Uterotonics in pregnant patients with cardiac disease: a focused review

Cardiac disease complicates approximately 1-4% of pregnancies and is a leading cause of maternal morbidity and mortality worldwide. The spectrum includes congenital heart disease, valvular disorders, cardiomyopathy, pulmonary hypertension, ischaemic heart disease and hypertensive disorders, including preeclampsia, which can cause significant cardiac dysfunction. Management during delivery requires careful attention to haemodynamic stability, especially when preventing or treating postpartum haemorrhage. Uterotonics are central to management, but can alter systemic vascular resistance, myocardial contractility, pulmonary artery pressure, and heart rate, with varying implications depending on the underlying cardiac pathology. This focused review examines the pharmacology, haemodynamic effects and clinical considerations of uterotonic agents in women with cardiac disease, integrating evidence from studies, case series, and consensus recommendations. Oxytocin and its long-acting analogue carbetocin are discussed in detail, alongside alternatives such as carboprost, ergometrine, misoprostol, and adjuncts including calcium and tranexamic acid. Uterotonic use in maternal cardiac disease should be individualised according to cardiovascular physiology. Careful titration, slow infusion, and appropriate haemodynamic monitoring may reduce the risk of adverse effects. Early multidisciplinary planning and protocolised care are essential for optimal outcomes. Prospective studies across different cardiac conditions are needed to inform definitive guidance.