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Pregnancy and the Heart: What Every Woman Should Know

Medically Reviewed & Edited

Board-Certified Invasive Cardiologist
Encinitas and La Jolla, CA

Developed with digital research and writing assistance, then medically reviewed and edited by Dr. Rasch to ensure clinical accuracy and adherence to current evidence-based guidelines.

You're pregnant, or you're hoping to be soon, and someone has told you your heart needs to be watched. Maybe you have a known condition. Maybe a family member had a scary pregnancy and you want to be ready. Maybe you're already months past delivery and your heart still doesn't feel right. Whatever brought you here, you deserve a clear conversation about what pregnancy does to the heart, what can go wrong, and what good care looks like.

I see women in clinic in every one of these situations. The pregnant patient with palpitations worried she's harming the baby. The new mom who can't lie flat six weeks after delivery. The 30-year-old with a repaired congenital defect asking if pregnancy is safe. The patient whose pregnancy was complicated by preeclampsia, hearing for the first time, two years later, that her lifetime heart risk is now higher. Every one of those conversations is worth having early and worth having well.

This article walks through the cardiovascular changes a normal pregnancy puts a body through, the heart conditions tied to pregnancy you should know about, what we do about heart medications when you're pregnant or breastfeeding, and how to think about preconception planning if your heart history is part of the story.

What Pregnancy Does to Your Heart in a Normal, Healthy Course

A healthy pregnancy is a major cardiovascular event. By the third trimester your blood volume has expanded by about 50 percent. Your heart is pumping more blood per minute than it ever has in your life. The blood vessels relax to make room for all that volume, so your blood pressure usually dips a bit in the middle of pregnancy before rising back toward your baseline near term. Your resting heart rate climbs by 10 to 20 beats per minute. The peak workload on your heart lands around weeks 28 to 32.

If you have a healthy heart going in, you handle this fine. You might notice your heart pounding when you climb stairs, or skipped beats more than you used to. Both are common and usually harmless. The same changes can strain a heart that has a leaky valve, a tight valve, a thickened muscle, or a previous repair. That's why we take the cardiac history seriously before pregnancy when we can.

Then there's labor and delivery. Each contraction sends an extra slug of blood back to your heart. Pain and adrenaline drive your heart rate up. Right after the baby is delivered, the uterus releases another big chunk of blood back into circulation, and your heart sees a sudden surge in workload. The first few days after delivery are when many women with underlying heart conditions actually decompensate, not during labor itself. Over the following weeks your body sheds the extra fluid through postpartum diuresis, and you slowly return toward your pre-pregnancy state.

Most women feel back to baseline by 6 to 12 weeks postpartum. If you don't, bring it up.

The Pregnancy Heart Conditions to Know About

A handful of heart problems are tied closely to pregnancy. Some show up during pregnancy, some after delivery, and some are unmasked by the demands of carrying a baby. Knowing the names and warning signs is the best thing a patient or family member can do.

Peripartum Cardiomyopathy (PPCM)

Peripartum cardiomyopathy is heart failure that shows up in the last month of pregnancy or within the first five months after delivery, in a woman with no known heart disease before. The heart muscle weakens, sometimes dramatically, and can't pump blood the way it should. In the United States it happens in roughly 1 in 1,000 to 1 in 4,000 pregnancies. The risk is higher in Black women, in women over 30, in women carrying twins, and in pregnancies complicated by preeclampsia or high blood pressure.

The tricky part is that early symptoms look a lot like normal late pregnancy or new-mom exhaustion. Shortness of breath while walking around. Trouble lying flat at night. Swollen ankles. A cough that won't quit. Feeling like you can't catch your breath after a flight of stairs. The mistake we don't want to make is shrugging off real heart failure as postpartum fatigue.

If you've had a baby in the last five months and any of those symptoms feel out of proportion, ask for an echocardiogram. It's a simple ultrasound of your heart and answers the question quickly. Treatment is the same as for other types of heart failure, with two adjustments. We avoid medications that aren't safe in pregnancy or breastfeeding. We watch closely for blood clots, because PPCM raises that risk.

A lot of women recover their heart function over the following 6 to 12 months, sometimes longer. Roughly half end up with full or near-full recovery. The rest have some lasting weakness in the heart muscle. Whether or not you can safely have another pregnancy after PPCM depends on whether your heart pump number returned to normal and stayed there. Women whose hearts fully recover still face a real risk of recurrence with another pregnancy. That's a conversation to have with a cardio-obstetrics team well before you try to conceive again.

