Heart disease
In women with heart disease, left and right ventricular adaptation to pregnancy can be suboptimal and can lead to heart failure (HF) and atrial and ventricular tachyarrhythmias.
Acute heart failure algorithmPhysiology explorer
Haemodynamics [FIG]
| Cardiac output | rising |
|---|---|
| Plasma volume | rising |
| Heart rate | rising |
| Peripheral vascular resistance; diastolic and systolic BP | falling |
Figure 1, printed p4474 (curves of % change from pre-pregnancy; no values are read from them). Direction only.
Pregnancy induces physiological changes in the cardiovascular system to meet the increased metabolic needs of the mother and foetus (Figure 1). These changes occur from the early stages of pregnancy onward. Starting at 6 weeks of gestation, stroke volume and cardiac output (CO) increase by 30%–50%, and heart rate increases by 10–20 beats per minute. Peripheral vascular resistance decreases by 20%–50%.
§3.2, printed pp4473–4474 [TXT]
ECG [FIG]
- PR interval shortened
- Prominent Q wave
- Flattened/inverted T wave
Figure 1, printed p4474. The figure compares the normal ECG with the pregnancy ECG and prints no timing.
Pregnant women may present changes in their surface electrocardiogram (ECG), including increased heart rate, minor leftward QRS axis shift (15–20 degrees), slightly decreased (20 ms) PR interval, prominent Q waves in II, III, and aVF, and flat or inverted T-waves in III, aVF, V1, V2, and V3 (Figure 1).
§4.3.1, printed p4484 [TXT]
Major ischaemic ECG changes due to pregnancy itself are not expected (Figure 1).
§12.2.1.2, printed p4515 [TXT]
ECG changes, such as transient ST-segment depression and T-wave inversion can be normal during pregnancy, but a serum troponin rise suggests myocardial injury as in non-pregnant women. ST elevation is not normal in pregnancy and warrants urgent attention.
§12.2.1.2, printed p4515 [TXT]
Echocardiography [FIG]
Increased
- ↑ LA size and volume
- ↑ LVEDD
- ↑ LV mass
- ↑ RV basal and mid diameters
Small changes
- Small pericardial effusion
Unchanged
- Aortic root diameter
- LVEF
- RVEF
- SPAP
Figure 1, printed p4474
Physiological changes in cardiac geometry and functioning are expected during pregnancy (Figure 1).
§4.3.2, printed p4484 [TXT]
Why it matters §3.2, printed p4474 [TXT]
Arrhythmia
Atrial arrhythmias may develop in response to cardiac stretch and hormonal changes in pregnancy and may not be well tolerated in women with CVD.
Aortopathy
The haemodynamic and hormonal changes during pregnancy are risk factors for aortic dissection in women with aortopathy.
Aortopathy sliderThrombosis
Pregnancy is a hypercoagulable state associated with an increased risk of thromboembolism.
Pulmonary embolism algorithmDrugs
Increased activity of gastrointestinal–hepatic metabolism, liver enzyme systems, glomerular filtration rate and plasma volume, changes in protein binding, and decreased serum albumin levels all contribute to changes in the pharmacokinetics of many drugs.
Drug safety navigatorSource discrepancies and working choices (2)
- In Figure 1 the trough of the peripheral vascular resistance / blood pressure curve looks smaller than the text's 20%–50% fall in peripheral vascular resistance. The text's ranges are used for every number; the curve is described by direction only and no value is read from it.
- Figure 1 is drawn against trimesters, not weeks; the text's '6 weeks of gestation' and '∼6 weeks post-partum' are shown as printed.
Educational summary of the 2025 ESC Guidelines. It does not replace clinical judgement or local protocol.