Heart Murmurs During Pregnancy: Symptoms, Monitoring, and Support

Key Takeaways

Most heart murmurs during pregnancy are benign and result from normal physiological changes in blood volume and cardiac output.
Symptoms like progressive shortness of breath, orthopnea, and nocturnal cough warrant medical evaluation to distinguish regular pregnancy changes from cardiovascular disease.
A multidisciplinary approach involving obstetricians and cardiologists provides optimal monitoring and support for pregnant women with heart murmurs or other cardiac concerns.

Understanding Heart Murmurs During Pregnancy

Pregnancy creates significant changes in the cardiovascular system that can lead to heart murmurs. These murmurs may be innocent physiological findings or indicators of underlying heart conditions that require careful monitoring and evaluation.

Pathophysiology and Hemodynamic Changes

During pregnancy, blood volume increases by approximately 40-50%, peaking around 32 weeks of gestation. Cardiac output rises by 30-50%, and heart rate typically increases by 10-20 beats per minute.

These adaptations help meet the increased oxygen demands of both mother and fetus. The increase in blood volume leads to faster blood flow through the heart valves, which can generate turbulence.

This turbulence is often heard as a functional or “flow” murmur during routine examinations. Your heart also undergoes mild structural changes, including slight ventricular hypertrophy to accommodate the increased workload.

Blood pressure typically decreases during the first and second trimesters due to peripheral vasodilation. It gradually returns to pre-pregnancy levels in the third trimester.

These hemodynamic shifts are most pronounced during the second trimester.

Types and Causes of Heart Murmurs

Physiological Murmurs (60-80% of pregnant women):

Systolic “flow” murmurs – soft, grade 1-2/6 intensity
Usually heard best at the left sternal border
Due to increased blood flow, not valve abnormalities

Pathological Murmurs (indicate underlying heart disease):

Congenital disabilities (ventricular septal defect, atrial septal defect)
Valvular conditions (mitral valve prolapse, aortic stenosis)
Rheumatic heart disease
Cardiomyopathies (hypertrophic or dilated)

Some pre-existing heart conditions may become symptomatic for the first time during pregnancy due to the increased cardiac workload. Conditions like patent ductus arteriosus or tetralogy of Fallot can pose significant risks if undiagnosed before pregnancy.

Diagnosis and Assessment

Your healthcare provider will perform a thorough cardiac examination, paying special attention to heart sounds and murmurs. Timing (systole vs. diastole), location, intensity, and murmur quality provide crucial diagnostic information.

Diagnostic Tools:

Physical examination with auscultation
Echocardiography (primary imaging tool)
Electrocardiogram (ECG)
Laboratory tests (BNP, troponin if concerning symptoms)

Echocardiography is particularly valuable because it is non-invasive, safe during pregnancy, and provides detailed information about the heart’s structure and function. It can differentiate between innocent flow murmurs and those indicating structural abnormalities.

Risk assessment depends on the specific heart condition, its severity, and the individual’s functional status. Your cardiologist and obstetrician will work together to develop a personalized monitoring plan tailored to your specific needs and cardiac function.

Symptoms and Clinical Presentation

Identifying heart murmurs during pregnancy requires careful attention to typical and atypical symptoms. Cardiovascular changes in pregnancy can mask or mimic cardiac conditions, making clinical evaluation challenging for healthcare providers.

Recognizing Symptoms in Pregnant Individuals

Pregnant individuals with heart murmurs may experience shortness of breath (dyspnea) that exceeds normal pregnancy-related breathlessness. This often worsens when lying flat (orthopnea) or may wake you at night (paroxysmal nocturnal dyspnea).

Fatigue beyond typical pregnancy tiredness can indicate cardiovascular strain. You may notice persistent tiredness that does not improve with rest.

Palpitations can manifest as racing, pounding, or irregular heartbeats. While occasional palpitations are common in pregnancy, frequent or sustained episodes warrant evaluation.

Chest pain or pressure is never normal and requires immediate medical attention. Similarly, dizziness or fainting episodes may indicate insufficient cardiac output.

Peripheral edema (swelling) that extends beyond typical pregnancy swelling, especially when it involves the face or hands, may signify cardiac involvement.

Distinguishing Benign vs. Pathological Murmurs

Benign murmurs in pregnancy typically:

Are systolic in timing
Grade 1-2 in intensity (soft)
Located at the left sternal border or the pulmonary area
Don’t radiate to other areas
Decrease or disappear with position changes

Pathological murmurs often present with:

Higher intensity (grade 3+)
Diastolic timing
Accompanied by other abnormal heart sounds (S3, S4)
Associated with symptoms like dyspnea or fatigue
Radiation to carotid arteries or axilla

Blood volume increases by 40-50% during pregnancy, potentially making existing murmurs louder or revealing previously undetected ones. Your healthcare provider will listen for the murmur’s timing, location, and quality to determine its significance.

