For additional information, view Part I: Care of the Competitive Female Athlete

Introduction

To date, studies of competitive sports participation on fetal development and female athletes' health during and after pregnancy are not well described. Here, we will share our current understanding of peri- and postpartum cardiac complications and management of female athletes.

Cardiopulmonary Adaptations to Pregnancy and the Implications of Exercise on Fetal Development
At approximately 5 weeks gestation in pregnant females, estrogen leads to a reduction in afterload and increase in vascular capacitance, causing a 50% increase in cardiac output versus non-pregnant athletes, and 10% increase in stroke volume by first trimester's end.¹ Ventricular size and aortic capacitance increase and resting heart rate (HR) increases by 15-20 beats per minute (bpm).² While these hemodynamic shifts can precipitate symptoms such as lightheadedness, pre-syncope/syncope, and exertional dyspnea, there may also be a 5-10% increase in peak VO₂ and improved anaerobic capacity in athletes. Thus aerobic fitness remains the same or slightly improves if pregnant female athletes remain active.^3,4 Additionally, a randomized control trial evaluating both safety and efficacy of supervised moderate-vigorous resistance exercise versus a home-based program during gestational weeks 14-25 in 92 healthy pregnancy females showed that both female and fetus were not negatively impacted.⁵

Maternal exercise provokes a 10-15 bpm increase in fetal HR, which may reflect a protective mechanism on the fetus. However, there have been reports where strenuous exertion can precipitate transient decelerations in fetal HR that normalize upon cessation of exercise. Fortunately, no neonatal abnormalities occurred in these instances.⁶

Arrhythmias in Pregnancy
Arrhythmias, pre-existing or new, are considered the most common cardiac complication in pregnancy.⁷ Premature atrial and ventricular contractions are common, with high prevalence of 57% and >50%, respectively.⁸ Treatment with cardio-selective beta-blockers (BB) may be used after the first trimester without significantly impacting maximum power output and maximal VO₂.⁹ Supraventricular tachycardias (SVT), specifically AV nodal reentrant tachycardia (AVNRT), are common among females during childbearing years. During pregnancy, 3.9% of females have SVT-onset; 22% of pregnant females with established SVT endorse exacerbations.¹⁰ In non-pregnant athletes, SVT ablation is recommended rather than lifelong medical therapy.¹¹ In pregnant athletes, catheter ablation with limited fluoroscopy may be ideal, as the safety and efficacy of antiarrhythmic drugs (AADs) in pregnancy are uncertain. While ablation therapy may be reasonable, it is important to discuss risk for fetal compromise in case of maternal hemodynamic instability as well as fetal radiation exposure and consequences (e.g., intellectual disability, fetal anomalies, fetal loss). Abdominal shielding and use of electroanatomic mapping and intracardiac echocardiography should be used to further minimize radiation exposure for both female athlete and fetus.¹²

Atrial fibrillation/flutter (AF/AFL) are less common in pregnancy, occurring in 2/100,000 hospital admissions, though may increase in prevalence with increasing maternal age.¹³ Current studies show competitive athletes, particularly men, are at greater risk for developing AF.¹⁴ At present, there is no clear association between pregnancy and AF. Treatment strategies include electric cardioversion if hemodynamically unstable and rate control with BB and/or calcium channel blockers. AADs (e.g., sotalol, flecainide) may be considered in pregnant athletes' refractory to rate control strategies, though their safety profile must be considered. Amiodarone and dronedarone are contraindicated. Finally, catheter ablation is not considered first-line treatment for AF due to high radiation exposure risk.¹⁵ For athletes requiring systemic anticoagulation, while low molecular weight heparin or unfractionated heparin is preferred, warfarin may be used during the second and third trimesters. To date, safety data in the use of direct oral anticoagulants in pregnancy is lacking; thus, they are not recommended. Note, the World Anti-Doping Agency does not prohibit BB for treatment of SVT, ventricular arrhythmias, and long QT syndrome.¹⁶

Preeclampsia
Hypertension and hypertensive-related disorders are a leading cause of maternal morbidity and mortality in both developed and developing countries.¹⁷ Preeclampsia, new-onset hypertension with end-organ damage, and proteinuria at 20+ weeks gestation impacts approximately 2-8% of pregnancies.¹⁸

Case-control and cohort studies suggest that exercise may be protective in preventing and/or minimizing the impact of preeclampsia.¹⁹ Exercise for 50 minutes at least three times a week is advised by the International Society for the Study of Hypertension in Pregnancy for the prevention of preeclampsia.²⁰ While the impact of competitive sports participation on the incidence of preeclampsia is unknown, there are no studies to date that suggest competitive sports participation is associated with heightened risk.

