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A meta‐analysis of myocardial infarction in pregnancy, including 66,470,100 pregnancies from high income countries, found the pooled incidence of myocardial infarction in pregnancy was 3.34 per 100,000 (95% CI 2.09–4.58) with a maternal fatality rate of around 5% [7]. Currently in the UK, approximately a quarter of all cardiovascular deaths in pregnancy are due to myocardial ischemia. With increasing prevalence of obesity, type 2 diabetes and advanced female age, the incidence of acute coronary syndromes in pregnancy is likely to rise, and with every year of increasing maternal age, the risk of myocardial infarction rises by 20% [8]. Therefore, women with multiple risk factors for coronary disease such as hypertension, diabetes, smoking, dyslipidemia and older reproductive age should have a cardiac assessment prior to undergoing ART.

A high index of suspicion is needed to diagnose acute coronary syndrome (ACS) in a young pregnant or postpartum patient. As in the nonpregnant patient, there is often a history of chest pain, palpitations and breathlessness. However, presentation may be atypical with dizziness, nausea or epigastric pain without chest pain. Interpretation of the ECG may be challenging with T‐wave inversion and ST shift frequently seen in the pregnant population in the absence of coronary ischemia. ST elevation, however, is always abnormal, and elevated troponin levels, even in the presence of preeclampsia, should trigger investigations for ACS. The treatment is the same as in the nonpregnant patient. Complications include arrhythmia, heart failure, cardiogenic shock and death of both mother and baby.

Due to improved outcomes for patients with congenital heart disease (CHD), there is an increasing number of women with congenital heart disease who reach childbearing age [9,10]. In most cases, the woman is well known to adult congenital heart disease services where individualized prepregnancy counseling should take place. Individual risk is dictated by the nature and complexity of the defect, but in general those with more complex disease have a higher risk of obstetric complications. Maternal risk is strongly influenced by cardiac output and functional class prior to pregnancy, and during pregnancy women with CHD are at risk of arrhythmia. The presence of cyanosis is also relevant to offspring outcome: if maternal oxygen saturation is <85% the chance of a life birth is only 12% [11]. Prematurity and low birth weight are frequent complications.