A medication called bromocriptine is added to standard heart failure therapy for PPCM at some centers, mostly in Europe, based on a small trial showing faster recovery. It isn't standard practice across the United States and is best discussed in a center that has experience with it.

Preeclampsia and Eclampsia

Preeclampsia is high blood pressure that develops in the second half of pregnancy, usually with protein in the urine or signs of organ stress. It complicates 5 to 8 percent of pregnancies. Eclampsia is preeclampsia plus seizures, a true emergency. Most patients recognize preeclampsia from prenatal visits, swelling, a headache that won't go away, blurry vision, upper-belly pain. Your obstetrician manages the pregnancy side. My job is what comes next.

Here's what I want every woman who's had preeclampsia to know. Your lifetime cardiovascular risk roughly doubles. That's a lifelong, real change in your risk of heart attack, heart failure, and stroke compared with women who had normal-pressure pregnancies. The mechanism isn't fully understood. We think the same vascular biology that drove the preeclampsia tracks with long-term vascular risk in your blood vessels and kidneys.

This isn't about scaring you. It's about leveraging that information. A history of preeclampsia is one of the strongest, most usable risk markers we have in a young woman. Knowing about it lets us start lifestyle and medical prevention years before you'd otherwise show up on anyone's radar. That means blood pressure checks at every visit, a baseline cholesterol panel, attention to weight and exercise, screening for diabetes, and serious thought about a statin earlier than the standard age cutoff if your numbers and family history warrant it. The American Heart Association now lists pregnancy complications as a sex-specific cardiovascular risk factor that should change clinical decisions.

If you had preeclampsia, tell your primary care doctor. Tell every cardiologist you ever see. Don't let it disappear from your record after the postpartum visit.

Spontaneous Coronary Artery Dissection (SCAD)

Spontaneous coronary artery dissection, or SCAD, is a tear in the wall of a coronary artery that blocks blood flow to part of the heart muscle, causing a heart attack. The classic SCAD patient is a woman in her 40s or 50s without the usual heart-attack risk factors. The peripartum period, especially the first few weeks after delivery, is one of the highest-risk windows. Hormonal shifts of late pregnancy and the postpartum period appear to make the artery wall vulnerable.

If you're pregnant or recently postpartum and you have a sudden onset of chest pain, pressure, jaw or arm pain, severe shortness of breath, or a cold sweat, take it seriously. Go to the emergency department. Don't talk yourself out of it because you're young or your symptoms feel atypical. SCAD is a real cause of heart attack in women who otherwise look low-risk. The treatment differs from a typical heart attack, and getting to a center that recognizes SCAD matters.

If you've had SCAD, future pregnancies need a careful conversation. Recurrence risk in pregnancy is real. We don't have a number that fits every patient. The decision needs a cardiologist familiar with SCAD and an obstetrician working in concert.

Pregnancy with Congenital Heart Disease

Modern care has made it possible for many women with congenital heart conditions to have safe pregnancies. The risks vary widely depending on the specific defect, what was repaired, and how well the heart is functioning right now. A few situations deserve special attention.

Marfan syndrome and related connective tissue disorders carry a real risk of aortic tearing during pregnancy. The aorta, the main artery leaving the heart, is more vulnerable to dissection in late pregnancy and the postpartum period. If you have Marfan syndrome or a known aortic root that's enlarged, you need imaging before pregnancy and ongoing monitoring during it. The size of the aorta and the rate at which it's growing guide the decision about whether pregnancy is safe to attempt and how delivery should be managed. Some patients are told their aorta should be repaired before they try to conceive.

Mitral stenosis, a tight mitral valve usually from prior rheumatic fever, is one of the valve conditions that gets worse during pregnancy. The increased blood volume backs up behind the tight valve and can trigger heart failure, fluid in the lungs, and dangerous heart rhythms. Many of these patients did fine before pregnancy and decompensate sometime in the second or third trimester. If you have known mitral stenosis and you're planning pregnancy, get evaluated. We can sometimes open up the valve before pregnancy with a balloon procedure, which makes everything safer.

Other situations we worry about include severe aortic stenosis, severe pulmonary hypertension, single-ventricle physiology, prior PPCM with incomplete recovery, and a prosthetic mechanical heart valve. Each of these deserves an individualized plan made with a cardio-obstetrics team. The plan covers the pre-pregnancy workup, the monitoring during pregnancy, the choice of medications, the delivery plan, and what postpartum looks like.

