Echocardiographic strain in pregnancy: distinguishing physiological and pathological changes

Purpose of the review: Pregnancy induces cardiovascular adaptations, including increased cardiac output, blood volume, and heart rate, to support fetal development. These changes can sometimes unmask or exacerbate underlying myocardial dysfunction. Traditional echocardiographic measures, such as left ventricular ejection fraction (LVEF), often fail to detect subtle myocardial dysfunction. The purpose of this review is to evaluate the use of myocardial strain by echocardiography for early identification of myocardial impairment. Recent findings: In pathological pregnancies, speckle-tracking echocardiography reveals subclinical myocardial dysfunction across various conditions. Women with gestational diabetes mellitus (GDM) exhibit significantly reduced LV global longitudinal strain (GLS), even in the absence of overt systolic dysfunction. They also have reduced right ventricular (RV) GLS, indicating biventricular dysfunction, and reduced left atrial (LA) reservoir and conduit strain, suggesting early diastolic dysfunction. Hypertensive disorders of pregnancy (HDP), such as preeclampsia and gestational hypertension, have been linked to lower GLS values reflecting early myocardial dysfunction before overt changes in LVEF. HDP also show reduced RV strain indices and altered LA mechanics. Additionally, women with peripartum cardiomyopathy (PPCM) exhibit markedly lower GLS, often below −15% (28). GLS at diagnosis has been shown to predict recovery outcomes, with lower strain values associated with prolonged hospitalization and higher rates of persistent cardiac dysfunction postpartum. PPCM also involves RV dysfunction and LA strain impairment correlating with unfavorable clinical outcomes. Lastly, obesity in pregnancy is associated with impaired myocardial deformation, including reduced LVGLS. Summary: Strain echocardiography is a sensitive tool for early detection of myocardial dysfunction in pregnancies, aiding in risk stratification of women at increased risk of adverse cardiovascular outcomes. Key challenges exist including variability in reference ranges, operator dependency, and the need for cost-effective implementation in routine practice. Future research should focus on standardizing 2D strain imaging protocols and conducting longitudinal outcome studies. By bridging these gaps, strain imaging echocardiography can be used for earlier disease detection. Further research is needed to determine its role in optimizing risk stratification and improving cardiovascular health for both mother and offspring.