Society for Maternal‐Fetal Medicine Special Statement: Checklists for triage and work‐up of persons with symptoms suggestive of cardiovascular disease in pregnancy and postpartum

Abstract

Maternal cardiovascular disease is a leading cause of pregnancy‐related death in the United States. Symptoms associated with cardiovascular disease include shortness of breath, palpitations, dizziness, syncope, chest pain, edema, and fatigue. Unfortunately, these symptoms are nonspecific and are common in pregnancy and postpartum. When a pregnant or postpartum person reports any of these symptoms, the provider needs a systematic approach to evaluate whether further work‐up and consultation are needed or whether the patient can be reassured that the symptoms are likely “normal for pregnancy.” The Society for Maternal‐Fetal Medicine presents a checklist for triage of patients who report these symptoms and a checklist outlining the initial work‐up of those who need further evaluation.

1. HYPOTHETICAL CASE SCENARIO

A 32‐year‐old primigravida is diagnosed with preeclampsia without severe features at 38 weeks of gestation and undergoes induction of labor and vaginal delivery. After an uneventful recovery, she is discharged from the hospital on postpartum day 2 with a follow‐up appointment scheduled for 1 week.

On postpartum day 5, she calls the provider's advice nurse, reporting unusual fatigue and shortness of breath when walking up the stairs at home. She has no headache, visual change, epigastric pain, or edema. The nurse provides reassurance that her symptoms are common in the postpartum period.

On postpartum day 6, she presents to an urgent care clinic complaining of worsening shortness of breath and a nonproductive cough when lying down. Her temperature is 37.4°C (99.3°F), blood pressure 134/82 mmHg, pulse 86 bpm, respiratory rate 24 breaths/min, and oxygen saturation 96%. On auscultation, heart sounds are normal, and there are bilateral lower lung crackling sounds. There is mild pretibial edema. The presumptive diagnosis is upper respiratory infection, and she is sent home with advice to follow up with her primary physician or obstetrician.

On postpartum day 7, she collapses at home and is taken by ambulance to the hospital, where her heart rate is 20 bpm and she is unresponsive. Attempts at resuscitation are unsuccessful. Autopsy concludes that her death was caused by severe dilated cardiomyopathy.

2. INTRODUCTION

Maternal cardiovascular disease (CVD) is a leading cause of pregnancy‐related death in the United States [1, 2]. Up to half of deaths from cardiovascular events in pregnancy and postpartum are considered potentially preventable [3, 4, 5].

Most pregnancy‐related CVD deaths occur in people with no prior history of CVD and no findings suggestive of CVD at the initial prenatal visit. In a series of 64 pregnancy‐related CVD deaths, CVD was known before pregnancy in only 3% and was diagnosed in the prenatal period in 8%, intrapartum in 6%, and postpartum in 34%; remarkably, the diagnosis of CVD was not made until postmortem in 48%, highlighting the importance of timely diagnosis when pregnant or postpartum people with no history of CVD present with new‐onset symptoms [6]. Failure to recognize symptoms, delay in diagnosis, and delay in referral are frequent contributors to preventable death from CVD [2, 7]. These failures may be worsened by racial biases that affect provider interpretation of reported symptoms and by barriers such as language, insurance coverage, and other social drivers of health.

Toolkits, guidelines, and bundles for CVD screening and management have been presented by the California Maternal Quality Care Collaborative (CMQCC) [8], the American College of Obstetricians and Gynecologists (ACOG) [9], and the Alliance for Innovation on Maternal Health (AIM) [10]. These resources all recommend screening pregnant persons for CVD based on history and exam findings at the initial prenatal visit. However, recognizing that most persons who develop pregnancy‐related CVD do not have findings at the initial visit, the documents also emphasize the importance of recognizing and acting upon new‐onset symptoms, a theme that is echoed by the HEAR HER Campaign of the Centers for Disease Control and Prevention (CDC) [11].

Symptoms that suggest possible CVD include shortness of breath, palpitations, dizziness, syncope, chest pain, edema, and fatigue. Each of these symptoms occurs so commonly in pregnant and postpartum persons that providers are often tempted to dismiss them as “normal for pregnancy.” While this avoids the expense and inconvenience of a thorough cardiovascular work‐up that will most often be negative, it also poses the risk of missing a diagnosis of significant CVD. Clearly, providers need to be able to determine when symptoms warrant further work‐up and when they can be considered benign.

