Anesthetic Management of Pregnant Patients With Cardiovascular Disease: A Practical, Lesion-Based Clinical Review

Cardiovascular disease (CVD) is a major cause of maternal morbidity and mortality and increasingly complicates pregnancy as more women with congenital and acquired heart disease reach reproductive age.Anesthetic management of these patients requires integrating lesion-specific cardiovascular physiology, pregnancy-related hemodynamic changes, obstetric considerations, and the anticipated effects of labor, anesthesia, delivery, hemorrhage, and the postpartum transition.Despite contemporary cardiovascular and obstetric guidelines, translating lesion-specific physiology into practical anesthetic decisions remains challenging.This narrative review provides a practical framework for the peripartum anesthetic management of pregnant patients with CVD.We discuss contemporary risk assessment using the modified World Health Organization 2.0 classification and the Cardiac Disease in Pregnancy II risk model, followed by principles of Pregnancy Heart Team planning, labor analgesia, cesarean delivery, monitoring, anticoagulation, uterotonic therapy, and postpartum surveillance.Lesion-specific considerations are reviewed for mitral stenosis, aortic stenosis, aortic disease and coarctation, pulmonary hypertension, pregnancy-associated myocardial infarction, peripartum cardiomyopathy, congenital heart disease, and Fontan circulation.Particular attention is given to maintaining appropriate preload, ventricular filling, systemic vascular resistance, cardiac rhythm, and oxygenation while avoiding abrupt changes in vascular resistance or cardiac loading conditions.The review emphasizes individualized anesthetic planning rather than universal preferences for a particular anesthetic technique or mode of delivery.Neuraxial anesthesia can be advantageous in selected patients but should be considered in the context of ventricular function, pulmonary pressures, anticoagulation, urgency, and the expected hemodynamic response.General anesthesia remains an important option when neuraxial anesthesia is contraindicated or inadequate, rapid delivery is required, airway or ventilatory control is necessary, or maternal or surgical circumstances dictate.Uterotonic therapy should similarly be individualized according to cardiovascular physiology, with careful attention to dose, route, and hemodynamic effects.Close multidisciplinary planning and coordinated postpartum care are particularly important for women with pulmonary hypertension, ventricular dysfunction, complex congenital heart disease, and Fontan circulation.