Feeling safe but still anxious: understanding early pregnancy in congenital heart disease

This invited commentary refers to ‘The experience of pregnancy for women with congenital heart disease: a qualitative study of women in Sweden’, by M. Berghammer et al. https://doi.org/10.1093/eurjcn/zvaf147. The qualitative study by Berghammer et al.1 offers valuable exploration of early pregnancy experiences in women with congenital heart disease (CHD). By documenting lived experiences during the first 15 weeks of pregnancy, the study provides critical insights into concerns, coping strategies, and informational needs during this vulnerable period. Given increasing numbers of women with CHD reaching childbearing age, this research contributes significantly to patient-centred cardiovascular and maternal health care. The overarching theme ‘Concerned but feeling safe during pregnancy’ captures the complex emotional paradox experienced by CHD patients during early pregnancy.1 This balance between emotional distress and perceived safety from multidisciplinary care aligns with previous research highlighting the importance of dedicated cardio-obstetrics teams and pre-pregnancy counselling, as outlined in European Society of Cardiology guidelines.2 A critical insight is the unique emotional landscape of early pregnancy in women with CHD. Although cardiac stress is relatively minimal in early pregnancy, emotional burden during this period correlates with poorer neonatal outcomes.3 Women experience anxiety due to multiple interconnected concerns: fears of cardiac complications, worries about inherited defects, uncertainty about physical adaptation to haemodynamic changes, concerns about foetal wellbeing, potential medication effects, and long-term implications for both mother and child.4 These findings highlight that successful pregnancy outcomes in CHD patients depend not only on cardiac stability but also on comprehensive psychosocial support established early in pregnancy.5 This underscores the critical need for trust-building, emotional reassurance, and robust supportive systems during this vulnerable period. The study illuminates a fundamental clinical challenge: correctly attributing symptoms during pregnancy.1 Women with CHD face the complex task of distinguishing between CHD-related symptoms and normal pregnancy changes. Common symptoms such as dyspnoea, palpitations, and fatigue overlap considerably between normal pregnancy physiology and cardiac decompensation, creating diagnostic uncertainty. Targeted education and coaching in symptom interpretation could prevent unnecessary emergency visits or delayed recognition of cardiac complications. This aligns with Harb et al.’s identification of insufficient information and emotional support as key care gaps.4 Unlike later pregnancy stages characterized by increased physical burden, the first trimester is primarily defined by psychological demands and adaptation challenges. Healthcare providers are uniquely positioned to foster effective coping mechanisms and address anxiety proactively during this critical period.6 Despite the study’s strengths, several limitations warrant consideration. First, manual coding was used without reporting inter-coder reliability, which limits reproducibility and may affect thematic analysis validity.7 Second, the sample composition—mainly women with mild to moderate CHD severity—significantly limits generalizability to women with more complex cardiac defects. Moreover, functional status such as New York Heart Association (NYHA) classification, a known predictor of maternal risk, was not explicitly addressed. Recent studies demonstrate that NYHA class III–IV and biomarkers such as BNP > 100 pg/mL are independently associated with adverse pregnancy outcomes.8,9 Including women with broader CHD severity and functional impairment spectrum could have enriched thematic diversity and strengthened external validity. Furthermore, the study does not account for influential variables such as pre-existing psychological conditions, prior pregnancy experience, socioeconomic status, and social support levels, all known to shape symptom perception and emotional adjustment during pregnancy. These factors may significantly modify pregnancy experience and could explain variability in coping strategies observed among participants.10 Finally, while the authors advocate multidisciplinary care, they do not propose specific interventions to operationalize findings into clinical practice. The gap between research findings and clinical implementation remains a significant challenge in translating qualitative insights into improved patient outcomes. Future research should focus on developing and testing targeted early pregnancy interventions across diverse CHD populations. Nevertheless, the study’s transparent discussion of methods, including digital interviews and gestational variability, aligns with evolving qualitative standards and demonstrates methodological rigour. Its focus on early pregnancy fills an important gap in CHD literature and provides valuable insights for developing comprehensive care models. In conclusion, despite limited cardiac risk, early pregnancy in women with CHD entails significant emotional challenges that demand timely psychosocial support. Future efforts should focus on developing targeted interventions for diverse CHD populations to improve maternal and foetal outcomes. Ju Ryoung Moon (Conceptualization [lead], Writing—original draft [lead], Writing—review & editing [equal]), and Sung-A Chang (Writing—review & editing [equal]) This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.