Management of Acute Cardiovascular Complications in Pregnancy

Gabriele Egidy Assenza; Konstantinos Dimopoulos; Werner Budts; Andrea Donti; Katherine E. Economy; Gaetano Domenico Gargiulo; Michael Gatzoulis; Michael Job Landzberg; Anne Marie Valente; Jolien Roos-Hesselink


Eur Heart J. 2021;42(41):4224-4240. 

In This Article

Abstract and Introduction


The growing population of women with heart disease of reproductive age has been associated with an increasing number of high-risk pregnancies. Pregnant women with heart disease are a very heterogeneous population, with different risks for maternal cardiovascular, obstetric, and foetal complications. Adverse cardiovascular events during pregnancy pose significant clinical challenges, with uncertainties regarding diagnostic and therapeutic approaches potentially compromising maternal and foetal health. This review summarizes best practice for the treatment of common cardiovascular complications during pregnancy, based on expert opinion, current guidelines, and available evidence. Topics covered include heart failure (HF), arrhythmias, coronary artery disease, aortic and thromboembolic events, and the management of mechanical heart valves during pregnancy. Cardiovascular pathology is the leading cause of non-obstetric morbidity and mortality during pregnancy in developed countries. For women with pre-existing cardiac conditions, preconception counselling and structured follow-up during pregnancy are important measures for reducing the risk of acute cardiovascular complications during gestation and at the time of delivery. However, many women do not receive pre-pregnancy counselling often due to gaps in what should be lifelong care, and physicians are increasingly encountering pregnant women who present acutely with cardiac complications, including HF, arrhythmias, aortic events, coronary syndromes, and bleeding or thrombotic events. This review provides a summary of recommendations on the management of acute cardiovascular complication during pregnancy, based on available literature and expert opinion. This article covers the diagnosis, risk stratification, and therapy and is organized according to the clinical presentation and the type of complication, providing a reference for the practicing cardiologist, obstetrician, and acute medicine specialist, while highlighting areas of need and potential future research.

Graphical Abstract

Multidisciplinary and expert team ('pregnancy heart team') should be ideally involved early in the care of a pregnant woman presenting with an acute cardiovascular complication during gestation. Proposed staged approach to expedite risk stratification, diagnosis and management is summarised in the graphical abstract.


The number of pregnancies and deliveries in women with cardiovascular conditions has been growing for several decades, largely due to the increasing population of adults surviving with congenital heart disease (CHD) and the rising average age of pregnant women in developed countries.[1–3] Cardiovascular diseases are the most common cause of non-obstetric death during pregnancy,[4] whereas cardiac patients requiring emergency hospitalization during pregnancy (high dependency of intensive care, 6.4/1000 pregnancies) have a significant mortality of 5%.[5,6] There is limited evidence to guide the management of pregnant women with cardiovascular disease, with most data deriving from retrospective series or large international registries; therefore, expert opinion remains important in formulating clinical recommendations.[4,7]

Cardiovascular complications during pregnancy often occur outside tertiary referral centres and pose significant challenges to practitioners in cardiac and emergency medicine.[7] Our paper is aimed at practitioners who may encounter such patients in emergency, non-tertiary settings, and discusses the diagnosis and management of acute cardiovascular complications during pregnancy, based on expert opinion and best evidence (Graphical abstract).[4,7,8]