Management of preeclampsia/eclampsia in athletes is akin to that of non-athletes. High-risk females are advised to take a daily low-dose aspirin to reduce preeclampsia risk.^21,22 Pravastatin, shown to prevent vascular dysfunction in rat models, has also been recommended.^23,24 Definitive treatment is fetal delivery.

Peripartum Cardiomyopathy and Sports Participation
The 2010 Heart Failure (HF) Association of the European Society of Cardiology Working Group defines peripartum cardiomyopathy (PPCM) as "an idiopathic cardiomyopathy presenting with HF secondary to left ventricular (LV) systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of HF is found," with LV ejection fraction (LVEF) less than 45% with or without LV dilatation.²⁵ Standard HF medical therapy safe for both pre-term fetus and breastfeeding postpartum includes loop diuretics, BB, hydralazine/nitrates, and digoxin. Angiotensin converting enzyme inhibitors (ACEi)/angiotensin-receptor blockers (ARBs), aldosterone receptor antagonists, sacubitril-valsartan, and ivabradine are contraindicated during pregnancy and breastfeeding. LVEF is the most reliable predictor of prognosis and long-term recovery, with a median recovery time of 8-months and lower recovery rates seen with LVEF <30%.^26,27 African American ethnicity is associated with greater morbidity and mortality and longer recovery time.²⁸ Though most patients with PPCM may not have late gadolinium enhancement (LGE) indicative of fibrosis on cardiac magnetic resonance imaging, LGE presence may be associated with less myocardial recovery.²⁹

While most females will have recovery of LV systolic function, risk of recurrence with subsequent pregnancies is high. Consequently, risk stratification of athletes with prior PPCM is important. Cardiopulmonary exercise testing (CPET) with first-pass radionuclide ventriculography to assess VO₂ and biventricular contractile reserve, respectively, may be a promising method to predict recurrence. Of six asymptomatic non-athletes with recovered PPCM, most had impaired exercise capacity (peak VO₂) indicating greater risk of cardiac decompensation with subsequent pregnancies and need for long-term medications.³⁰ Finally, there are no established guidelines for exercise and competitive sports participation in athletes with PPCM. An individualized approach to return to sports inclusive of CPET and cardiac imaging for risk stratification should be implemented alongside a sports cardiologist.

Key Takeaways
Pregnancy is not a disability, nor contraindication to competitive sports participation. Athletes should remain active and may continue to participate in competitive sports, as advised by an athlete's sports cardiologist and obstetrician. With numerous uncertainties present, there is need to develop guidelines on cardiovascular management of pregnant and postpartum athletes. Ongoing education of athletes and providers is imperative to ensure we remain advocates for both the athlete and fetus rather than unnecessarily limiting competitive sports participation.