Associated Conditions and Complications

Heart murmurs may indicate underlying conditions that can complicate pregnancy. Valvular heart disease can worsen during pregnancy due to increased cardiac demand, potentially leading to heart failure.

Arrhythmias are more common in pregnant women with structural heart abnormalities. You may experience tachycardia (a rapid heartbeat) or, less commonly, bradycardia (a slow heartbeat).

Pulmonary hypertension carries significant risks during pregnancy and can present with exertional dyspnea, fatigue, and sometimes a persistent cough.

Anemia can produce functional murmurs and exacerbate underlying cardiac conditions, presenting with fatigue and, in some cases, a rapid heartbeat.

Serious complications requiring vigilant monitoring include:

Heart failure (watch for increasing dyspnea, fatigue, edema)
Infective endocarditis (fever, night sweats, new or changing murmur)
Paradoxical embolism (sudden neurological symptoms)

Cyanosis, characterized by bluish discoloration, is a late and serious sign that requires emergency evaluation.

Monitoring, Management, and Multidisciplinary Support

Effective management of heart murmurs during pregnancy requires coordinated care from multiple specialists and careful monitoring throughout each trimester. The goal is to minimize risks while optimizing outcomes for both mother and baby.

Screening and Follow-Up During Pregnancy

Screening for heart murmurs should occur during the initial prenatal visit. If you have a pre-existing heart condition, your healthcare provider will likely schedule more frequent check-ups than the standard prenatal visits.

Follow-up evaluations typically include regular echocardiograms to assess cardiac function and track changes in your heart’s performance. The frequency of these evaluations depends on the severity of your heart murmur and underlying condition.

For women with moderate to severe heart disease, monitoring may occur every 4-6 weeks during the first and second trimesters. This increases to every 2-3 weeks in the third trimester.

Your care team will track specific cardiac parameters, including ejection fraction, valve function, and pulmonary pressures, to detect early signs of cardiac decompensation.

Medical and Interventional Management

Medication management during pregnancy requires careful consideration of both maternal and fetal safety. Beta-blockers are often used to manage symptoms in pregnant women with heart murmurs, particularly those stemming from mitral stenosis or aortic valve disorders.

Diuretics may be prescribed to manage fluid retention and reduce cardiac workload. However, ACE inhibitors are typically avoided during pregnancy due to potential fetal harm.

Interventional procedures might be necessary for severe cases that don’t respond to medication. These include percutaneous balloon valvuloplasty for severe mitral stenosis, valve repair or replacement (in rare, life-threatening situations), and pacemaker implantation for certain arrhythmias.

The Cleveland Clinic and other specialized centers offer tailored approaches for pregnant women requiring cardiac interventions, with timing based on gestational age and maternal status.

Monitoring Mother and Fetus

Dual monitoring of both maternal and fetal health is essential throughout pregnancy. Your care team will track:

Maternal monitoring:

Vital signs and oxygen saturation
Cardiac function through echocardiograms
Exercise tolerance and functional capacity
Signs of heart failure or arrhythmias

Fetal monitoring:

Growth parameters via ultrasound
Heart rate and rhythm
Blood flow through the umbilical cord
Amniotic fluid levels

The frequency of fetal assessments increases as pregnancy progresses. Weekly monitoring is often recommended in the third trimester for high-risk cases.

Non-stress tests and biophysical profiles help evaluate fetal well-being. These monitoring strategies help detect early signs of fetal distress that may indicate maternal cardiac deterioration requiring immediate intervention.

Special Considerations in High-Risk Cases

Women with congenital heart disease, rheumatic heart disease, or peripartum cardiomyopathy (PPCM) require specialized management plans. If you have Down syndrome or DiGeorge syndrome with associated cardiac defects, your care requires additional considerations.

Peripartum cardiomyopathy deserves special attention as it can develop in the last month of pregnancy or within five months postpartum. Warning signs include unusual fatigue, shortness of breath, and swelling of the extremities.

A multidisciplinary team including cardiologists, obstetricians, perinatologists, neonatologists, and anesthesiologists should collaborate on your care plan. This team approach is crucial for managing complications and planning delivery.

Genetic counseling is recommended if your heart condition has a hereditary component. Counselors can discuss recurrence risks and options for fetal genetic testing when appropriate.

