Cardiovascular Risk During Pregnancy: Scoping Review on the Clinical Implications and Long-Term Consequences

1. Introduction

Cardiovascular adaptations and hormonal changes during pregnancy accommodate fetal demands but may unmask or exacerbate latent cardiovascular disorders, leading to hypertensive disorders of pregnancy such as gestational hypertension and preeclampsia [1,2,3]. Cardiovascular disease remains a leading cause of maternal morbidity and mortality worldwide [4,5], with preeclampsia and gestational hypertension disproportionately affecting women with advanced maternal age, obesity, diabetes mellitus, and a family history of cardiovascular disease [6,7,8,9]. These conditions not only increase perinatal complications but also elevate long-term cardiovascular risk (CVR) for both mother and offspring [6,10,11].

Early diagnosis and appropriate blood pressure control are critical to minimizing adverse outcomes [12,13,14], and emerging evidence implicates nitric oxide dysregulation in the pathophysiology of hypertensive disorders in pregnancy [15,16]. Pre-pregnancy obesity further compounds these risks by promoting insulin resistance, systemic inflammation, and endothelial dysfunction, thereby heightening the incidence of gestational diabetes, hypertension, and preeclampsia [6,17,18,19]. Notably, paternal obesity has also been shown to negatively impact fetal development and contribute to pregnancy complications [20].

The global increase in the prevalence of gestational diabetes reflects broader trends in obesity and sedentary lifestyles [21,22,23]. This condition demands early screening, tailored dietary and lifestyle interventions, and, when indicated, pharmacologic management to prevent both short- and long-term cardiometabolic sequelae [24,25,26,27].

International guidelines emphasize the importance of multidisciplinary prenatal care, regular monitoring, and patient education to prevent and effectively manage these complications [3,14,28]. However, the evolving landscape of cardiovascular research, including novel diagnostic biomarkers and updated treatment protocols, underscores the need for a comprehensive and up-to-date review.

This review aims to synthesize and update the current scientific evidence (2019–2024) regarding CVR during pregnancy. It will focus on identifying key risk factors, examining maternal and fetal outcomes, and evaluating modern clinical strategies. The ultimate goal is to support evidence-based decision-making and reduce pregnancy-related cardiovascular morbidity and mortality.

2. Materials and Methods

2.1. Search Strategy

This comprehensive review adhered to the guidelines outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and has been registered in Open Science Framework (https://osf.io/4xv7k).

The primary information sources used for this work were EMBASE, MEDLINE/PubMed, and SCOPUS. The time frame for the eligible publications was from 2019 to November 2024.

An advanced search was conducted in the PubMed/MEDLINE database using the terms “Pregnancy” and “Cardiovascular risk” in the title, combined with the following MeSH terms: “Pregnancy,” “Cardiovascular diseases,” and “Risk factors.” The final search query was as follows:

((((pregnancy[Title]) AND (cardiovascular risk[Title])) AND (pregnancy[MeSH Terms])) AND (cardiovascular diseases[MeSH Terms])) AND (risk factors[MeSH Terms])

A temporal filter was applied to restrict the results to publications from 2019 onwards. This search returned 75 results.

For EMBASE, the search strategy involved selecting the term’ pregnancy’ as a title term, combined with the keyword’ cardiovascular disease.’ The PICO framework was used to define the population as ‘pregnancy’ and the intervention as ‘cardiovascular risk.’ The final query was:

‘pregnancy’/exp AND ‘cardiovascular risk’/exp AND ‘cardiovascular disease’/exp AND ‘pregnancy':ti AND ‘cardiovascular disease':kw

This search resulted in 63 articles.

A similar search strategy was applied in SCOPUS. The terms “cardiovascular risk” and “pregnancy” were used as title terms, and “cardiovascular disease” and “risk factors” were keywords. Filters were applied to include only English-language articles published between 2021 and 2024 and with a document type of “article” (ar). The final query was:

(TITLE (cardiovascular AND risk AND during AND pregnancy) AND KEY (cardiovascular AND disease AND risk AND factors)) AND PUBYEAR > 2020 AND PUBYEAR < 2026 AND (LIMIT-TO (LANGUAGE, “English”)) AND (LIMIT-TO (DOCTYPE, “ar”))

This search yielded 67 articles.

A total of 205 articles were retrieved from the three databases.

