Cardiovascular Conditions in Pregnancy: Diagnosis, Risks, and Management

Abstract

Pregnancy places unique demands on the cardiovascular system, increasing blood volume, cardiac output, and hormonal stress. For some women, these changes reveal pre-existing heart conditions or cause new, pregnancy-specific disorders. This paper explores key cardiovascular conditions that emerge or worsen during pregnancy—such as hypertensive disorders, peripartum cardiomyopathy, arrhythmias, and congenital heart disease—highlighting the pathophysiology, diagnosis, management strategies, and maternal health implications. The focus includes African populations where diagnostic challenges, limited obstetric cardiology services, and late referrals contribute to high maternal morbidity and mortality.

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Introduction

Cardiovascular disease (CVD) is a leading cause of maternal mortality worldwide, with disproportionate impacts in Sub-Saharan Africa due to late diagnosis and limited access to specialized care (Say et al., 2014). Pregnancy-related cardiovascular complications can be life-threatening if unrecognized. Physiological changes—including a 40–50% increase in blood volume and increased cardiac workload—can unmask underlying heart disease or trigger new conditions.

Pregnancy-related cardiac conditions are a major cause of indirect maternal deaths (non-obstetric), particularly where pre-pregnancy screening is minimal. This paper presents common cardiovascular diseases developed or exacerbated during pregnancy, their mechanisms, clinical presentations, and management pathways relevant to African and global settings.

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1. Hypertensive Disorders of Pregnancy (HDP)

💡 Includes:

• Gestational Hypertension
• Preeclampsia / Eclampsia
• Chronic Hypertension with Superimposed Preeclampsia

🔬 Pathophysiology:

Abnormal placentation leads to systemic endothelial dysfunction, vasospasm, and increased afterload. This raises maternal BP and causes organ damage (especially kidney, brain, liver).

🩺 Key Symptoms:

• High blood pressure (≥140/90 mmHg after 20 weeks)
• Proteinuria, edema, visual changes
• Seizures in eclampsia

🧠 Cardiac Impact:

• Left ventricular dysfunction
• Increased risk of future CVD and stroke

📊 Africa Data:

Preeclampsia accounts for up to 25% of maternal deaths in some African hospitals (Nkoke et al., 2020).
DOI: 10.1016/j.ijgo.2020.07.019

🩺 Management:

• Magnesium sulfate for eclampsia prevention
• Labetalol, hydralazine, nifedipine as antihypertensives
• Timely delivery if severe and near term

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2. Peripartum Cardiomyopathy (PPCM)

🧬 Definition:

A form of heart failure that occurs in the last month of pregnancy or up to 5 months postpartum, without another identifiable cause.

🔬 Pathophysiology:

Thought to involve inflammatory, hormonal, and oxidative stress mechanisms. Prolactin cleavage and myocarditis may contribute.

🩺 Symptoms:

• Fatigue, dyspnea, orthopnea
• Lower limb edema, palpitations
• Can mimic normal pregnancy discomforts

🧠 Cardiac Findings:

• Dilated left ventricle, reduced ejection fraction (≤45%)
• Global hypokinesis on echocardiogram

🌍 Africa Perspective:

Highest rates reported in Nigeria, South Africa, and DRC (0.1–1% of pregnancies). Delayed diagnosis and cultural beliefs around rest or postpartum seclusion worsen outcomes (Sliwa et al., 2017).
DOI: 10.1093/eurheartj/ehx764

🩺 Treatment:

• Diuretics, ACE inhibitors (postpartum), beta-blockers
• Bromocriptine (experimental in Africa)
• Avoid further pregnancies if severe dysfunction persists

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3. Congenital Heart Disease (CHD) in Pregnant Women

💡 Common Conditions:

• Atrial/ventricular septal defects
• Tetralogy of Fallot (repaired/unrepaired)
• Eisenmenger’s syndrome (contraindicates pregnancy)

🔬 Pathophysiology:

Hemodynamic changes in pregnancy can exacerbate left-to-right shunts, cause cyanosis, or increase pulmonary pressures.

🩺 Risks:

• Arrhythmias
• Hypoxia
• Sudden cardiac death

🌍 Africa Context:

Many women with CHD reach reproductive age undiagnosed due to lack of early screening or cardiac surgery access. In Kenya and Ghana, adult congenital heart clinics are still rare.

🩺 Management:

• Pre-pregnancy echocardiogram
• Multidisciplinary care (cardio-obstetric team)
• Vaginal delivery preferred if hemodynamically stable

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4. Arrhythmias and Conduction Disorders

⚡ Common Types:

• Supraventricular tachycardia (SVT)
• Atrial fibrillation
• Long QT syndrome (may worsen postpartum)

🔬 Causes:

Increased adrenergic tone, anemia, electrolyte imbalances, and heart strain.

🩺 Symptoms:

• Palpitations
• Dizziness, syncope
• Chest discomfort

🩺 Management:

• Beta-blockers (metoprolol or labetalol)
• Adenosine for acute SVT
• Cardioversion in emergencies
• Avoid QT-prolonging medications

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5. Rheumatic Heart Disease (RHD) in Pregnancy

🌍 African Burden:

RHD is still common in rural African women due to untreated streptococcal infections in childhood.

🧬 Cardiac Involvement:

• Mitral stenosis or regurgitation
• Heart failure risk with pregnancy volume load

🩺 Management:

• Monthly penicillin prophylaxis
• Diuretics, beta-blockers for heart failure
• Valve surgery ideally pre-pregnancy

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6. Risk Factors for Poor Outcomes

• Age >35 or teenage pregnancy
• Obesity, diabetes
• Pre-existing hypertension or heart disease
• Multiple pregnancies (twins/triplets)
• Delayed ANC visits or rural residence

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WHO and FIGO Recommendations

• Early risk screening during ANC
• Establish cardio-obstetric units at referral hospitals
• Educate health workers to differentiate normal vs. pathological pregnancy symptoms
• Refer promptly to specialized care for women with heart murmurs, unexplained breathlessness, or edema

WHO Maternal Health Resources:
https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/maternal-health

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Conclusion

Pregnancy can unmask or exacerbate cardiovascular conditions, many of which are preventable or manageable with early diagnosis and multidisciplinary care. In African contexts, where CVD-related maternal deaths remain high, community awareness, risk-based ANC, and training frontline providers in cardio-obstetrics are urgently needed. Investing in integrated maternal–cardiac care could dramatically improve both maternal and infant outcomes.

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References

Nkoke, C., et al. (2020). Hypertensive disorders of pregnancy in Africa: A systematic review. International Journal of Gynecology & Obstetrics, 150(1), 1–9. https://doi.org/10.1016/j.ijgo.2020.07.019

Say, L., et al. (2014). Global causes of maternal death: A WHO systematic analysis. The Lancet Global Health, 2(6), e323–e333. https://doi.org/10.1016/S2214-109X(14)70227-X

Sliwa, K., et al. (2017). Peripartum cardiomyopathy: An African perspective. European Heart Journal, 38(34), 2741–2750. https://doi.org/10.1093/eurheartj/ehx764

World Health Organization. (2023). Maternal health and cardiovascular disease. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality