BackgroundCardiovascular disease (CVD) and risk factors for CVD are important indirect causes of maternal mortality in lower-middle-income countries (LMIC). The purpose of this research was to assess the prevalence of pre-existing CVD and risk factors for CVD in pregnant women and their relationship to maternal mortality in LMIC.ResultsThis was a cross-sectional study conducted on 3190 pregnant patients with pre-existing CVD and risk factors for CVD from 1st January 2018 through 31st December 2020 at a tertiary care hospital of Pakistan-a LMIC. A two-tailed Mann-Whitney two-sample rank-sum test, fisher’s exact test, and binary logistic regression were used for statistical analysis.Of 3190 patients, 517 (16.21%) individuals had risk factors for CVD, whereas 533 had pre-existing CVD (16.71 %). Diabetes mellitus type II was the most common risk factor for CVD, accounting for 238 (7.46 %) of all patients, followed by dyslipidemia in 162 (5.08 %), obesity in 153 (4.8 %), chronic hypertension in 151 (4.73 %), and family history (FH) of premature coronary artery disease (CAD) in 56 (1.76 %). Among patients with pre-existing CVD, 197 (6.18%) had ischemic heart disease (IHD), 182 (5.71%) had valvular heart disease (VHD), and 146 (4.58%) had cardiomyopathy. In this study majority of maternal deaths occurred in patients with diabetes (128(54%), p<.001) and ischemic heart disease (87(37%), p<.001). A one-unit rise in BMI increased maternal mortality by 13%. In contrast, the absence of Pre-existing CVD and risk factors for CVD conferred a protective effect from the adverse outcome i.e. maternal death. Maternal mortality was reduced by 66% in normoglycemic pregnant patients, 47% in patients without chronic HTN, 90% in patients without valvular heart disease, 97% without ischemic heart disease, and 99% without cardiomyopathy.ConclusionCVD and risk factors for CVD are major determinants of maternal mortality in pregnancy. Identifying such patients is imperative so that prompt measures can be taken beforehand to prevent adverse outcomes.