2.2. Article Selection

The initial step involved removing duplicate records. All 205 references were imported into the Mendeley reference manager, which automatically identified and removed 47 duplicates.

2.1.1. Inclusion Criteria

• Topical Relevance: Articles were included based on a review of their title and abstract, provided their primary focus was CVR in pregnant women, ensuring their relevance to the objective of this review.
• Study Design: Priority was given to original research studies (e.g., cohort studies), as well as systematic and narrative reviews that addressed the topic from clinical, epidemiological, or preventive medicine perspectives.
• Target Population: Studies focusing exclusively on pregnant women were included. Studies involving mixed populations (e.g., men or non-pregnant women) were included only if results for pregnant women were reported separately.
• Language: Only articles published in English or Spanish were selected to ensure complete comprehension and rigorous analysis.
• Publication Date: Articles published between 2019 and 2024 were included to ensure the current relevance of the studies.

2.1.2. Exclusion Criteria

• Lack of Thematic Relevance: Articles that, although mentioning CVR and pregnancy, focused on unrelated topics such as oncology, autoimmune diseases, or other conditions outside of pregnancy were excluded.
• Limited Population Representativeness: Studies with small sample sizes (under 60 participants) or those focused on particular geographic regions or ethnic groups were excluded if their results were not generalizable to the broader context of CVR in pregnant women.
• Low Methodological Quality or Inadequate Design: Editorials, letters to the editor, conference abstracts, and case reports were excluded, as were articles lacking structural integrity or presenting incomplete data.
• After applying these criteria, the final selection included n = 20 articles for inclusion in this review.

2.3 Methodological Approach for Literature Analysis

A structured methodology was employed to classify and synthesize the most salient aspects of the included studies, ensuring a thorough and systematic analysis of the selected literature. This approach facilitated the subsequent development of summary tables, enhancing the clarity, interpretability, and comparability of the findings.

A core thematic framework was established, comprising four principal categories that reflect critical domains of CVR in pregnancy:

• General Considerations of CVR during Pregnancy. This category encompasses publications that address foundational concepts related to CVR during gestation, including epidemiological data and the conceptual underpinnings of CVR in pregnant populations.
• Pregnancy Complications and CVR. This group includes studies examining pregnancy-specific complications, such as preeclampsia and gestational diabetes mellitus, and their association with both immediate and long-term cardiovascular outcomes.
• Genetics and Molecular Biology of CVR Factors in Pregnancy. This thematic area encompasses investigations into the genetic, molecular, and pathophysiological mechanisms underlying CVR during pregnancy, providing a biomedical perspective to the broader clinical understanding.
• Clinical Management of CVR during Pregnancy. This section comprises literature addressing strategies for preventing, diagnosing, and managing CVR in pregnant individuals, with an emphasis on evidence-based guidelines and implications for obstetric care.

Within each thematic group, studies were further categorized by publication type, distinguishing between original research articles (e.g., cohort or case-control studies) and review articles (including narrative reviews, systematic reviews, and meta-analyses). This dual-level classification supports methodological consistency and contextual interpretation, facilitating the integration of evidence across diverse study designs.

2.4. Construction of Summary Tables: Original Research Articles

Standardized tables were developed for original studies to summarize and compare key characteristics across articles. Each table included the following components:

• Author and Year of Publication: For citation and identification purposes.
• Study Design: Type of research conducted (e.g., cohort, cross-sectional, case-control).
• Inclusion and Exclusion Criteria: The Criteria used to define the study population are relevant for assessing external validity.
• Gestational Period Analyzed: Specific trimester(s) or pregnancy stage(s) addressed.
• Study Objective and Primary Variables: The main research aim and the variables employed to evaluate it.
• Principal Findings: Primary results, emphasizing outcomes related to CVR.
• Limitations: The authors reported methodological limitations or identified them during critical appraisal, which aids in assessing study quality and internal validity.

2.5. Construction of Summary Tables: Review Articles

For review articles, a separate table format was designed to align with the structure and objectives of this publication type. The table included:

• Author and Year of Publication, Study Design, Gestational Period, Primary Objective, Key Findings, and Limitations: As in the original studies, these fields ensure consistent reporting and comparability.
• Main Focus: Summary of the central topic or hypothesis addressed in the review.
• Number of Included Studies and Time Frame Covered: Total articles reviewed and the temporal scope of the literature search.
• Quality of Evidence: An assessment of the methodological rigor of included studies and the review process, based on criteria such as the Newcastle-Ottawa Scale or other validated quality appraisal tools.
• Secondary Findings: Additional observations or findings beyond the primary objective of the review.

