Cardiovascular maladaptation in women with hypertensive disorders of pregnancy and long-term cardiovascular risk

Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal and perinatal morbidity and mortality. Pregnancy is increasingly viewed as a physiological "stress test" capable of revealing latent cardiovascular susceptibility in women predisposed to future cardiovascular disease (CVD). In HDP, this vulnerability becomes clinically evident as impaired cardiovascular adaptation during pregnancy. It remains uncertain whether women who develop both HDP and CVD share common pre-existing risk factors or whether HDP contribute directly to long-term cardiovascular impairment. In normotensive pregnancy, systemic vascular resistance declines, blood volume and cardiac output increase significantly, and the heart undergoes reversible structural remodeling. In contrast, HDP are characterized by abnormal placentation, angiogenic imbalance, endothelial dysfunction, disrupted maternal hemodynamic balance, and adverse cardiac remodeling. Importantly, these maladaptive cardiovascular changes may persist well beyond delivery, leading to prolonged ventricular dysfunction and chronic cardiovascular changes. This review focuses on the cardiovascular maladaptation in HDP and its long-term effects on affected women and their offspring, as well as targeted interventions to reduce the risk of HDP and subsequent CVD.