In addition to less restrictive guidance for some high-risk patients, the document advises vaginal birth whenever possible.
Personalized pregnancy-related risk assessments and shared decision-making are crucial for women and their physicians making reproductive health choices when maternal CVD is present, according to updated guidelines from the European Society of Cardiology (ESC).
Endorsed by the European Society of Gynecology (ESG), the guidelines supplant the previous version, published in 2018, and they highlight new evidence as well reorganize and revise certain sections to make them more user-friendly. Among other things, the task force emphasizes autonomy regarding reproductive choice in high-risk pregnancy, as well as the importance of multidisciplinary teams to ensure comprehensive care from preconception through the postpartum period.
”Evidence has shown that women who are managed by a pregnancy heart team have better outcomes,” said Julie De Backer, MD, PhD (Ghent University Hospital, Belgium), in a press conference at the ESC Congress 2025 in Madrid, Spain, where the guidelines were presented. The organization of these teams should take into account regional differences in care, she added.
“There are countries where people are living very far away, and may need to travel a long way to get to get to these pregnancy heart teams. This is not the case in all countries,” De Backer added.
At their core, these teams should consist of a cardiologist, anesthesiologist, midwife obstetrician, and clinical nurse specialist. Additional medical specialists, including geneticists, electrophysiologists, primary care physicians, psychologists, social workers, and a pulmonary embolism response team, among others, may also be part of extended case-based teams depending on the needs of the patient.
Rather than advising against pregnancy for certain rare health conditions such as Ehlers-Danlos syndrome and pulmonary arterial hypertension, as other guidance has done, the new document recommends counselling women with these conditions about their risks, taking into account their genetic background, family history, and any previous vascular events.
The guidelines were simultaneously published in the European Heart Journal.
Modifications and Revisions for 2025
In presenting the guidelines, De Backer said a critical change that the committee made was to the modified World Health Organization (mWHO) 2.0 classification of maternal cardiovascular risk. The change refines and expands clinical categories, including arrhythmias and cardiomyopathy, as well as some acquired heart diseases.
The document also incorporates data from the CARPREG II study, from which a risk index was derived to predict the likelihood of maternal cardiac complications. De Backer said these changes allow for a more nuanced understanding of risk estimation for the different classes of maternal CV risk. This section of the guidelines also helps clinicians to know which women need referral to a pregnancy heart team.
Detailed sections of the document address peripartum cardiomyopathy, congenital cardiac disease, venous thromboembolism in pregnancy and postpartum, hypertension, valvular diseases, arrhythmias, special populations—including those with active or prior cancer—and drugs that are and are not recommended during pregnancy and lactation.
With regard to delivery, the guideline writers are clear that vaginal birth should be preferred for most women with CVD, including most who are taking vitamin K antagonists (VKA) or heparins. The exceptions to that recommendation are women have taken VKAs within the 2 weeks prior to delivery and those with high-risk aortopathy (mWHO 2.0 class III), hypertrophic cardiomyopathy (HCM) with severe left ventricle outflow tract obstruction, or acute intractable HF. In those cases, the guidelines recommend cesarean section delivery for the safety of both the mother and fetus.
Another important aspect of the guidelines, De Backer noted, is that it addresses adverse pregnancy outcomes (APO) ranging from postpartum hypertensive disorders to preterm birth and pregnancy loss. Among the recommendations listed here are that in women with a history of any APO, cardiovascular risk assessment should be considered at 3 months postpartum, followed by a repeat assessment at 6 to 12 months after implementation of appropriate lifestyle interventions, and regular long-term follow-up thereafter.
Also presenting during the session, Kristina Hermann Haugaa, MD, PhD (Oslo University Hospital, Norway), who co-chaired the guidelines update with De Backer, pointed to flow charts that walk clinicians through management of specific patient scenarios, including heart failure occurring in pregnancy or postpartum, and cardiac arrest.
Haugaa noted that the guide to drugs in pregnancy and postpartum are color coded. “We have marked them with green if there is a first safe medication, with yellow if there is a second-choice medication, and in red if they are contraindicated due to fetal toxicity,” she added.
“ Furthermore, we have included the primary arrhythmia syndromes and the cardiomyopathies in the new guidelines, and . . . we have sorted them into classifications,” Haugaa said. These tables also provide levels of evidence to aid in the management of women with long QT syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT), and Brugada syndrome.
De Backer said the committee hopes this extensive guideline update “will be very useful for all healthcare providers having pregnant women in their care.”