Mechanical Heart Valves and Anticoagulation

If you have a mechanical heart valve, you need a blood thinner for life to keep the valve from clotting. Pregnancy makes this complicated. Warfarin, the older blood thinner, works well for the valve. It crosses the placenta and can harm the developing baby, especially in the first trimester. The newer injectable blood thinner, low molecular weight heparin (LMWH), doesn't cross the placenta but is harder to dose correctly to fully protect the valve, and there are reports of valve clots during pregnancy on heparin alone.

There's no perfect option. The choice depends on the type and position of your valve, the dose of warfarin you're on, and your own values. Some teams switch from warfarin to LMWH for the first trimester to avoid fetal harm and switch back to warfarin in the second and third trimesters. Some stay on LMWH the whole time. Some stay on warfarin the whole pregnancy. Each path has trade-offs that need to be discussed with a cardiologist, an obstetrician familiar with high-risk pregnancies, and a hematologist when needed. This is one of the situations where you want a center that does this regularly, not a generalist managing it alone.

The newer pill blood thinners (apixaban, rivaroxaban, dabigatran, edoxaban) are not approved for use in pregnancy and shouldn't be used in mechanical valve patients regardless.

Long-Term Heart Risk After Preeclampsia

I want to come back to this because it's the most under-recognized piece of cardio-obstetrics. A woman who had preeclampsia, especially severe or early-onset preeclampsia, has roughly twice the lifetime risk of cardiovascular disease as a woman who didn't. Several large studies have now confirmed this with long follow-up. Gestational diabetes, gestational hypertension without preeclampsia, preterm birth, and a baby small for gestational age also carry lower but real increases in long-term risk.

What does that mean in practice? You should make sure your primary care doctor and your cardiologist know about every pregnancy complication you've had. Your blood pressure should be measured at every visit, not just rounded off as "fine" when it sits at 130 over 85. Cholesterol should be checked early, in your 30s rather than waiting for 50. Diabetes screening should be on the calendar. Smoking, weight, sleep, and exercise should all get attention earlier than the standard schedules suggest. If risk factors stack up, statin therapy may be reasonable in your 40s rather than your 50s.

There's good news here. The interventions we have for cardiovascular prevention are the same whether your risk comes from family history, lifestyle, or pregnancy complications. Knowing about the elevated risk gives you and your team a head start, and a head start in cardiovascular medicine pays back over decades.

Heart Medications and Pregnancy: What's OK, What Isn't

Many women come in pregnant or hoping to be, already on a medication for blood pressure, rhythm, or heart failure. The first thing I'll say is don't stop your medication on your own. Some of these drugs need to be replaced before pregnancy. Some are fine to continue. Stopping cold turkey is rarely the right move.

Here's the broad picture for the medications I see most often.

ACE inhibitors and ARBs (lisinopril, losartan, valsartan and similar) are off the table during pregnancy. They can damage the developing kidneys in the second and third trimester and are associated with birth defects. Most women on these for blood pressure switch to a pregnancy-safe drug like labetalol, nifedipine, or methyldopa before trying to conceive or as soon as a pregnancy is recognized.

Beta-blockers are usually acceptable in pregnancy. Labetalol and metoprolol are the most commonly used. Atenolol has been linked to slower fetal growth and is usually avoided. If you're on a beta-blocker for arrhythmia or heart failure, we'll often continue it through pregnancy with monitoring.

Statins are usually held during pregnancy. The data on harm are limited and not as alarming as we used to think, and the standard practice is still to pause statins for the duration of pregnancy and resume after delivery, or after breastfeeding if you're nursing. If you have a very high-risk situation like familial hypercholesterolemia, the conversation gets more individualized.

Diuretics like furosemide are used carefully in pregnancy and only when the benefit clearly outweighs the risk. They can affect the placenta. Women in heart failure may still need them.

Spironolactone is avoided in pregnancy.

Amiodarone, a strong rhythm-control drug, is usually avoided in pregnancy because it affects the fetal thyroid. We use it only when nothing safer is working.

Aspirin low-dose (81 mg) is now recommended for women at increased risk of preeclampsia, started in the late first trimester. That's a positive for cardiovascular care. If your obstetrician hasn't brought it up and you have risk factors, ask.

The honest bottom line on medications is that most heart conditions can be managed safely in pregnancy with the right substitutions. The work happens before pregnancy, not after a positive test.