At the end of the selection process, a total of 20 studies were included in the review. The complete process of identification, screening, eligibility assessment, and inclusion is summarized in the PRISMA flow diagram (Figure 1).

3. Results

The results have been organized into four thematic sections to facilitate the analysis of the impact of CVR during pregnancy. These sections address the general aspects of CVR during pregnancy, including pregnancy complications and their short- and long-term effects, advances in genetics and molecular biology, and CVR biomarkers in pregnant women, as well as clinical management strategies. Below, we detail the most relevant findings from each area, integrating evidence from original studies and reviews. The results are presented in table form, followed by an integrated summary of the evidence obtained from each.

Table 1 and Table 2 show research and review articles, respectively, that examined the general aspects of CVR factors during pregnancy from various perspectives. It can be concluded that pregnancy is considered a stage where the demands on the cardiovascular system (CVS) are increased, making it a period in which conditions that elevate CVR both in the short and long term may emerge or be revealed.

Four research articles regarding methodology were included [29,30,31,32]. One of them [30] has a significantly larger sample size compared to the other three, whose study populations consist of only a few hundred participants, which may limit the generalizability of the results to larger populations.

Most of these studies do not focus on a specific period of pregnancy but examine pregnancy as a whole, with some also covering the early postpartum period. Only the study by Harville et al. [29] also investigates the pre-pregnancy state. Therefore, while these studies may offer a limited view of pregnancy individually, they collectively provide a more integrative temporal perspective.

In terms of results, it is evident that CVR observed during pregnancy largely reflects the pre-existing risk state [29], underscoring the importance of proper prevention and control of CVR factors both during and before pregnancy. Parameters showing the strongest correlation between pre-pregnancy and pregnancy levels include BMI, systolic blood pressure (SBP), diastolic blood pressure (DBP), LDL and HDL cholesterol, and triglycerides. In contrast, the correlation is weaker for glucose and insulin [29].

This finding aligns with the fact that CVRFs such as hypertension, obesity, gestational diabetes (GDM), and elevated CRP levels negatively affect the CVS in pregnant women, influencing cardiac remodeling through increased concentric cardiac hypertrophy and reducing the ability to reverse cardiovascular adaptations that occur during pregnancy [32]. Moreover, these factors, such as preeclampsia (PE) and GDM, also increase the risk of adverse cardiovascular events, such as major adverse cardiovascular events (MACE), which are of particular interest due to their high mortality and predominant occurrence in the immediate postpartum period [30].

Conversely, the ST2/IL33 receptor is associated with better postpartum recovery, suggesting it could be a biomarker for reversing cardiac hypertrophy [32].

It has also been observed that women with higher CVR are more likely to experience preterm birth and ICU admissions [31]. However, for a woman with good control of cardiovascular diseases, different modes of delivery do not impact perinatal mortality, further emphasizing the importance of appropriate monitoring and control in women with CVRFs and cardiovascular diseases during pregnancy [31].

Thus, pregnancy is globally projected as a period of special vulnerability for the CVS, highlighting the importance of pre-pregnancy risk profiles and the short- and long-term consequences of presenting CVRFs and complications during pregnancy.

The only review article found analyzes the impact of parity on CVR [33]. It is a meta-analysis that incorporates data from multiple studies involving over 3 million participants, placing it among the highest levels of evidence in the research pyramid. Specifically, the study by Li et al. [33] demonstrates that a higher number of pregnancies and, therefore, gestations leads to an increased risk of cardiovascular events (CVE), with each childbirth increasing the risk by 4%. Overall, women with children have a 14% higher risk of developing cardiovascular disease (CVD) compared to nulliparous women. These findings suggest that pregnancy is a biological state with a direct impact on long-term cardiovascular health, manifesting as an increase in CVR and CVD.

Moreover, the relationship between the number of births and the relative risk of CVD is not linear but follows a J-shaped curve [33].

Table 3 and Table 4 show original and review publications that examine the association between pregnancy complications and the long-term risk of developing CVD.