The postpartum period requires continued vigilance as hemodynamic changes can stress the cardiovascular system, particularly in the first 48 hours after delivery.

Frequently Asked Questions

Heart conditions during pregnancy require special attention and understanding. The following questions address common concerns about heart murmurs, monitoring procedures, and management strategies for pregnant women with cardiac issues.

What are the common symptoms of heart murmurs in pregnant women?

Common symptoms of heart murmurs during pregnancy include shortness of breath that exceeds the normal breathlessness associated with pregnancy. You may experience a pounding, fast, or unusual heartbeat that feels different from typical pregnancy palpitations.

Dizziness and fainting spells can occur, especially when changing positions quickly. Some women report chest pain or discomfort that isn’t related to other pregnancy symptoms.

Swelling in your legs, arms, or abdominal area beyond normal pregnancy edema might indicate a heart murmur requiring medical attention. Excessive fatigue that interferes with daily activities can also signal cardiac issues.

How should heart murmurs be monitored during pregnancy?

Regular prenatal appointments should include cardiac evaluations, during which your healthcare provider listens to your heart to assess its function. You’ll likely need consultations with a cardiologist specializing in maternal health for known heart murmurs.

Echocardiograms are commonly used to visualize heart function and are safe during pregnancy. Your doctor may recommend more frequent monitoring during the third trimester, when cardiovascular demands are at their peak.

Home monitoring includes tracking your pulse, weight, and new symptoms daily. Report any changes in symptoms immediately rather than waiting for your next appointment.

What are the guidelines for managing heart failure in pregnant patients?

Management focuses on carefully selecting medications that balance maternal and fetal safety. ACE inhibitors are typically avoided. At the same time, beta-blockers, such as metoprolol, may be prescribed when the benefits outweigh the risks.

Regular assessment of fluid status is crucial, with careful management of salt and fluid intake. A multidisciplinary team approach involving obstetricians, cardiologists, and anesthesiologists ensures comprehensive care throughout pregnancy.

Delivery planning is tailored to your specific condition, taking into account timing, method, and monitoring needs. Post-delivery monitoring remains important as cardiovascular stress can continue for several weeks after birth.

What preventive measures can reduce the risk of heart attacks during pregnancy?

Regular, moderate physical activity as approved by your healthcare provider strengthens your cardiovascular system. A heart-healthy diet low in sodium and rich in fruits, vegetables, and lean proteins supports cardiac function.

Managing stress through mindfulness techniques, adequate rest, and support systems helps reduce cardiovascular strain. Avoiding tobacco, alcohol, and caffeine eliminates substances that increase cardiac workload.

Adhering to medication schedules and attending all prenatal appointments ensures early intervention if problems arise. Maintaining a healthy weight within the recommended guidelines for pregnancy helps prevent additional cardiac stress.

Why is an ECG recommended for pregnant women, and when is it typically performed?

An ECG is recommended when you have symptoms like irregular heartbeats, chest pain, or shortness of breath beyond normal pregnancy changes. It’s also advised if you have pre-existing heart conditions or a family history of cardiac issues.

ECGs are typically performed during the first trimester to establish a baseline for women with known heart conditions. Additional ECGs may be scheduled at the beginning of the third trimester when cardiovascular demands increase significantly.

This noninvasive test poses no risk to you or your baby and provides valuable information about heart rhythm and electrical activity.

The results help distinguish between normal pregnancy-related changes and actual cardiac concerns.

Can pregnancy lead to the development of new heart problems, and how are they managed?

Pregnancy can unmask previously undiagnosed heart conditions due to increased blood volume and cardiac output. Conditions like peripartum cardiomyopathy may develop during the last month of pregnancy or within five months after delivery.

Management involves prompt diagnosis through imaging studies and blood tests to determine the type and severity of the condition. Treatment plans are individualized based on specific cardiac issues, with medication choices carefully selected for pregnancy safety.

Close monitoring continues throughout pregnancy and the postpartum period. Adjustments to care are made as needed.

Schedule an Appointment at Cardiovascular Group

Heart murmurs during pregnancy are often benign and related to natural cardiovascular changes. However, some may indicate underlying conditions requiring specialized care. With proper monitoring, early diagnosis, and a team-based approach between obstetricians and cardiologists, most women can expect a safe pregnancy and delivery, even with heart murmurs.

If you’re pregnant and have been told you have a heart murmur, don’t wait. Get expert cardiac care designed for maternal health—schedule an appointment with Cardiovascular Group today.