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Background Evidence regarding cardiovascular adaptation to pregnancy in women with pregestational diabetes is limited. Our study aimed to describe left ventricular (LV) remodelling and vascular adaptation to pregnancy in women with type 1 diabetes.Methods In this prospective cohort study, three consecutive cardiac MRI scans were conducted on age-matched and BMI-matched pregnant women with pregestational type 1 diabetes and pregnant women without diabetes. The scans were performed at gestational weeks 15–20, 26–30 and 34–37 from November 2020 to April 2023. Data collection and analysis included LV imaging results, brachial blood pressure and stroke volume derived functional vascular parameters.Results The study included 24 women with pregestational type 1 diabetes and 39 controls. Compared with controls, women with type 1 diabetes had significantly reduced LV end-diastolic volume index: 64.2±11.1 mL/m 2 vs 77.6±13.9 mL/m2 (p<0.001), reduced end-systolic volume index: 26.0±7.3 mL/m2 vs 33.5±7.7 mL/m2 (p=0.003), increased concentricity: 0.84±0.13 g/mL vs 0.68±0.10 g/mL (p<0.001), reduced stroke volume index: 38.2±7.2 mL/m2 vs 44.1±8.4 mL/m2 (p=0.008), reduced cardiac index: 3.37±0.55 L/min/m2 vs 3.62±0.51 L/min/m2 (p=0.046), reduced global longitudinal strain: −13.5±2.3% vs −15.2±2.1% (p=0.04), increased myocardial T1 values: 998±28 ms vs 983±25 ms (p=0.03), increased systolic blood pressure: 128.1±7.8 mmHg vs 117.4±11.1 mmHg (p=0.007), increased mean arterial pressure: 94.8±6.7 mmHg vs 88.1±9.7 mmHg (p=0.03), increased total peripheral vascular resistance: 28.9±5.3 mmHg·min·m2/L vs 24.7±4.0 mmHg·min·m2/L (p=0.001), and reduced total arterial compliance: 0.79±0.19 mL/m2/mmHg vs 1.02±0.21 mL/m2/mmHg (p<0.001).Conclusion Our study provides evidence of impaired LV remodelling and suboptimal vascular adaptation to pregnancy in women with type 1 diabetes when compared to women without diabetes. The clinical implications of these findings, particularly their association with the development of later cardiovascular disease, require further investigation.