Regarding methodology, the study by Honigberg et al. [34] is a cohort study with a large sample size, strengthening the validity of the results. However, all data are derived from the UK Biobank, which may limit the applicability of the evidence to populations from other regions.

The study does not examine CVR during pregnancy itself. Instead, it focuses on the postpartum study of women who had experienced hypertensive disorders of pregnancy (HDP), such as preeclampsia, and whether they have a higher risk of developing CVD later in life. The results show that women with a history of HDPs have a higher risk of a CVD diagnosis. Specifically, this population shows an increased prevalence of coronary artery disease, heart failure, and valvular dysfunction. Thus, it can be concluded that HDPs not only represent a risk during pregnancy but also have long-term cardiovascular consequences for women who have experienced them, highlighting the need for rigorous and prolonged postpartum follow-up.

However, the main limitation of this study is that the inclusion of women with a history of HDP was based on patient testimony rather than clinical records, which may introduce recall bias that limits the evidence. Therefore, further research is needed to study the long-term consequences of pregnancy-related cardiovascular disorders using more detailed clinical records, including comprehensive histories of HDPs.

Regarding methodological analysis, seven narrative reviews are included [35,36,37,38,39,40,41], encompassing over 580 references from the late 20th century to 2024, which provide a comprehensive view of pregnancy complications over recent decades. The reviews found examine how different pregnancy complications, such as HDP, GDM, preterm birth, and low birth weight, are associated with short- and long-term maternal CVR, with some complications, such as myocardial infarction (MI) or cardiogenic shock (CS), being potentially fatal both for the mother and fetus in the immediate term. However, as narrative reviews, they lack clear protocols for article selection and review, which may introduce selection bias, making the evidence less robust.

Although the reviews address different stages of pregnancy, collectively they provide a comprehensive overview of pregnancy, from its onset to the late postpartum period. However, they do not focus on the pre-pregnancy CVR condition, except for the study by Fürniss & Stiller [40], which focuses on pregnant women with congenital heart diseases.

Four studies address the impact of more prevalent cardiovascular complications during pregnancy [35,36,37,39], while three focus on less prevalent but more fatal complications such as myocardial infarction (MI) [41], cardiogenic shock [38], and arrhythmias [40].

In general, all adverse pregnancy events are predisposed to increased CVR. However, more specifically, preeclampsia is associated with a 2-4 times higher risk of developing CVDs such as hypertension and coronary artery disease throughout life [35,36,37,39]. GDM, on the other hand, increases the risk of type 2 diabetes (T2DM) up to 7 times, playing a key role in the increase of CVR [36]. Furthermore, even in women who regain normoglycemia after delivery, there remains an elevated risk for developing CVD [39]. Additionally, mothers who give birth before 37 weeks have a 1.79-fold higher risk of vascular mortality [39].

All the evidence presented in the various studies is consistent. Clearly, it shows that any cardiovascular event or disruption of pregnancy progression has long-term adverse effects on the cardiovascular system. The pathophysiological mechanisms underlying these findings are primarily linked to chronic pro-inflammatory states and endothelial dysfunction [37,39].

In contrast, breastfeeding is proposed as a valuable tool for CVS protection, as it is associated with a significant reduction in CVR in the mother [35,39]. Thus, the importance of promoting breastfeeding as part of postpartum management is emphasized as a strategy to reduce maternal CVR.

Focusing on more specific cardiovascular disorders, the importance of CS is highlighted since, although it is infrequent, it has high maternal and fetal morbidity and mortality. Understanding and considering its primary etiologies, such as maternal cardiomyopathy and arrhythmogenic right ventricular dysplasia, is crucial as these occur primarily during the late stages of pregnancy and peripartum [38].

Regarding MI, it is essential to understand the role of spontaneous coronary artery dissection (SCAD) as the primary etiological factor in young pregnant women [38,41]. The incidence of MI is three to five times higher in pregnant women compared to non-pregnant women of the same age. Moreover, it is associated with a high recurrence rate of cardiovascular events postpartum, as well as complications such as preterm birth. These findings underscore pregnancy as a period of heightened cardiovascular demand, during which abnormal cardiovascular function can result in fatal maternal and fetal outcomes [41].

As for arrhythmias during pregnancy, it is noted that women with congenital heart disease are particularly susceptible to this event, making it the most frequent complication in this population, and strict CV monitoring is recommended [40].