Breastfeeding and Heart Medications

Breastfeeding adds another layer. Many women want to nurse and are anxious about whether their heart medications are passing through into breast milk. The good news is that most cardiovascular drugs we commonly use are compatible with breastfeeding. The risks have been studied for many of them.

Among beta-blockers, metoprolol and propranolol are well tolerated in breastfed infants. Labetalol is acceptable. Atenolol concentrates in breast milk and is usually avoided in nursing mothers. ACE inhibitors are largely considered acceptable in breastfeeding for the older infant, with captopril, enalapril, and benazepril having the most reassuring data. Spironolactone is acceptable. Diuretics can suppress milk production in some women, which is a separate issue from infant safety.

For PPCM, the heart failure medications we'd choose first in a non-pregnant patient need adjustment in a nursing mother. Most teams can find a regimen that's safe for both mother and infant. If you're being told you need to stop breastfeeding because of heart medication, get a second opinion before you do. Many of the drugs in question are compatible with nursing.

A useful resource for any specific drug question is the LactMed database from the National Library of Medicine. It's free, it's regularly updated, and it lists what we know about every medication and breastfeeding.

Labor and Delivery for Women with Heart Conditions

A common misconception is that women with heart conditions need C-sections. For most heart conditions, vaginal delivery is actually preferred. The blood loss is usually less, the infection risk is lower, and the abrupt fluid shifts are smaller than they are in a planned C-section. The exceptions are specific. Women with severe aortic disease, women on uninterrupted warfarin near term, and a few other situations call for C-section. Most women with heart disease can plan a vaginal delivery with appropriate anesthesia and monitoring.

An epidural is friendly to the heart in most cardiac patients. It blunts the pain-driven adrenaline surges that can stress a vulnerable heart. The anesthesiologist needs the cardiac diagnosis to choose technique and dosing.

For some patients we shorten the pushing phase with assisted delivery using forceps or vacuum, to limit cardiac strain. The plan is made ahead of time with a team of obstetrics, cardiology, anesthesia, and sometimes maternal-fetal medicine.

The first 24 to 48 hours after delivery deserve close monitoring for women with heart disease. That's when the postpartum fluid shift hits and when many cardiac decompensations show up. Many high-risk patients are watched in a stepdown or ICU setting for that window.

Preconception Counseling: Who Needs It

Preconception cardiology referral isn't for every patient. It is for any patient who falls into these groups, ideally three to six months before trying to conceive:

A preconception visit covers what your heart looks like right now (an echo and ECG, sometimes more), what medications need to change, what the risk level looks like for your specific situation, and what monitoring schedule pregnancy will require. We talk through a delivery plan and which hospital is right for you. It's not a single visit, it's a relationship.

Cardio-obstetrics teams exist at many academic centers now. These are joint cardiology and maternal-fetal medicine clinics built for women like you. If you're in a region with one, it's worth the drive. The plan that comes out of a cardio-obstetrics visit is much more useful than the one cobbled together visit by visit through a regular OB and a regular cardiologist who don't talk to each other.

Red-Flag Symptoms in Pregnancy and Postpartum

A few symptoms in pregnancy or the months after delivery should never be brushed off as just pregnancy or just new-mom fatigue. If you have any of these, seek evaluation:

These symptoms can mean preeclampsia, peripartum cardiomyopathy, pulmonary embolism, SCAD, or aortic dissection. Each is treatable when caught early.

What to Ask Your OB and Cardiologist

If you have a heart history and you're pregnant or planning to be, here are the questions worth bringing in.

For your OB: Do I need a maternal-fetal medicine specialist on my team? Should I be on low-dose aspirin to lower preeclampsia risk? What's my plan if my blood pressure rises? At what week will we discuss delivery timing? Where will I deliver and is that hospital equipped for cardiac complications?

For your cardiologist: Do my current medications need to change before or during pregnancy? Should I have a baseline echo before trying to conceive? What's my risk category for this pregnancy? How often will you see me? What are the warning signs to watch for in my case? After delivery, when do I check in, and for how long?

For both: Will the two of you talk to each other directly? In my experience the patients who do best have a team where the OB and cardiologist actually communicate, share notes, and agree on a plan. If that isn't happening for you, ask why.

Frequently Asked Questions

I had preeclampsia three years ago. Do I really need to see a cardiologist?

