Structured evaluation of maternal cardiac disease BETA
This wizard combines modified WHO pregnancy risk class, NYHA functional class, lesion-specific maternal risk, an SMFM pregnancy/postpartum cardiovascular symptom triage card, a lesion-specific management card, an aortic disease mini-panel, and stage-based antepartum, intrapartum, and postpartum planning.
It includes a dedicated Long QT syndrome evaluation and management section, a QT-prolonging medication alert list, an SMFM checklist-based symptom work-up pathway, and auto-generated mWHO / delivery location banners after lesion selection.
Urgent hospital-based evaluation
- Dyspnea at rest, orthopnea, pulmonary edema, syncope, chest pain, cyanosis, hemoptysis, new sustained arrhythmia
- Hypoxemia, hypotension, rapid edema/weight gain, severe tachycardia, or clear worsening heart failure symptoms
- Suspected peripartum cardiomyopathy, pulmonary hypertension crisis, significant stenotic lesion decompensation, torsades, or aortic syndrome
Daily-use principles
- mWHO is lesion-based baseline risk.
- NYHA is current functional burden.
- Symptoms, EF, RV function, oxygenation, PH, aortic disease, and arrhythmia history may shift practical risk upward.
- Postpartum is often the highest-risk window for heart failure, pulmonary vascular disease, Long QT events, and aortic complications.
Useful delivery defaults
- Vaginal delivery is preferred in many stable patients.
- Early neuraxial analgesia is often beneficial.
- Avoid fluid overload and abrupt hemodynamic change.
- Cesarean is usually for obstetric indication or a specific cardiac indication.
Start here
Choose the quickest entry point for everyday clinical use
Start by selecting symptoms or a known cardiac lesion.
No pathway selected yet
🔴 New symptoms
Dyspnea, chest pain, palpitations, syncope, edema/crackles, or fatigue out of proportion to routine pregnancy symptoms.
🟡 Known cardiac disease
Known lesion, inherited arrhythmia syndrome, cardiomyopathy, valve disease, PH, Fontan, aortopathy, or mechanical valve.
🟢 Routine risk assessment
Asymptomatic or nonspecific symptoms with risk factors only. Enter the lesion if known; otherwise use SMFM as a safety screen.
Clinical workflow quick guide
- Step 1: Decide whether this is primarily a symptom problem, a known-lesion management problem, or both.
- Step 2: If symptoms are spontaneous or seem out of proportion, open the SMFM symptom triage section first.
- Step 3: If a lesion is known, enter lesion, NYHA, EF, oxygenation, RV/PH status, and aortic features.
- Step 4: Click Calculate plan. The higher-acuity pathway should drive disposition.
- Step 5: Use the EMR summary as your starting draft, then customize to the patient.
Interactive wizard
Step 1
Patient and lesion profile
Use this row for the existing lesion-based risk engine. The SMFM checklist below is for spontaneous pregnancy/postpartum cardiopulmonary symptoms and can be used even when no lesion is known.
SMFM pregnancy/postpartum cardiovascular symptom triage
Use when symptoms are reported spontaneously. Work-up is recommended for any red flag, for at least one box in each category, or for four or more total boxes checked. In everyday use, this section is the safest starting point when symptoms feel disproportionate to routine pregnancy physiology.
Open SMFM triage checklist 0 items checked
Symptoms
Risk factors
Exam findings / red flags
mWHO class
Not yet calculated
Clinical risk
Awaiting inputs
Preferred disposition
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Delivery emphasis
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SMFM symptom-triage overlay
No SMFM triage triggered.
Trigger
Not triggered
Total boxes
0
Threshold met
No
Disposition
Reassure only if not triggered
Recommended work-up and details Open details
Category counts
No SMFM findings entered yet.
Concerning / red-flag findings
No SMFM findings entered yet.
Suggested initial work-up
No SMFM work-up generated yet.
Consultation / follow-up
No SMFM consultation plan yet.
Auto-expanded lesion card
Selected lesion
Typical mWHO
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Suggested surveillance
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Delivery location
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Postpartum observation
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Key physiology / practical concerns
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Medication themes
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Antepartum priorities
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Delivery and postpartum priorities
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Aortic disease mini-panel
Aortic disease in pregnancy
Root diameter
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Ascending aorta
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Interval change
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Panel impression
No aortic prompt yet
What to verify now
Delivery / postpartum implications
This panel is meant to structure bedside thinking. Final recommendations should be individualized to syndrome, body size, prior imaging,
growth trend, family history, symptoms, and subspecialty input.
Management summary
Key interpretation
Enter the lesion and risk factors, then click Calculate plan.
Antepartum plan
No plan generated yet.
Intrapartum / delivery plan
No plan generated yet.
Postpartum plan
No plan generated yet.
Medication cautions / reminders
No medication guidance yet.