Table 5 and Table 6 present the results from original and review works focused on the genetics, molecular biology, and biomarkers of CV risk factors in pregnant women. The findings from both original studies highlight a significant association between CVR in pregnancy and underlying biological markers or predispositions.

In the prospective observational study by Abu-Awwad et al. [42], pregnant women with CVR factors demonstrated significantly shorter telomere lengths compared to those without such risk factors (mean: 0.3537 vs. 0.5728 megabases; p = 0.0458). Furthermore, 32% of fetuses in the high-risk group exhibited intrauterine growth restriction (IUGR). These results suggest that telomere length may serve as a potential biomarker for identifying CVR during pregnancy. However, the study was limited by its small sample size, single-center recruitment, and lack of control over external variables such as lifestyle and stress.

Complementing these findings, the Mendelian randomization study by Tschiderer et al. [43] utilized genetic data from over 221,000 pregnant women in the UK Biobank to examine long-term cardiovascular outcomes. The study found that genetic predisposition to hypertensive pregnancy disorders (HPDs)—including preeclampsia and gestational hypertension—was associated with a 20–24% increased risk of CVD later in life. This genetic susceptibility was also linked to elevated blood pressure, earlier hypertension diagnosis, and adverse metabolic profiles, such as increased cholesterol and triglycerides. The inclusion of nulliparous women and men as controls further supported the conclusion that these risks extend beyond pregnancy itself, pointing to shared genetic and metabolic pathways. Nonetheless, the study’s findings may be limited by its reliance on a predominantly European population and potential residual confounding.

Together, these studies underscore both molecular (telomere shortening) and genetic (HPD predisposition) indicators of CVR in pregnant populations, suggesting the potential for future risk stratification and early intervention strategies, while also emphasizing the need for further research with broader and more diverse populations.

The narrative review by Aldo et al. [44] synthesized findings from 102 articles published between 1981 and 2023, focusing on the use of cardiac biomarkers in pregnancy for CVR assessment. The authors reported that NT-proBNP and BNP levels typically increase during the first trimester, decrease in the second and third trimesters, and rise again around delivery. Values exceeding 200 ng/L of NT-proBNP were associated with an elevated risk of heart failure and hypertensive disorders, particularly in women with pre-existing cardiac conditions.

In contrast, high-sensitivity cardiac troponin levels remained stable in uncomplicated pregnancies but were found to increase in the presence of hypertensive disorders and other cardiovascular complications, suggesting their potential utility in risk stratification. However, the review emphasized that troponins require further validation before being used routinely in pregnancy.

The original and review publications included in Table 7 and Table 8, respectively, examine the management of CV risk in pregnant women. The prospective cohort study by Marschner et al. [45] assessed the effectiveness of a postpartum CVR management program among 156 women with a history of pregnancy complications, including HDP, GDM, and IUGR. Over a six-month follow-up period, 80.5% of women enrolled in the program achieved blood pressure targets (<140/90 mmHg, or <130/80 mmHg for those with type 2 diabetes), compared to 69.2% in the non-participating group.

Participants in the program also demonstrated significant reductions in LDL and total cholesterol, as well as improvements in body mass index (BMI) and waist circumference, indicating enhanced cardiovascular health. Additionally, the intervention group reported healthier lifestyle habits, including increased consumption of fish and olive oil, as well as decreased intake of fast food.

Despite these promising outcomes, the study’s non-randomized design limits causal interpretation. Moreover, selection bias may be present due to the high educational level of participants, and the results may not be generalizable beyond the single Australian healthcare setting in which the study was conducted.

The review studies [46,47,48] agree on identifying pregnancy as a physiological “cardiovascular stress test,” capable of triggering or exacerbating underlying conditions, some of which are critical, such as CS or MI. These complications not only represent immediate risks but also have long-term repercussions by increasing the risk of CVD. Therefore, a multidisciplinary approach to prevention, diagnosis, and therapy is necessary to manage cardiovascular consequences effectively.

4. Discussion

The evidence from the various studies analyzed demonstrates that pregnancy is a biological period during which the CVS undergoes significant demands, leading to functional changes and physiological adaptations that pose a unique challenge to cardiovascular function. These dynamics have been consistently reflected throughout the present review [29,30,31,32,33] (Table 1 and Table 2). The discussion section not only provides a critical interpretation of the findings but also examines their clinical and methodological implications, identifies areas for improvement, and offers a comprehensive and applied perspective on the preceding analysis.

