How to Use Cardiovascular Imaging in Pregnancy

Cardiovascular imaging plays a central role in the diagnosis, risk stratification, and longitudinal management of cardiovascular disease during pregnancy. Physiological adaptations-including increased blood volume, cardiac output, and chamber remodeling-pose important challenges for image acquisition and interpretation, necessitating a nuanced understanding of normal versus pathological findings. This review provides a practical, cardiology-focused framework for the use of imaging in pregnant patients with suspected or established cardiovascular disease. We emphasize key aspects relevant to cardiac imagers, including appropriate modality selection, pregnancy-adapted imaging protocols, and interpretation of findings in the context of dynamic physiological changes. Transthoracic echocardiography remains the first-line modality, while cardiovascular magnetic resonance offers complementary, radiation-free evaluation in selected cases. Imaging techniques involving ionizing radiation, such as computed tomography and invasive angiography, should be reserved for acute or high-risk scenarios and carefully optimized to minimize fetal exposure. We further discuss common diagnostic pitfalls, limitations of each modality, and areas of uncertainty, including the use of contrast agents and thresholds for advanced imaging. The importance of integrating imaging findings into multidisciplinary decision-making within Pregnancy Heart Teams is highlighted. By providing a structured, clinically oriented approach, this review aims to support cardiac imagers in delivering safe, accurate, and evidence-informed care to this complex patient population.