EMR-ready summary
Lesion comparison table
| Lesion / physiology | Typical mWHO | What pregnancy stresses | Main maternal risks | Antepartum focus | Delivery / postpartum focus | Suggested observation |
|---|---|---|---|---|---|---|
| Uncomplicated mild regurgitant lesions | I–II | Usually tolerated because lower SVR favors forward flow | Arrhythmia if dilation; HF if ventricular function worsens | Baseline echo; symptom review | Usually vaginal; avoid unnecessary fluid loading | Routine postpartum unless symptoms |
| Mitral stenosis | II–III to IV if severe | Tachycardia shortens diastole and raises pulmonary venous pressure | Pulmonary edema, AF, right-sided strain | Rate control, diuresis if congested, serial echo | Early neuraxial, avoid tachycardia/fluid overload | At least 48–72 h if moderate/severe or symptomatic |
| Aortic stenosis | II–III or IV if severe symptomatic | Fixed-output lesion poorly tolerates vasodilation or hemorrhage | Syncope, angina, HF, arrhythmia | Symptoms + gradients + ventricular response | Avoid hypotension, abrupt preload loss, prolonged pushing if not tolerated | 24–72 h depending on severity |
| Dilated cardiomyopathy / PPCM | III to IV | Pregnancy increases preload and output demand | HF, arrhythmia, thromboembolism, shock | Echo, BNP/troponin if indicated, optimize therapy | Strict fluid strategy; postpartum is high risk | At least 72 h or ICU/step-down if unstable |
| Fontan circulation | III | Preload-dependent circulation with limited reserve | HF, arrhythmia, thrombosis, hypoxemia | Adult congenital co-management; fetal growth surveillance | Avoid large volume shifts; extend postpartum observation | 72 h or longer if concerns |
| Long QT syndrome | II–III | Hormonal change, adrenergic surges, sleep deprivation, and QT-prolonging exposures may increase arrhythmic risk | Syncope, torsades, sudden cardiac arrest | Confirm diagnosis, review genotype/family history, continue beta-blocker, avoid QT-prolonging drugs | Telemetry if significant history; correct K/Mg; postpartum vigilance | 24–72 h depending on history and risk |
| Pulmonary arterial hypertension / Eisenmenger | IV | Pregnancy and postpartum shifts can be catastrophically poorly tolerated | Right HF, collapse, maternal death | Expert PH center only | Highly individualized delivery; ICU-level care often needed | Prolonged ICU/high-acuity postpartum |
| Mechanical heart valve | III | Hypercoagulability increases valve thrombosis risk | Valve thrombosis, hemorrhage, anticoagulation complications | Formal anticoagulation pathway | Planned transition around delivery and restart postpartum | Usually at least 48 h; depends on anticoagulation |
| Marfan / Loeys-Dietz / vascular EDS / inherited thoracic aortic disease | III to IV | Aortic wall stress rises in pregnancy and postpartum | Dissection, progressive dilation, hemorrhagic or vascular complications depending on syndrome | Serial imaging, BP control, syndrome-specific planning | Hemodynamic control, rapid escalation for chest/back pain | Often 48–72 h or longer |
Long QT syndrome: evaluation and management
Evaluation
- Confirm whether this is congenital or acquired QT prolongation.
- Review current ECGs and prior ECGs; do not rely only on automated QTc.
- Manually measure QT in lead II or V5 when possible, include biphasic T waves, and review overall ECG context.
- Review for QT-prolonging medications, electrolyte abnormalities, bradycardia, thyroid disease, eating disorder, vomiting, or other reversible causes.
- Ask about syncope, seizure-like events, family history of sudden death, known genotype, prior torsades, and ICD/pacemaker history.
- Consider cardiology/electrophysiology input, genetic counseling/testing if not already established, and fetal assessment if persistent fetal bradycardia or suspicious rhythm is present.
Management
- Continue indicated beta-blocker therapy through pregnancy and postpartum unless contraindicated.
- Avoid QT-prolonging medications and maintain potassium and magnesium in the normal range.
- Use telemetry intrapartum/postpartum if prior cardiac arrest, torsades, recurrent syncope, severe QT prolongation, ICD, or high-risk history.
- Reduce adrenergic surges when possible with good analgesia, avoidance of severe sleep deprivation, and prompt treatment of electrolyte loss.
- Postpartum is a high-risk period; emphasize medication adherence and early follow-up.
- If torsades or unstable ventricular arrhythmia occurs, this is a cardiac emergency requiring immediate ACLS-level management.
Long QT medication safety
QT-prolonging medication alert list
This is a practical screening list for common pregnancy, labor, postpartum, and periprocedural medications that may require review in patients with congenital or acquired Long QT. It is not exhaustive.
Common medication groups to review carefully
Practical bedside reminders
Examples below are intentionally practical rather than exhaustive. Individual drugs vary by patient context such as baseline QTc,
bradycardia, hypokalemia, hypomagnesemia, structural heart disease, interacting drugs, and postpartum sleep deprivation.
High-risk state reminders
Peripartum cardiomyopathy
- Think of PPCM in late pregnancy or postpartum dyspnea/orthopnea or pulmonary edema.
