Sailing Across Contraception, Pregnancy, and Breastfeeding: The Complex Journey of Women with Cardiomyopathies

Abstract

Gender-specific cardiology has gained increasing recognition in recent years, emphasizing the need for tailored management strategies for women with cardiovascular disease. Among these, cardiomyopathies-dilated, arrhythmogenic, hypertrophic, and restrictive-pose unique challenges throughout a woman's reproductive life, affecting contraception choices, pregnancy outcomes, and breastfeeding feasibility. Despite significant advances in cardiovascular care, there is still limited guidance on balancing maternal safety and neonatal well-being in this complex setting. This review provides a comprehensive overview of the current evidence on reproductive counseling, pregnancy management, and postpartum considerations in women with cardiomyopathies. We discuss the cardiovascular risks associated with each cardiomyopathy subtype during pregnancy, highlighting risk stratification tools and emerging therapeutic strategies. Additionally, we address the safety and implications of breastfeeding, an often overlooked but increasingly relevant aspect of postpartum care. A multidisciplinary approach involving cardiologists, gynecologists, obstetricians, and anesthesiologists is crucial to optimizing maternal and fetal outcomes. Improved risk assessment, tailored patient counseling, and careful management strategies are essential to ensuring safer reproductive choices for women with cardiomyopathy. From now on, greater attention is expected to be given to bridging existing knowledge gaps, promoting a more personalized and evidence-based approach to managing these patients throughout different stages of reproductive life.

Keywords: breastfeeding; cardiomyopathy; gender differences; gynecology; lactation; neonatology; obstetrics; pregnancy; reproductive health; sexual health; women’s health.

Figure 1

Reproductive journey of women with cardiomyopathy.

Figure 2

Transthoracic echocardiogram from a young pregnant woman with non-obstructive hypertrophic cardiomyopathy. (Panel A): Parasternal long-axis view showing marked septal hypertrophy. (Panel B): Parasternal short-axis view at mid-ventricular level, demonstrating severe hypertrophy of the inferolateral wall. (Panel C): Aneurysmal appearance of the true apex, with mildly reduced global systolic function due to diffuse hypokinesia. (Panel D): No significant intraventricular gradient detected at rest or following the Valsalva maneuver (* indicates a peak gradient of 7 mmHg).

Figure 3

Genetic considerations in pregnancy associated with dilated cardiomyopathy.

Figure 4

Echocardiographic images of a patient at 38 weeks of gestation affected by dilated cardiomyopathy with left ventricular systolic function at the lower limit of normal. She had a history of syncope and previously documented second-degree atrioventricular block (type 2:1), which alternated with trifascicular block. The patient also experienced episodes of non-sustained ventricular tachycardia and paroxysmal atrial fibrillation. Genetic testing revealed a variant of uncertain significance in the myopalladin gene. Pregnancy did not result in a deterioration of left ventricular systolic function or an increase in ventricular volumes.

Figure 5

Transthoracic echocardiographic images from a woman who presented with sustained ventricular tachycardia during pregnancy. Subsequent evaluation revealed a pathogenic variant in a desmosomal gene, leading to the diagnosis of arrhythmogenic cardiomyopathy. Left ventricular systolic function is preserved. (Panel A): Parasternal long-axis view showing normal left ventricular wall thickness and chamber dimensions. (Panel B): Parasternal short-axis view showing right ventricular dilation. (Panel C): The right ventricle appears mildly dilated (The line between the asterisks), with reduced tissue Doppler velocities (Panel D).