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BACKGROUND: Cardiac and vascular complications are the leading causes of maternal mortality and morbidity, but the contemporary burden of and secular trends in pregnancy-related cardiovascular complications are not well-characterized. We developed a multi-institutional electronic health record-based pregnancy cohort with rigorously defined cardiovascular outcomes to examine trends in prevalence of maternal cardiovascular comorbidities and cardiovascular disease (CVD) and incidence of pregnancy-related cardiovascular complications.METHODS: We identified pregnancy encounters that occurred between 2001 and 2019 from a primary care electronic health record cohort using International Classification of Diseases and Current Procedural Terminology codes. We used regular expressions to recover estimated gestational age from unstructured notes and used gestational age to define the pregnancy episode for each individual pregnancy. Leveraging this cohort, we quantified and examined trends in the prevalence of maternal cardiovascular comorbidities and CVD and incidence of cardiovascular complications in pregnancies over the course of 19 years of follow-up. We also compared clinical factors for pregnancies with and those without cardiovascular complications.RESULTS: Our pregnancy cohort comprised 56 833 pregnancies among 38 996 individuals (mean age at start of pregnancy, 32±5 years). Regular expressions recovered gestational age for 75% of pregnancies, with good correlation between gestational age ascertained by regular expressions versus manual review (Pearson =0.9). Among 56 833 pregnancies, overall prevalence of maternal CVD was 4% (age-adjusted 8%) and increased over 19 years (age-adjusted prevalence 1% in 2001 and 7% in 2019; <0.001). Incidence of pregnancy-related cardiovascular complications was 15% (age-adjusted 17%) and increased over the study follow-up period (age-adjusted incidence 11% in 2001 and 13% in 2019; <0.001). Cardiovascular complications within 1 year postpartum were more frequent in individuals with greater burden of maternal cardiovascular comorbidities and CVD (diabetes, 6% versus 3%; hypertension, 23% versus 5%; CVD, 10% versus 3%; <0.001 for all).CONCLUSIONS: In a large-scale electronic health record-based pregnancy cohort, both the prevalence of maternal cardiovascular comorbidities and CVD as well as the incidence of pregnancy related cardiovascular complications within 1 year postpartum increased over the course of 2 decades. Our findings demonstrate an alarming rise in pregnancy-related cardiovascular complications in a contemporary real-world setting and highlight pregnancy as a crucial life opportunity for cardiovascular health optimization.