- Exclude alternative causes of HF before assigning diagnosis.
- Pregnancy: diuresis plus pregnancy-compatible afterload reduction as needed.
- Postpartum: ACE inhibitor/ARB/ARNI may become options depending on overall context.
- Low EF may justify thromboprophylaxis consideration.
Pulmonary hypertension / Eisenmenger
- Pregnancy is extremely high risk and generally contraindicated.
- Avoid hypoxemia, hypotension, hemorrhage, acidosis, severe pain, and fluid overload.
- Even stable-appearing patients can decompensate intrapartum or postpartum.
- Postpartum is a particularly dangerous hemodynamic period.
Fontan / complex congenital physiology
- Assess ventricular function, AV valve regurgitation, saturation, arrhythmias, thrombosis history, and liver disease.
- Monitor fetal growth because placental insufficiency and prematurity risk may be increased.
- Avoid large fluid swings and prolonged postpartum under-observation.
Medication cautions at a glance
Avoid in pregnancy: ACE inhibitors, ARBs, ARNIs, spironolactone, DOACs
Often used selectively: beta-blockers, diuretics, digoxin, hydralazine, nitrates
Use lesion-specific anticoagulation plans for mechanical valves / AF / severe LV dysfunction
Long QT: review QT-prolonging drugs carefully
- Mechanical valves require a written pregnancy, delivery, and postpartum anticoagulation pathway.
- For acute decompensated HF during pregnancy, diuresis and pregnancy-compatible afterload reduction are often central.
- In Long QT syndrome, review antiemetics, antibiotics, psychotropics, methadone, and QT-active antiarrhythmics before use.
- Breastfeeding compatibility should be reviewed medication by medication postpartum.
References
- Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018;39(34):3165–3241. PMID: 30165544
- American College of Obstetricians and Gynecologists. Practice Bulletin No. 212: Pregnancy and Heart Disease. Obstet Gynecol. 2019;133(5):e320–e356. PMID: 31022123
- Society for Maternal-Fetal Medicine (SMFM), Hameed, A.B., Licon, E., Vaught, A.J., Shree, R. and SMFM Publications Committee (2025), Society for Maternal-Fetal Medicine Consult Series #73: Diagnosis and management of right and left heart failure during pregnancy and postpartum. Pregnancy, 1: e70059. https://obgyn.onlinelibrary.wiley.com/doi/10.1002/pmf2.70059
- Elkayam U, Goland S, Pieper PG, High-risk Cardiac Disease in Pregnancy. High-risk cardiac disease in pregnancy: part I. J Am Coll Cardiol. 2016;68(4):396–410. PMID: 27443437
- Elkayam U, Goland S, Pieper PG. High-risk cardiac disease in pregnancy: part II. J Am Coll Cardiol. 2016;68(5):502–516. PMID: 27443948
- Thorne S, Nelson-Piercy C, MacGregor A, et al. Risks of contraception and pregnancy in heart disease. Heart. 2006;92(10):1520–1525. PMID: 16973809
- Bauersachs J,et al. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail. 2019 Jul;21(7):827-843. PMID: 31243866.
- Silversides CK, Grewal J, Mason J, et al. Pregnancy outcomes in women with heart disease: the CARPREG II Study. J Am Coll Cardiol. 2018;71(21):2419–2430. PMID: 29793631
- Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease (CARPREG). Circulation. 2001;104(5):515–521. PMID: 11479246
- van Hagen IM, Thorne SA, Taha N, et al. Pregnancy outcomes in women with mechanical heart valves: ROPAC registry. Eur Heart J. 2015;36(23):1509–1516. PMID: 26100109.
- Warnes CA. Pregnancy and pulmonary hypertension. Circulation. 2004;110(24):e438–e440. PMID: 15590074
- Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy. Eur J Heart Fail. 2010;12(8):767–778. PMID: 20675664
- Seth R, Moss AJ, McNitt S, et al. Long QT syndrome and pregnancy. J Am Coll Cardiol. 2007;49(10):1092–1098. PMID: 17349890
- Meijboom LJ, Vos FE, Timmermans J, et al. Pregnancy and aortic root growth in Marfan syndrome. Eur Heart J. 2005;26(9):914–920. PMID: 15749707
- Immer FF, Bansi AG, Immer-Bansi AS, et al. Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg. 2003;76(1):309–314. PMID: 12842575
- Society for Maternal-Fetal Medicine (SMFM), Combs, C.A., Atallah, F., Kern-Goldberger, A., Chavan, N.R. and SMFM Patient Safety and Quality Committee (2025), Society for Maternal-Fetal Medicine Special Statement: Checklists for triage and work-up of persons with symptoms suggestive of cardiovascular disease in pregnancy and postpartum. Pregnancy, 1: e70120. https://doi.org/10.1002/pmf2.70120
This tool integrates ESC, ACOG, and SMFM guidance with major cohort data (CARPREG, ROPAC) and condition-specific literature. Clinical decisions should always be individualized based on lesion-specific physiology, functional status, and multidisciplinary input.