References

1. Morris EA, Hale SA, Badger GJ, Magness RR, Bernstein IM. Pregnancy induces persistent changes in vascular compliance in primiparous women. Am J Obstet Gynecol 2015;212:633.e1-6.
2. Cong J, Fan T, Yang X, et al. Structural and functional changes in maternal left ventricle during pregnancy: a three-dimensional speckle-tracking echocardiography study. Cardiovasc Ultrasound 2015;13:6.
3. Clapp JF 3rd, Capeless E. The VO2max of recreational athletes before and after pregnancy. Med Sci Sports Exerc 1991;23:1128-33.
4. Wolfe LA, Brenner IK, Mottola MF. Maternal exercise, fetal well-being and pregnancy outcome. Exerc Sport Sci Rev 1994;22:145-94.
5. Petrov Fieril K, Glantz A, Fagevik Olsen M. The efficacy of moderate-to-vigorous resistance exercise during pregnancy: a randomized controlled trial. Acta Obstet Gynecol Scand 2015;94:35-42.
6. Szymanski LM, Satin AJ. Strenuous exercise during pregnancy: is there a limit? Am J Obstet Gynecol 2012;207:179.e1-6.
7. Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001;104:515-21.
8. Shotan A, Ostrzega E, Mehra A, Johnson JV, Elkayam U. Incidence of arrhythmias in normal pregnancy and relation to palpitations, dizziness, and syncope. Am J Cardiol 1997;79:1061-64.
9. Fikenzer S, Fikenzer K, Laufs U, Falz R, Schulze A, Busse M. Effects of cardioselective beta-blockade on plasma catecholamines and performance during different forms of exercise. J Sports Med Phys Fitness 2020;60:643-49.
10. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2016;67:e27-115.
11. Zipes DP, Link MS, Ackerman MJ, Kovacs RJ, Myerburg RJ, Estes NA 3rd. Eligibility and isqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 9: arrhythmias and conduction defects: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2412-23.
12. Bongiorni MG, Di Cori A, Soldati E, et al. Radiofrequency catheter ablation of atrioventricular nodal reciprocating tachycardia using intracardiac echocardiography in pregnancy. Europace 2008;10:1018-21.
13. Li JM, Nguyen C, Joglar JA, Hamdan MH, Page RL. Frequency and outcome of arrhythmias complicating admission during pregnancy: experience from a high-volume and ethnically-diverse obstetric service. Clin Cardiol 2008;31:538-41.
14. Eijsvogels TMH, Thompson PD, Franklin BA. The "Extreme Exercise Hypothesis": recent findings and cardiovascular health implications. Curr Treat Options Cardiovasc Med 2018;20:84.
15. Enriquez AD, Economy KE, Tedrow UB. Contemporary management of arrhythmias during pregnancy. Circ Arrhythm Electrophysiol 2014;7:961-67.
16. Cardiovascular Conditions: The Therapeutic Use of Beta-Blockers in Athletes (wada-ama.org). Available at: https://www.wada-ama.org/sites/default/files/resources/files/cardiovascular_conditions_v_2.0_jan2018_en.pdf. Accessed 02/15/2022.
17. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014;2:e323-33.
18. Goel A, Maski MR, Bajracharya S, et al. Epidemiology and mechanisms of de novo and persistent hypertension in the postpartum period. Circulation 2015;132:1726-33.
19. Kasawara KT, do Nascimento SL, Costa ML, Surita FG, Pinto e Silva JL. Exercise and physical activity in the prevention of pre-eclampsia: systematic review. Acta Obstet Gynecol Scand 2012;91:1147-57.
20. Brown MA, Magee LA, Kenny LC, et al. The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens 2018;13:291-310.
21. ACOG Committee Opinion No. 743: low-dose aspirin use during pregnancy. Obstet Gynecol 2018;132:e44-e52.
22. LeFevre ML. Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161:819-26.
23. Fox CS, Golden SH, Anderson C, et al. Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2015;132:691-718.
24. Kräker K, O'Driscoll JM, Schütte T, et al. Statins reverse postpartum cardiovascular dysfunction in a rat model of preeclampsia. Hypertension 2020;75:202-10.
25. Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur Heart Fail 2010;12:767-78.
26. McNamara DM, Elkayam U, Alharethi R, et al. Clinical outcomes for peripartum cardiomyopathy in North America: results of the IPAC Study (Investigations of Pregnancy-Associated Cardiomyopathy). J Am Coll Cardiol 2015;66:905-14.
27. Mahowald MK, Basu N, Subramaniam L, Scott, R, Davis MB. Long-Term outcomes in peripartum cardiomyopathy. Open Cardiovasc Med J 2019;13:13-23.
28. Goland S, Modi K, Hatamizadeh P, Elkayam U. Differences in clinical profile of African-American women with peripartum cardiomyopathy in the United States. J Card Fail 2013;19:214-18.
29. Schelbert EB, Elkayam U, Cooper LT, et al. Myocardial damage detected by late gadolinium enhancement cardiac magnetic resonance is uncommon in peripartum cardiomyopathy. J Am Heart Assoc 2017;6:e005472.
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Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Anticoagulation Management and Atrial Fibrillation, EP Basic Science, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Statins, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging, Exercise, Hypertension, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging

Keywords: Sports, Athletes, Female, Angiotensin Receptor Antagonists, Anti-Arrhythmia Agents, Calcium Channel Blockers, Contrast Media, Dronedarone, Flecainide, Gadolinium, Heparin, Ivabradine, Mineralocorticoid Receptor Antagonists, Nitrates, Pravastatin, Sodium Potassium Chloride Symporter Inhibitors, Stroke Volume, Warfarin, Return to Sport, Physical Exertion, Electric Countershock, Exercise Test, Heart Rate, Anaerobiosis, Atrial Fibrillation, Breast Feeding, Dilatation, Dizziness, Eclampsia, Pre-Eclampsia, Ethnic Groups, Exercise Tolerance, Maternal Age, Peripartum Period, Pregnancy Trimester, First, Pregnancy Trimester, Second, Pregnancy Trimester, Third, Prevalence, Resistance Training, Tachycardia, Atrioventricular Nodal Reentry, Vascular Capacitance, Ventriculography, First-Pass, Angiotensin-Converting Enzyme Inhibitors, Cohort Studies, Case-Control Studies, Risk Assessment, Heparin, Low-Molecular-Weight, Tachycardia, Supraventricular, Magnetic Resonance Imaging, Radiation Exposure, Catheter Ablation, Contraindications, Echocardiography, Long QT Syndrome, Anticoagulants, Risk Management, Cardiomyopathies, Heart Failure, Angiotensins, Hypertension, Proteinuria, Fluoroscopy, Hydralazine, Postpartum Period, Estrogens, Prognosis, Dyspnea, Fibrosis, Hospitals, Syncope, Aspirin, Digoxin

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