute cardiovascular events, particularly in those with risk factors such as hypertension, diabetes, obesity, or advanced maternal age (>35 years).

This editorial focuses on acute cardiovascular emergencies that develop during pregnancy or in the postpartum period, including pregnancy-associated myocardial infarction (MI), pregnancy-related spontaneous coronary artery dissection (P-SCAD), peripartum cardiomyopathy (PPCM), arrhythmias, and cardiopulmonary arrest. These conditions often arise suddenly in otherwise healthy individuals and require rapid recognition and multidisciplinary management to optimize maternal and fetal outcomes. [4]

Pregnant individuals are three to four times more likely to experience acute MI compared with their nonpregnant counterparts. [5] Although rare, MI is a life-threatening event with an estimated incidence of 0.6 to 1.0 per 10,000 pregnancies and accounts for more than 20 % of maternal cardiac deaths. Risk is highest in the third trimester and early postpartum period and increases with maternal age and parity. [5] Etiologies include atherosclerotic coronary artery disease, coronary thrombosis, MI with nonobstructive coronary arteries, and P-SCAD. [5] Complications range from heart failure and arrhythmias to cardiogenic shock and maternal death. In all cases, care should be guided by a multidisciplinary pregnancy heart team composed of cardiologists, maternal-fetal medicine specialists, anesthesiologists, and obstetric nurses, with maternal stabilization taking priority. [5]

The most common cause of pregnancy-associated MI is P-SCAD, accounting for more than 40 % of cases, with an estimated incidence of 1.81 per 100,000 pregnancies. P-SCAD is a dissection or tear in the wall of the coronary artery that occurs during pregnancy or early postpartum. This tear allows blood to enter the vascular wall, forming a false lumen which then narrows or completely restricts blood flow to the heart. [6] It typically presents with sudden-onset chest pain in otherwise healthy women and is often more severe than non-pregnancy SCAD, with higher rates of ST-segment elevation MI, greater likelihood of multivessel or left-main involvement, and more frequent reductions in left ventricular function. [6] Without prompt recognition, it can lead to rapid hemodynamic compromise and fatal arrhythmias.

Another major cardiovascular complication of pregnancy is PPCM, which is a form of heart failure with reduced ejection fraction that typically presents in the final month of pregnancy or within the first five months postpartum. [7] It may develop in women with preexisting cardiac disease or present de novo, with left ventricular ejection fraction <30 % predicting worse outcomes. PPCM accounts for over 9 % of in-hospital maternal deaths among pregnancy-related hospitalizations, with overall mortality estimated at roughly 4 % in high-income countries and up to 14 % in low-income countries. [7] Symptoms often mirror normal pregnancy changes such as shortness of breath or fatigue, leading to underrecognition and delayed diagnosis. The cause is multifactorial and remains incompletely understood, but risk is strongly associated with hypertensive disorders of pregnancy, particularly pre-eclampsia, which is present in approximately one-third of PPCM cases. Other risk factors include multiple gestation, chronic or gestational hypertension, gestational diabetes, obesity, diabetes, chronic kidney disease, and hyperlipidemia. [7]

Arrhythmias in pregnancy range from supraventricular tachycardia to atrial fibrillation, with an incidence of 68–166 per 100,000 pregnancy-related hospitalizations. Individuals with a prior history of arrhythmias are at increased risk of recurrence during pregnancy due to increased sympathetic tone and expanded intravascular volume. [8] A 10-year review of maternal cardiovascular deaths found arrhythmias to be the immediate or underlying cause in more than 10 % of cases. [8] Antiarrhythmic therapy should be selected carefully, weighing efficacy against potential teratogenicity and fetal effects. Agents such as flecainide, sotalol, quinidine, procainamide, and lidocaine are considered relatively safe in pregnancy, while amiodarone is reserved for life-threatening refractory arrhythmias. In addition, urgent electrical cardioversion can be performed in cases of hemodynamic instability or concern for fetal perfusion. [9]

Cardiopulmonary arrest is one of the most challenging obstetric emergencies, with an incidence of 13.4 per 100,000 delivery-related hospitalizations and a case fatality rate of over 30 %. [10] It often develops abruptly, in previously healthy women, and can be associated with hemorrhage, amniotic fluid embolism, cardiomyopathy, pregnancy-associated MI, or sepsis. [10] The rising incidence of maternal cardiac arrest may be related to the increasing prevalence of risk factors such as hypertensive disorders of pregnancy, preexisting heart disease, and severe obstetric hemorrhage.

Acute cardiovascular complications of pregnancy range from MI and P-SCAD to PPCM, arrhythmias, and cardiopulmonary arrest and represent a leading and often preventable causes of maternal morbidity and mortality. Their sudden onset in otherwise healthy individuals underscores the importance of early recognition and timely intervention. A multidisciplinary medical team approach remains essential to optimizing outcomes for both mother and fetus. As maternal risk factors continue to rise, preventive strategies will be critical to reversing current trends and improving the cardiovascular health of pregnant and postpartum individuals.

Contributors

The two authors contributed equally to the manuscript.

Both authors approved the final submitted manuscript.

Provenance and peer review

This editorial was commissioned and not externally peer reviewed. Chrisandra Shufelt, an editorial board member of Case Reports in Women's Health, was not involved in editorial consideration of the manuscript and was blinded to the process.

Funding

No funding from an external source supported the publication of this editorial.

Declaration of competing interest

The authors declare that they have no competing interest regarding the publication of this editorial.