We thank Dr Ben-Shlomo and colleagues for their interest regarding our article and we would like to reply to some of the comments expressed in their letter titled “Does twin gestation really have long-term maternal cardiac sequelae?”

Firstly, regarding their concern of a persistent cardiac deterioration following an uncomplicated twin gestation, although we have reported in fact a reduced systolic function at postpartum assessment, we interpreted these findings as transient changes or as a relative systolic dysfunction, not as a proper deterioration of systolic function. All the echocardiographic parameters remained actually within the normal ranges. Moreover, the reference interval of most echocardiographic findings during a normal pregnancy is actually poorly defined and even less defined during or after a normal twin gestation. The aim of our article was to describe longitudinally the profound functional adjustments occurring at the level of maternal heart during an overloading condition such as a twin pregnancy. Such profound changes do not seem to disappear quickly after delivery, but we are not allowed to state that they would persist longer in life or that they are early signs of poor cardiovascular maternal prognosis. Different is the case of preeclampsia, a well-defined (even if still not completely understood) gestational disorder that has been demonstrated to carry an increased risk of a long-term poorer cardiovascular prognosis. On the other hand, although twin pregnancy may be considered a high-risk condition, also because of its increased cardiac overload, the vast majority of the women may actually cope well with this high-volume status, and we cannot consider the twin pregnancy a pathological condition per se.

The suggestion to capture each woman for detailed echocardiography prior to pregnancy would be attractive, but it is obviously difficult in practice. On the other hand, we are collecting data also from nonpregnant women (comparable for baseline characteristics), which would be an acceptable control group to assess if the postpartum data obtained following a twin pregnancy were the persistence of a hemodynamic overload or a mere return to baseline. Even in the former case, however, we are not expected to look at the postpartum data as reliable prognostic factors for a woman’s cardiovascular risk during life.