Pregnancy and structural cardiovascular disease

This dissertation explores the complex interaction between pregnancy and structural cardiovascular disease, a growing global health concern affecting up to 4% of all pregnancies and accounting for approximately 17% of maternal deaths. Using data from international registries, including ROPAC I–III, it analyses risk factors, outcomes, and management strategies among women with various cardiac conditions.

Part I examines pregnancy outcomes in specific cardiovascular disorders. Women with congenital heart defects, mechanical or bioprosthetic valves, and aortopathies demonstrate heterogeneous risks for maternal and neonatal complications. Pregnancies in women with Turner or Marfan syndrome were generally better tolerated than previously assumed, provided that multidisciplinary expert care was available. Pre-existing heart failure and prior aortic dissection were identified as major predictors of adverse outcomes.
Part II focuses on the use of cardiovascular medication during pregnancy and lactation. Diuretics appeared safe when clinically indicated, whereas ACE inhibitors and ARBs should be avoided due to teratogenicity. Furthermore, flecainide was shown to be safe during breastfeeding, based on plasma and breast milk concentration measurements.
Part III addresses acute and intensive obstetric care, including maternal ICU admissions, mechanical circulatory support, and emergency valve replacement during pregnancy. The added value of point-of-care ultrasound (POCUS) is highlighted for rapid bedside assessment of maternal and fetal conditions.

Overall, this dissertation underscores the importance of preconception counseling, individualized risk stratification, and management in specialized centers. Future research should focus on optimizing anticoagulation in women with mechanical valves, preventing pregnancy-related aortic dissections, and understanding the cardiovascular implications of fertility treatments.