Maternal–Fetal Outcomes and Management of Severe Dyslipidemia, Familial Hypercholesterolemia, and Atherosclerotic Cardiovascular Disease during Pregnancy: A Systematic Review

Pregnancy has traditionally been regarded as a physiological state; however, in women with severe dyslipidemia, familial hypercholesterolemia (FH), severe hypertriglyceridemia, or established atherosclerotic cardiovascular disease (ASCVD), the normal metabolic adaptations of gestation may also function as an atherogenic cardiovascular stress test capable of unmasking latent vascular vulnerability. This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 reporting principles to critically appraise and qualitatively synthesize the available evidence regarding maternal and fetal outcomes, underlying pathophysiological mechanisms, and contemporary management strategies in these high-risk pregnancies. Comprehensive searches of PubMed/MEDLINE, PubMed Central, Embase, Scopus, Web of Science, and the Cochrane Library identified 946 records, of which 34 studies met predefined eligibility criteria and were included in the qualitative synthesis. The available evidence consistently indicates that physiological gestational increases in circulating lipids, insulin resistance, endothelial activation, inflammation, and hypercoagulability may amplify preexisting metabolic and vascular abnormalities, thereby increasing susceptibility to adverse maternal cardiovascular and obstetric outcomes. FH and severe hypertriglyceridemia were associated with acute pancreatitis, hypertensive disorders of pregnancy, myocardial infarction, placental dysfunction, fetal growth restriction, preterm birth, and neonatal complications, although evidence certainty varied across clinical phenotypes. Current management favors individualized risk assessment supported by multidisciplinary care, with lifestyle intervention, omega-3 fatty acids, bile acid sequestrants, lipoprotein apheresis, and therapeutic plasma exchange representing important treatment options in carefully selected patients. Overall, the synthesized evidence supports pregnancy as an important window for identifying women with increased lifetime cardiovascular vulnerability while emphasizing individualized management to optimize both maternal cardiovascular health and fetal outcomes.