Maternal Cardiovascular Phenotype in Fetal Growth Restriction with or Without Pre-Eclampsia: Insights from Echocardiography and Clinical Implications

Fetal growth restriction (FGR) has traditionally been attributed to placental insufficiency. However, accumulating evidence suggests that maternal cardiovascular maladaptation contributes to disease expression, clinical heterogeneity, and long-term maternal cardiovascular risk. To review maternal echocardiographic findings in pregnancies complicated by FGR, with or without preeclampsia and to explore the role of cardiovascular phenotyping in risk stratification and clinical management. Narrative review of the current literature, including observational studies, systematic reviews, meta-analyses, and expert consensus statements on maternal hemodynamics and echocardiographic assessment in FGR. FGR is associated with a maladaptive cardiovascular profile characterized by reduced cardiac output, increased systemic vascular resistance and adverse cardiac remodeling. Echocardiography frequently identifies subclinical myocardial dysfunction, including impaired diastolic function and reduced global longitudinal strain despite preserved ejection fraction. Distinct maternal cardiovascular phenotypes emerge across the FGR spectrum, ranging from high-risk hypodynamic, resistance-dominant phenotypes to intermediate and low-risk phenotypes with preserved hemodynamic adaptation. Integration of maternal cardiovascular assessment with fetal Doppler findings may improve risk stratification and support phenotype-guided surveillance and therapeutic decision-making. Persistent postpartum cardiovascular abnormalities further support the concept of pregnancy as a cardiovascular stress test and identify women at increased long-term cardiovascular risk. FGR should be viewed as the clinical manifestation of a complex maternal–placental–cardiovascular interaction rather than an isolated placental disorder. Maternal cardiovascular phenotyping has the potential to refine risk stratification, support hemodynamic-guided management, and identify women who may benefit from structured long-term cardiovascular surveillance.