The following are key points to remember from this JACC Focus Seminar on diagnostic cardiovascular imaging and therapeutic strategies in pregnancy:

1. The prevalence of cardiovascular disease (CVD) in pregnancy, both diagnosed and previously unknown, is rising, and CVD remains a leading cause of maternal morbidity and mortality.
2. Since women of child-bearing potential have been under-represented in research, there exists knowledge gaps in the cardiovascular care of pregnant and lactating women.
3. Despite these limitations, clinicians should be familiar with the safety of frequently used diagnostic and therapeutic interventions to adequately care for this at-risk population.
4. In general, ultrasound and magnetic resonance without gadolinium-based contrast are preferred over other imaging modalities for pregnant woman to avoid radiation exposure.
5. If and when imaging with ionizing radiation is necessary during pregnancy, the strategy should be designed to minimize exposure.
6. Importantly, intravenous contrast should not be withheld if an additional scan with contrast might be needed as a follow-up study, which would expose the woman and fetus to additional radiation. For breast-feeding women, the American College of Obstetricians and Gynecologists recommends that breast-feeding be continued without interruption, as these agents are excreted into the breast milk at very low levels.
7. When choosing diagnostic tests and medications for pregnant and lactating women, the interplay between maternal and fetal/infant risks and benefits must be carefully considered. Shared decision making in consultation with the patient and cardio-obstetrics team is essential for optimal outcomes.
8. Although almost every drug administered to a mother crosses the placenta, fetal drug concentration may be similar to, higher than, or lower than the maternal concentration depending on the drug.
9. Direct oral anticoagulants (DOACs) are contraindicated during pregnancy. Rivaroxaban crosses the placental barrier and therefore is contraindicated in pregnancy. Other DOACs have not been evaluated. Pregnant women were excluded from DOAC trials. If a patient has an appropriate indication for anticoagulation, she should be switched to heparin products or warfarin during pregnancy and during lactation.
10. Finally, the conduct of both clinical care and research on CVD in pregnancy is complex, but these complexities must be confronted, and the ethical obligation to improve care for pregnant women must not be ignored.

Clinical Topics: Anticoagulation Management, Congenital Heart Disease and Pediatric Cardiology, Noninvasive Imaging, Prevention, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Echocardiography/Ultrasound, Magnetic Resonance Imaging

Keywords: Anticoagulants, Breast Feeding, Diagnostic Imaging, Diagnostic Tests, Routine, Fetus, Gadolinium, Heparin, Infant, Lactation, Magnetic Resonance Imaging, Pharmaceutical Preparations, Placenta, Pregnancy, Primary Prevention, Radiation, Radiation, Ionizing, Risk Assessment, Ultrasonography, Vascular Diseases, Warfarin

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