Pregnancy involves a series of physiological changes in the cardiovascular system, including an increase in blood volume, a decrease in vascular resistance, and a 50% increase in cardiac output [8,9,10,11,12]. These adaptations are crucial for meeting maternal-fetal demands during this biological stage. However, these changes also represent a “cardiovascular stress test” [29,30,31,32,33] (Table 1 and Table 2).

Recent studies suggest that both genetic and environmental factors may contribute to inadequate cardiovascular adaptations [42,43] (Table 5). These changes subject the cardiovascular system to stress and overstrain, resulting in increased CVR, which is manifested through various conditions, such as PE and GDM [35,36,37,38,39,40,41] (Table 4).

These conditions themselves constitute an elevated CVR during pregnancy, triggering harmful consequences for the cardiovascular system, which may have immediate fatal effects, such as MI, thromboembolism, or cardiogenic shock [35,36,37,38,39,40,41] (Table 4).

However, pregnancy not only triggers short-term CVR but also has long-term repercussions, as numerous studies show an increased prevalence of various cardiovascular conditions, such as ischemic heart disease, valvular heart disease, vasculopathies, or cardiomyopathies, later in life among women who have been pregnant, compared to those who have not [29,30,31,32,33,34,35,36,37,38,39,40,41] (Table 1, Table 2, Table 3, Table 4). There is a direct and robust correlation between parity and CVR, such that each pregnancy increases the long-term risk of developing cardiovascular disease (CVD) by up to 4%, clearly illustrating the impact pregnancy has on the cardiovascular system [33] (Table 2).

The impact of these complications extends beyond maternal health, also affecting fetal health and well-being. The risk of intrauterine growth restriction (IUGR), preterm birth, and, in some cases, fetal mortality is increased [35,36,37,38,39,40,41,45,46,47,48] (Table 4, Table 7, Table 8). These outcomes represent a major global health issue affecting a particularly vulnerable population—pregnant women. This situation underscores the importance of advancing research in this area. Furthermore, the existing evidence suggests the existence of molecular and genetic mechanisms that could be targeted for intervention, should a more comprehensive understanding be attained to control, delay, or even prevent the development and progression of cardiovascular disease [42–44, 46–48] (Table 5, Table 6, Table 8). Potential biomarkers, such as the ST2/IL-33 receptor and lysyl oxidase, related to cardiovascular remodeling [29,30,31,32] (Table 1), as well as troponins and telomere length, which are associated with cardiovascular remodeling [42,43,44] (Table 5 and Table 6), have been proposed.

On the other hand, it is essential to understand all the available options for the comprehensive management of cardiovascular complications related to pregnancy. It has been demonstrated that measures such as medication, cardiovascular marker monitoring (including blood pressure, glucose levels, and body weight), lifestyle changes, proper nutrition, and the administration of safe medications during pregnancy can result in a significant improvement in the development and prognosis of cardiovascular disease. Women who undergo prevention, treatment, and follow-up programs during pregnancy and postpartum experience significant improvements in their cardiovascular profile and a reduced risk of cardiovascular events and related complications [29,30,31,32] (Table 1). Preconception care is also emphasized, as the correlation between pre-existing CVR and that observed during pregnancy underscores the need to optimize the management of CVR factors before conception [29,30,31,32] (Table 1).

Regarding methodology, the reviewed research articles exhibit significant heterogeneity in sample size, ranging from 68 patients in the case of Abu-Awwad et al. [42], which is a small sample size that may limit statistical power, to hundreds of thousands of participants in studies based on databases such as the UK Biobank [34,43], which strengthens the generalizability of their results.

In terms of study design, observational studies — both retrospective and prospective — predominate, which are extremely useful for identifying associations but, in some cases, are insufficient to establish causality. This fact highlights the need for clinical trials in this area. However, pregnant women are routinely excluded from medical research due to various ethical, legal, and safety considerations. As a result, most of the recommendations related to the management of CVR during pregnancy, as well as the majority of associations identified in this area, arise from observational studies, retrospective analyses, or extrapolations from data obtained from the general population, which significantly limits the development of robust evidence to guide specific and safe interventions.