The CMQCC toolkit [8] includes a list of seven “red flags” that should trigger hospitalization or prompt evaluation, including consultation with maternal‐fetal medicine, cardiology, or primary care. The ACOG guidelines [9] and AIM bundle [10] include tables based on symptom severity to guide recommendations for reassurance, caution, or prompt evaluation by a pregnancy heart team. The CMQCC toolkit [8] and ACOG guidelines [9] include flowchart algorithms that combine symptoms, risk factors, vital signs, auscultation findings, diagnostic studies, and follow‐up. A limitation of these tools is that they are spread across separate pages in lengthy documents (134 pages [8], 36 pages [9], and 11 pages [10], respectively), making them difficult to access and use efficiently.

In this article, we present a simple one‐page checklist that integrates the tools provided by CMQCC, ACOG, and AIM to triage pregnant and postpartum persons who report symptoms suggestive of CVD. The “bottom line” of this checklist is a recommendation regarding which patients should have further work‐up and which can be reassured. We present another checklist outlining key elements of the initial cardiovascular work‐up if needed.

3. CHECKLIST FOR TRIAGE OF SYMPTOMS

Figure 1 presents a checklist for triaging patients who report symptoms suggestive of possible CVD. All pregnant persons should be screened for CVD at the initial prenatal visit, and patients who screen positive should be referred for appropriate team management by experts in cardiology and maternal‐fetal medicine, as outlined in depth in the CMQCC, ACOG, and AIM documents. The triage checklist presented here is intended for the 97% of pregnant persons who do not have known CVD and who later present with CVD symptoms.

FIGURE 1.

Checklist for triage of symptoms suggestive of possible cardiovascular conditions during pregnancy or postpartum [8, 9, 10]. Version date: October 2025. Based on CMQCC toolkit [8], ACOG guidelines [9], and AIM bundle [10]. ^aBlack or African American race as a risk factor for cardiovascular disease may be a reflection of racism rather than a genetic or biologic predisposition.

The trigger to start this checklist is a spontaneous report by the patient of any listed symptoms. If a patient reports any of these, the entire checklist should be reviewed. We do not recommend routinely asking patients about these symptoms during regular visits as part of the review of systems. This is because a patient who answers “yes” to a screening question is probably less likely to have an underlying cardiovascular condition than a patient who reports the same symptom without prompting.

The checklist specifies recommended actions based on the number and severity of signs and symptoms elicited. Certain findings are classified as “red flags,” which should trigger further evaluation if any one of them is present. Otherwise, the checklist recommends additional work‐up if one box is checked in each category (symptoms, risk factors, exam findings) or if four or more total boxes are checked. The recommended work‐up is consistent with a recent cardio‐obstetrics expert opinion [12].

4. CHECKLIST FOR WORK‐UP

Figure 2 presents a checklist outlining the initial work‐up of patients for whom work‐up is recommended according to Figure 1. The basic work‐up includes laboratory tests, cardiac imaging, and heart monitoring, depending on the indications outlined. These basic elements of cardiovascular evaluation should all be readily available in inpatient and outpatient settings.

FIGURE 2.

Suggested work‐up for patients with findings concerning for cardiovascular disease during pregnancy or postpartum [8, 9, 10]. Version date: October 2025. Based on CMQCC toolkit [8], ACOG guidelines [9], and AIM bundle [10]. BMI, body mass index; BNP, B‐type natriuretic protein; ECG, electrocardiogram.

Relevant laboratory studies include B‐type natriuretic peptide (BNP) or N‐terminal‐proBNP (NT‐proBNP). These hormones are released in response to cardiac strain and have high sensitivity for the detection of heart failure. Either one may be ordered, depending on availability in the local laboratory; it is not necessary to order both. Both BNP and NT‐pro‐BNP are mildly elevated in normal pregnancy owing to physiologic cardiac enlargement and may be further mildly elevated with preeclampsia [12]. False‐negative BNP may occur in obese persons [13].