A formal cardiology referral isn't required for every patient with prior preeclampsia. You should at least be having yearly visits with a primary care doctor who knows about it and is checking your blood pressure and cholesterol with that history in mind. If your blood pressure has crept up, your cholesterol is borderline, you have a family history of early heart disease, or you have other risk factors, a cardiology evaluation is reasonable.

I'm five weeks postpartum and short of breath when I walk up stairs. Is this normal?

Some shortness of breath in the first weeks after delivery can come from anemia, deconditioning, or normal recovery. Shortness of breath with mild activity, that lasts beyond a few weeks, that wakes you up at night, or that comes with a cough, leg swelling, or palpitations should be evaluated. An echocardiogram is quick and tells us a lot. Don't wait this out for months.

My mom died of an aortic dissection during pregnancy. Should I be tested?

Yes. A family history of aortic dissection, especially in pregnancy, raises the suspicion of an inherited connective tissue disorder like Marfan syndrome or a familial aortopathy. Genetic counseling and imaging of your aorta before any future pregnancy are both reasonable, and many centers have dedicated aortic clinics for exactly this kind of evaluation.

Can I exercise during pregnancy if I have a heart condition?

For most heart conditions, yes, with appropriate exercise. Walking, prenatal yoga, swimming, and stationary cycling are usually fine. The intensity needs to fit your condition and your trimester. Specific situations (severe aortic stenosis, severe pulmonary hypertension, certain arrhythmias, recent PPCM) may need exercise restriction. Ask your cardiologist for a specific answer rather than guessing from general pregnancy advice.

I'm 36 and on a statin. We want to start trying. What do I do?

Talk to your cardiologist before stopping. Most women hold the statin while trying to conceive and during pregnancy and breastfeeding. If your cardiovascular risk is very high (familial hypercholesterolemia, prior heart attack), the conversation may be different and more individualized. Plan it deliberately, don't drop the medication on your own.

Is it safe to breastfeed if I'm on heart medications?

Most cardiac medications are compatible with breastfeeding. Metoprolol, propranolol, labetalol, captopril, enalapril, benazepril, and many others have reassuring data. Atenolol is usually avoided. Amiodarone is avoided. The LactMed database is a good place to look up a specific drug, and your cardiologist or a lactation pharmacy specialist can help you decide.

I had peripartum cardiomyopathy two years ago and my pump function recovered. Can I have another baby?

Maybe. Recovery of pump function lowers the risk of a serious complication in another pregnancy and doesn't eliminate it. Many women whose hearts fully recovered have done well with another pregnancy. Some have had recurrence. The decision needs a cardiology evaluation that includes a stress test or stress echo, and a cardio-obstetrics team that can monitor you closely if you go forward. Don't assume the answer is no, and don't assume it's an automatic yes.

References

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4. Roos-Hesselink, Jolien W., Lucia Baris, Mark R. Johnson, et al. "Pregnancy Outcomes in Women with Cardiovascular Disease: Evolving Trends over 10 Years in the ESC Registry of Pregnancy and Cardiac Disease (ROPAC)." European Heart Journal 40, no. 47 (2019): 3848-3855.

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7. Hayes, Sharonne N., Esther S. H. Kim, Jacqueline Saw, et al. "Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association." Circulation 137, no. 19 (2018): e523-e557.

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9. American College of Obstetricians and Gynecologists' Presidential Task Force on Pregnancy and Heart Disease. "ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease." Obstetrics & Gynecology 133, no. 5 (2019): e320-e356.

10. Sliwa, Karen, Denise Hilfiker-Kleiner, Mark C. Petrie, et al. "Current State of Knowledge on Aetiology, Diagnosis, Management, and Therapy of Peripartum Cardiomyopathy: A Position Statement from the Heart Failure Association of the European Society of Cardiology Working Group on Peripartum Cardiomyopathy." European Journal of Heart Failure 12, no. 8 (2010): 767-778.

11. Halpern, Dan G., Catherine R. Weinberg, Robert Pinnelas, Shilpi Mehta-Lee, Katherine E. Economy, and Anne Marie Valente. "Use of Medication for Cardiovascular Disease During Pregnancy: JACC State-of-the-Art Review." Journal of the American College of Cardiology 73, no. 4 (2019): 457-476.

12. Drugs and Lactation Database (LactMed). National Library of Medicine, National Institutes of Health. https://www.ncbi.nlm.nih.gov/books/NBK501922/.

Published on damianrasch.com. The above information was composed by Dr. Damian Rasch, drawing on individual insight and bolstered by digital research and writing assistance. The information is for educational purposes only and does not constitute medical advice.