Regarding clinical practice, the findings of this review have direct implications for the primary and secondary prevention of cardiovascular events associated with pregnancy. Available tools—such as biomarker measurement (troponins, ST2/IL-33, telomere length) or the identification of obstetric histories, including preeclampsia or gestational diabetes—enable the early detection of elevated CVR and the initiation of timely interventions to prevent adverse outcomes. These goals can be achieved through the implementation of personalized management strategies. Additionally, the importance of proper postpartum follow-up for women with CVR factors is emphasized. Cost-effective and straightforward assessments, such as blood pressure monitoring and metabolic profiling, are easy to perform, require minimal time during consultations, and are low-cost. These tools can detect the early onset of cardiovascular complications, thereby preventing diagnostic delays and enabling the development of personalized management plans. Such strategies can reduce or prevent the onset of severe conditions, including myocardial infarction and stroke, which carry a high risk of morbidity and mortality. The value of this lies not only in improving maternal health but also in the unique periods of postpartum and infancy, during which children require considerable care and attention in all vital areas for proper development. Reducing both maternal mortality and morbidity enables these needs to be adequately met. Invalidating sequelae, such as those resulting from a stroke or, in extreme cases, maternal death, can have devastating consequences for the life and development of offspring.

Regarding areas for improvement and research proposals, there is solid and robust evidence of the direct and bidirectional relationship between pregnancy and CVR. Pregnancy itself represents an increase in cardiovascular demand that may lead to CVD, while conditions that increase CVR complicate pregnancy and long-term maternal health.

However, this evidence is not yet conclusive, and further research is required in fields such as CVR-related biomarkers, gene expression associated with CVR, nutritional supplements during pregnancy, and novel forms of early CVR diagnosis. These studies should follow appropriate and well-reasoned methodologies, prioritizing high-quality evidence such as meta-analyses or clinical trials. In such cases, studies should be designed ethically to include pregnant women, thereby generating robust evidence that applies to this population. Greater knowledge in these fields could open new therapeutic avenues, such as epigenetic interventions or using these biomarkers for early diagnosis.

Moreover, studies should be expanded to include underrepresented populations, as most reviewed studies are conducted in developed countries, leaving populations in developing countries largely overlooked. The prevalence of cardiovascular complications may differ in these populations due to socioeconomic factors, access to healthcare, and genetic differences. Therefore, expanding research to these lower-resource populations is crucial for obtaining a more comprehensive and less biased view of the problem.

In summary, pregnancy represents a period of high cardiovascular demand that can initiate or unmask underlying pathologies. However, it also provides a unique opportunity for identifying and managing risk factors, with beneficial effects on maternal and fetal health both in the short and long term. However, to achieve this goal, it is essential to overcome methodological barriers and expand the frontiers of knowledge through more innovative, in-depth, and collaborative research, ensuring optimal and safe care for this particularly vulnerable cardiovascular population.

5. Conclusions

In conclusion, pregnancy is a critical biological period that imposes significant demands on the cardiovascular system, leading to essential physiological adaptations. However, these adaptations also represent a cardiovascular stress test, which may reveal or exacerbate underlying cardiovascular conditions, posing both short-term and long-term risks to maternal health. The evidence reviewed highlights the complex relationship between pregnancy and CVR, emphasizing that pregnancy can increase the likelihood of cardiovascular disease both during and after the gestational period. Moreover, the findings demonstrate that women with a history of pregnancy may face elevated CVR later in life, with an increased prevalence of cardiovascular conditions such as ischemic heart disease, valvulopathies, and cardiomyopathies.

The implications of these findings extend beyond maternal health, affecting fetal well-being and overall health outcomes. Effective management of CVR during pregnancy, through early detection, appropriate monitoring, and tailored interventions, can significantly improve maternal and fetal outcomes. The review underscores the importance of preconception care, timely prenatal and postpartum management, and the development of personalized strategies to reduce the burden of cardiovascular complications.

The review also highlights several research gaps, particularly in cardiovascular biomarkers, genetic expression, and early detection methods. To better address these challenges, further high-quality studies, including clinical trials and meta-analyses, are necessary to establish robust evidence and guide evidence-based interventions. Additionally, expanding research to include underrepresented populations and exploring new therapeutic avenues such as epigenetic interventions may open promising opportunities for preventing or mitigating cardiovascular disease in pregnancy.

Addressing CVR in pregnancy improves maternal health and enhances the outcomes of future generations, underscoring the importance of ongoing research and clinical advancements in this critical area.