Troponin I, troponin T, and “high sensitivity” troponin are sensitive and specific markers of myocardial injury [9]. Chest pain is an indication to order one of these tests, depending on which one is available in the local laboratory. Troponin I may be mildly elevated postpartum in patients with preeclampsia [14].

Blood counts and chemistries, arterial blood gas, urine drug testing, and thyroid stimulating hormone level can be helpful in identifying noncardiac etiologies of symptoms or other organ system involvement. To respect patient autonomy and reduce racial disparities, substance use testing requires informed consent that includes potential consequences of a positive result and implications of declining [15].

Consultation with maternal‐fetal medicine and cardiology may be indicated if there are abnormal test results. For communities that do not have specialists available, telemedicine consultation can be considered. In‐person consultation with an internal medicine specialist or other primary care provider may be another alternative.

5. SUGGESTIONS FOR IMPLEMENTATION

One value of checklists is that they minimize the chance of errors of omission that might occur if a provider relies on memory alone to evaluate all the items. We believe the checklists will be most effective if kept close at hand and completed item‐by‐item when a patient presents with symptoms, even if the provider has performed the checklist many times and believes they have memorized it. Checklists also help to standardize care, thereby reducing variability, implicit bias, disparity, and inequity.

A simple method for operationalizing the checklists would be to copy them both onto letter‐sized paper sheets and laminate them together, front‐to‐back, into a single item that can be kept handy in exam rooms or at providers’ desks. This solution would be most useful for obstetrical hospital units and outpatient offices. However, it would be difficult to implement in emergency departments, urgent care centers, primary care offices, and other settings where obstetrical patients are relatively infrequent but may present with cardiovascular symptoms.

Alternatively, a facility might consider integrating the checklists into the electronic health record (EHR) system. This will have the advantage of making the tools readily available to both obstetrical and nonobstetrical providers. It would prevent the checklists from getting lost, a common hazard for paper forms. It might be possible to program the EHR to automatically trigger the triage checklist when one of the relevant symptoms is recorded in a pregnant or postpartum person and to bring up a cardiovascular order set when indicated by the triage checklist. However, modifying an EHR is a complex process requiring both clinical and technical expertise. The SMFM Informatics Committee works with some major EHR vendors to incorporate SMFM patient safety checklists into their systems, but the process typically takes a year or more. In the meantime, the paper solution might be best.

6. CRITIQUE OF HYPOTHETICAL CASE

Application of the triage checklist (Figure 1) for the case presented at the beginning of the article would have resulted in four boxes being checked for “concerning findings” (dyspnea with activity, pregnancy‐related hypertension [preeclampsia during the delivery admission and stage 1 hypertension in the postpartum urgent care visit], respiratory rate 24–29 breaths/min, and oxygen saturation 95%–96%) and the box for crackles (rales) being checked in the “red flags” column. A work‐up should have been recommended. With dilated cardiomyopathy, it is likely that electrocardiogram and BNP would have been abnormal, and therefore an echocardiogram would have been recommended, which would have led to the diagnosis. This death may have been preventable if the checklists had been used and if the indicated work‐up had been undertaken.

7. CONCLUSIONS

The symptom triage checklist (Figure 1) should simplify the evaluation of patients who report symptoms that may be associated with CVD. The initial work‐up checklist (Figure 2) provides a guide to additional tests and consultations to obtain for persons who screen positive on the triage checklist. Consistent application of these checklists should improve the detection and initial management of CVD in pregnant and postpartum persons.

8.

The use of this information is voluntary, and clinicians should be familiar with and comply with all applicable laws and regulations.

All authors and committee members have filed a disclosure of interests delineating personal, professional, business, or other relevant financial or nonfinancial interests in relation to this publication. Any substantial conflicts of interest have been addressed through a process approved by the Society for Maternal‐Fetal Medicine (SMFM) Board of Directors. SMFM has neither solicited nor accepted any commercial involvement in the specific content development of this publication.

This document has undergone an internal peer review through a multilevel committee process within SMFM. This review involves critique and feedback from the SMFM Patient Safety and Quality Committee and Document Review Committee and final approval by the SMFM Executive Committee. SMFM accepts sole responsibility for the document content. SMFM publications do not undergo editorial and peer review by Pregnancy. The SMFM Patient Safety & Quality Committee reviews publications every 24 to 36 months and issues updates as needed.

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