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Cardiac Disease Classification in Pregnancy

Risk stratification using modified WHO classification

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Kadın Hastalıkları ve Doğum department. Book Appointment →

What is Cardiac Disease Classification in Pregnancy?

The modified WHO classification (Roos-Hesselink et al., 2018) is the most validated tool for risk assessment in pregnant women with cardiac disease.

Class I: no detectable increased maternal risk; pregnancy outcome similar to general population.

Class II: small increased risk; conditions include uncomplicated atrial septal defect post-repair, mild mitral valve prolapse.

Class II–III: moderately increased risk; mild ventricular dysfunction, native moderate valvular disease, repaired tetralogy of Fallot.

Class III: significantly increased maternal morbidity and mortality; mechanical valves, systemic right ventricle, complex congenital disease.

Class IV: extremely high risk of maternal mortality or severe morbidity; pregnancy contraindicated. Includes pulmonary hypertension, severe systemic ventricular dysfunction (EF <30%), severe symptomatic obstructive lesions, severe aortic dilatation.

Symptoms

Pregnancy-related cardiovascular changes: 30–50 percent rise in cardiac output, plasma volume expansion, decreased systemic vascular resistance
Symptoms of decompensation: dyspnea at rest or during minimal exertion, orthopnea, paroxysmal nocturnal dyspnea, palpitations, syncope
Signs: rales, peripheral edema beyond physiologic, raised JVP, S3 gallop, new murmur
Arrhythmias: atrial fibrillation, ventricular ectopy, sustained tachycardia
Maternal cardiac complications: heart failure, arrhythmia, thromboembolism, endocarditis, valve dysfunction
Fetal complications: prematurity, growth restriction, fetal loss, congenital heart disease in offspring

Risk Factors

Higher mWHO class (especially III–IV)
Reduced systemic ventricular function (EF <40 percent)
Pulmonary hypertension (mPAP >25 mmHg or systolic PAP >50 mmHg)
Symptomatic severe obstructive lesions (aortic or mitral stenosis)
Mechanical valve prosthesis (anticoagulation challenges)
Aortopathy with significant aortic dilatation (Marfan, bicuspid, vascular Ehlers-Danlos)
Prior peripartum cardiomyopathy with persistent dysfunction
Cyanotic congenital heart disease, Eisenmenger syndrome

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Preconception counseling for any woman with known cardiac disease before attempting pregnancy
  • First trimester pregnancy confirmation in a cardiac patient — prompt referral to specialized care
  • New cardiac symptoms in pregnancy: chest pain, severe dyspnea, syncope, palpitations
  • Decline in exercise tolerance or new orthopnea
  • Postpartum heart failure symptoms (peripartum cardiomyopathy)

Treatment Methods

01
Preconception multidisciplinary evaluation: cardiology, obstetrics, anesthesia, genetics; baseline imaging and risk assessment
02
Class IV: discuss contraception and termination; if pregnancy continues, refer to highly specialized center
03
Antenatal care every 1–2 months early, more frequent after 24 weeks; serial echocardiography
04
Medication review: ACE inhibitors and ARBs contraindicated; beta-blockers preferred selective beta-1 (metoprolol, bisoprolol); avoid amiodarone if possible
05
Anticoagulation in mechanical valves: complex protocol with LMWH or warfarin balancing maternal and fetal risk
06
Delivery planning: vaginal delivery preferred for most; cesarean for obstetric indications or specific cardiac contraindications
07
Peripartum monitoring with cardiac team; postpartum surveillance for at least 6 weeks (peak risk) and beyond

Which Department to Visit?

You can visit our Kadın Hastalıkları ve Doğum department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

Learn About Kadın Hastalıkları ve Doğum Department

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.